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BACKGROUND: The imperative to train physicians in skills required to lead care transformation is increasingly recognized, yet few Graduate Medical Education (GME) programs exist to meet this need. AIM: Describe the development, outcomes, and lessons learned from a novel GME care transformation curricular program. SETTING: Department of Internal Medicine (IM) at Dell Medical School at The University of Texas, Austin. PARTICIPANTS: Between 2020 and 2023, 33 IM residents and fellows completed training with participation in the Care Transformation program. PROGRAM DESCRIPTION: Department leadership developed a comprehensive educational and experiential program that included (1) Dell Medical School-wide Distinction in Care Transformation curriculum; (2) Primary Care Residency track with care transformation projects; (3) participation in the national Veterans Affairs Chief Resident in Quality and Safety program; and (4) Hospital Medicine Fellowship in Quality and Safety. PROGRAM EVALUATION: Each trainee led a care transformation project spanning a variety of topics and settings. Graduates who responded to a follow-up survey (22 of 33 graduates) reported they used skills learned through the program in their current roles and these experiences better prepared them for fellowship and/or faculty positions. DISCUSSION: The Care Transformation program provides real-world experiences and skillsets that are increasingly valuable in modern healthcare delivery.
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BACKGROUND: STARS (Students and Trainees Advocating for Resource Stewardship) is a medical student leadership program that promotes integration of resource stewardship (RS) into medical education in at least seven countries. Little is known about how participation affects student leaders. AIM: To understand how partaking in STARS impacted participants' knowledge, skills, and influenced career plans, and aspirations. SETTING AND PARTICIPANTS: We conducted qualitative semi-structured interviews with STARS participants (n = 27) from seven countries. PROGRAM DESCRIPTION: STARS was designed to facilitate grassroots efforts that embed RS principles into medical education. STARS programs globally share common features: participation from several medical schools, centralized organizing hubs and leadership summits, and support from faculty mentors. Students take lessons learnt from centralized programming to implement changes that advance RS initiatives at their schools. PROGRAM EVALUATION: Students finished STARS with better RS knowledge, enhanced change management skills (leadership, advocacy, collaboration), and a commitment to incorporate RS into future practice. Nearly all respondents hoped to pursue leadership activities in medicine, but most were unclear if they would focus efforts to advance RS. DISCUSSION: STARS participants gained knowledge as it relates to RS, change management skills, and catalyzed a commitment to incorporate high-value care into future practice. Medical education initiatives should be leveraged as a key strategic approach to build RS capacity.
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BACKGROUND: Because physician practices contribute to national healthcare expenditures, initiatives aimed at educating physicians about high-value cost-conscious care (HVCCC) are important. Prior studies suggest that the training environment influences physician attitudes and behaviors towards HVCCC. OBJECTIVE: To explore the relationship between medical student experiences and HVCCC attitudes. DESIGN: Quantitative and qualitative analysis of a multi-institutional survey. PARTICIPANTS: Medical students from nine US medical schools. APPROACH: A 44-item survey that included the Maastricht HVCCC Attitudes Questionnaire, a validated tool for assessing HVCCC attitudes, was administered electronically. Attitudinal domains of high-value care (HVC), cost incorporation (CI), and perceived drawbacks (PD) were compared using one-way ANOVA among students with a range of exposures. Open text responses inviting participants to reflect on their attitudes were analyzed using classical content analysis. KEY RESULTS: A total of 740 students completed the survey (response rate 15%). Students pursuing a "continuity-oriented" specialty held more favorable attitudes towards HVCCC than those pursuing "technique-oriented" specialties (HVC sub-score = 3.20 vs. 3.06; p = 0.005, CI sub-score = 2.83 vs. 2.74; p < 0.001). Qualitative analyses revealed personal, educational, and professional experiences shape students' HVCCC attitudes, with similar experiences interpreted differently leading to both more and less favorable attitudes. CONCLUSION: Students pursuing specialties with longitudinal patient contact may be more enthusiastic about practicing high-value care. Life experiences before and during medical school shape these attitudes, and complex interactions between these forces drive student perceptions of HVCCC.
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Clinical practice guidelines recommend screening for primary hyperaldosteronism (PH) in patients with resistant hypertension. However, screening rates are low in the outpatient setting. We sought to increase screening rates for PH in patients with resistant hypertension in our Veterans Affairs (VA) outpatient resident physician clinic, with the goal of improving blood pressure control. Patients with possible resistant hypertension were identified through a VA Primary Care Almanac Metric query, with subsequent chart review for resistant hypertension criteria. Three sequential patient-directed cycles were implemented using rapid cycle improvement methodology during a weekly dedicated resident quality improvement half-day. In the first cycle, patients with resistant hypertension had preclinic PH screening labs ordered and were scheduled in the clinic for hypertension follow-up. In the second cycle, patients without screening labs completed were called to confirm medication adherence and counselled to screen for PH. In the third cycle, patients with positive screening labs were called to discuss mineralocorticoid receptor antagonist (MRA) initiation and possible endocrinology referral. Of 97 patients initially identified, 58 (60%) were found to have resistant hypertension while 39 had pseudoresistant hypertension from medication non-adherence. Of the 58 with resistant hypertension, 44 had not previously been screened for PH while 14 (24%) had already been screened or were already taking an MRA. Our screening rate for PH in resistant hypertension patients increased from 24% at the start of the project to 84% (37/44) after two cycles. Of the 37 tested, 24% (9/37) screened positive for PH, and 5 patients were started on MRAs. This resident-led quality improvement project demonstrated that a focused intervention process can improve PH identification and treatment.
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Instituições de Assistência Ambulatorial , Hiperaldosteronismo , Hipertensão , Programas de Rastreamento , Melhoria de Qualidade , Humanos , Hiperaldosteronismo/complicações , Hiperaldosteronismo/diagnóstico , Hipertensão/tratamento farmacológico , Hipertensão/complicações , Hipertensão/diagnóstico , Programas de Rastreamento/métodos , Programas de Rastreamento/normas , Programas de Rastreamento/estatística & dados numéricos , Feminino , Masculino , Pessoa de Meia-Idade , Instituições de Assistência Ambulatorial/organização & administração , Instituições de Assistência Ambulatorial/estatística & dados numéricos , Idoso , Estados Unidos , Internato e Residência/métodos , Internato e Residência/estatística & dados numéricos , Internato e Residência/normas , United States Department of Veterans Affairs/organização & administração , United States Department of Veterans Affairs/estatística & dados numéricosRESUMO
This JAMA Network Insight demonstrates examples of how clinicians can implement stepwise changes to reduce unnecessary patient harms, using the 4 E's.
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Hospitais , Cuidados de Baixo Valor , HumanosRESUMO
BACKGROUND: Healthcare organizations measure costs for business operations but do not routinely incorporate costs in decision-making on the value of care. AIM: Provide guidance on how to use costs in value-based healthcare (VBHC) delivery at different levels of the healthcare system. SETTING AND PARTICIPANTS: Integrated practice units (IPUs) for diabetes mellitus (DM) and for acute myocardial infarction (AMI) at the Leiden University Medical Center and a collaboration of seven breast cancer IPUs of the Santeon group, all in the Netherlands. PROGRAM DESCRIPTION AND EVALUATION: VBHC aims to optimize care delivery to the patient by understanding how costs relate to outcomes. At the level of shared decision-making between patient and clinician, yearly check-up consultations for DM type I were analyzed for patient-relevant costs. In benchmarking among providers, quantities of cost drivers for breast cancer care were assessed in scorecards. In continuous learning, cost-effectiveness analysis was compared with radar chart analysis to assess the value of telemonitoring in outpatient follow-up. DISCUSSION: Costs vary among providers in healthcare, but also between provider and patient. The joint analysis of outcomes and costs using appropriate methods helps identify and optimize the aspects of care that drive desired outcomes and value.
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Neoplasias da Mama , Cuidados de Saúde Baseados em Valores , Humanos , Feminino , Atenção à Saúde , Benchmarking , Países BaixosRESUMO
This Brief Report includes follow-up data about the sustainability and expansion of the Buprenorphine Team (B-Team), a hospital-based opioid treatment (HBOT) program. Between September 2018 and January 2023, the B-Team started 398 patients with opioid-use disorder (OUD) on buprenorphine therapy and coordinated outpatient care for 353 patients before discharge. Two-hundred and forty-nine of these patients were scheduled for follow-up at our partner addiction treatment clinic. Retention rates at our partner clinic remain relatively high: 73 patients (36% of eligible patients) continued to attend appointments between 6 and 12 months, and 40 of 180 patients (22%) who have been discharged from the hospital for at least 1 year continued to attend appointments. This model has been adopted at three additional Texas hospitals, resulting in rapid growth: 1037 patients were started on buprenorphine across these four sites during 2021-2022. Our longitudinal results support HBOT as an effective model for treating patients with OUD.
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Buprenorfina , Transtornos Relacionados ao Uso de Opioides , Humanos , Analgésicos Opioides/uso terapêutico , Tratamento de Substituição de Opiáceos/métodos , Texas , Buprenorfina/uso terapêutico , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , HospitaisRESUMO
BACKGROUND: The COVID-19 pandemic has presented new challenges surrounding end-of-life planning and has been associated with increased online discussion about life support. RESEARCH QUESTION: How has online communication about advance care planning (ACP) and specific life-sustaining interventions (LSIs) changed during the pandemic? STUDY DESIGN AND METHODS: Conversations on Twitter containing references to LSIs (eg, "ECMO") or ACP (eg, "DNR/DNI") were collected between January 2019 and May 2021. User account metadata were used to predict user demographic information and to classify users as organizations, individuals, clinicians, or influencers. The number of impressions was compared across these user categories and the content of tweets analyzed by using natural language processing models to identify topics of discussion and associated emotional sentiment. RESULTS: There were 202,585 unique tweets about LSIs and 67,162 unique tweets about ACP. Users who were younger, male, or influencers were more likely to discuss LSIs online. Tweets about LSIs were associated with more positive emotional sentiment scores than tweets about ACP (LSIs, 0.3; ACP, -0.2; P < .001). Among tweets about ACP, most contained personal experiences related to the death of loved ones (27%) or discussed discrimination through do-not-resuscitate orders directed at the elderly and disabled (19%). Personal experiences had the greatest retweet-to-tweet-ratio (4.7), indicating high levels of user engagement. Tweets about discrimination contained the most negative net sentiment score (-0.5). INTERPRETATION: The observed increase in tweets regarding LSIs and ACP suggests that Twitter was consistently used to discuss treatment modalities and preferences related to intensive care during the pandemic. Future interventions to increase online engagement with ACP may consider leveraging influencers and personal stories. Finally, we identified do-not-resuscitate-related discrimination as a commonly held public fear, which should be further explored as a barrier to ACP completion and can be proactively addressed by clinicians during bedside goals-of-care discussions.