Factors Associated with Medical Students' Attitudes About Cost-Conscious Care: A Mixed-Methods Multi-school Study.

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.

Appropriateness of exercise therapy delivery in chronic low back pain management: cross-sectional online survey of physiotherapy practice in Germany.

BACKGROUND: In Germany, exercise therapy represents the most commonly prescribed physiotherapy service for non-specific, chronic low back pain (NSCLBP). So far, little is known about current practice patterns of German physiotherapists in delivering this intervention. Thus, the aim of this study was to investigate the appropriateness of exercise therapy delivered to NSCLBP patients in German physiotherapy care and to identify practitioner-related drivers of appropriate exercise delivery. METHODS: We used a vignette-based, exploratory, cross-sectional, online-survey study design (76-items; data collection between May and July 2023). Eligible participants were required to hold a professional degree in physiotherapy and were required to be practicing in Germany. Access links to anonymous online surveys were spread via established German physiotherapy networks, educational platforms, social media, e-mail lists, and snowball sampling. Appropriateness of exercise therapy was calculated by an equally weighted total score (400 points) including scales on shared-decision-making, exercise dose selection, pain knowledge and self-management promotion. "Appropriate exercise delivery" was determined by a relative total score achievement of > 80%. "Partly appropriate exercise delivery" was determined by a relative total score achievement of 50-79%, and "inappropriate exercise delivery" by a score achievement of < 50%. Practitioner-related drivers of exercise appropriateness were calculated by bivariate and multiple linear regression analyses. RESULTS: 11.9% (N = 35) of 298 physiotherapists' exercise delivery was considered "appropriate", 83.3% (N = 245) was "partly appropriate", and 4.8% (N = 14) was "inappropriate". In the final multiple regression model, most robust parameters positively influencing appropriate delivery of exercise therapy were increased scientific literacy (B = 10.540; 95% CI [0.837; 20.243]), increased average clinical assessment time (B = 0.461; 95% CI [0.134; 0.789]), increased self-perceived treatment competence (B = 7.180; 95% CI [3.058; 11.302], and short work experience (B = - 0.520; 95% CI [-0.959; - 0.081]). CONCLUSION: Appropriate exercise delivery in NSCLBP management was achieved by only 11.9% of respondents. However, the vast majority of 95.2% of respondents was classified to deliver exercise therapy partly appropriate. Long work experience seemed to negatively affect appropriate exercise delivery. Positive influences were attributed to scientific literacy, the average clinical assessment time per patient as well as the perceived treatment competence in NSCLBP management. REGISTRATION: Open science framework: https://doi.org/10.17605/OSF.IO/S76MF .

Functional somatic symptoms in Emergency Department frequent presenters.

BACKGROUND: Patients with Functional Somatic Symptoms (FSS) are frequently encountered within healthcare settings such as Emergency Departments (ED). There is limited research regarding characterisation and frequency of FSS within frequent presenters to ED and no previous Australian evidence. This study aims to fill this gap. METHODS: A retrospective, single-centre study of frequent ED presenters over a 6-month period was undertaken. Patients with > 3 re-presentations/month were reviewed for the presence of FSS using Stephenson and Price's (Stephenson DT, Price JR. Medically unexplained physical symptoms in emergency medicine. Emerg Med J. 2006;23(8):595.) categorisation of FSS. Patients were divided into three groups - FSS, possible FSS (pos-FSS) and non-FSS. The characteristics of these groups were compared using descriptive statistics (chi-square tests, Welch's ANOVA). Person-time at risk during the 6-month study period was estimated for patients in each group and incidence of ED presentation for each group was then calculated. Psychological distress indicators for ED presenters with FSS, as noted by the treating clinician, were also analysed. RESULTS: 11% (71/638) of frequent ED presenters were categorised as having FSS and 72% (458/638) as having possible FSS (Pos-FSS). Mean ED presentations in the FSS group during the study period were significantly higher than in the non-FSS and Pos-FSS groups (p < 0.01). Anxiety was found to be the primary psychological distress indicator associated with ED presentations with FSS. CONCLUSION: We found that, amongst frequent ED presenters, patients with FSS presented significantly more frequently to ED than those without FSS. We propose revising the model of care for FSS in ED to promote appropriate referral to therapy services as a possible demand reduction strategy to improve patient care and efficiency in ED.

Residents' Reflections on Cost-Conscious Care after International Health Electives: A Single-Center Qualitative Study.

BACKGROUND: Estimates suggest 30% of health care expenditures are wasteful. This has led to increased educational interventions in graduate medical education (GME) training aimed to prepare residents for high value, cost-conscious practice. International health electives (IHE) are widely available in GME training and may be provide trainees a unique perspective on principles related to high value, cost-conscious care (HVCCC). OBJECTIVE: The purpose of this study was to explore how trainee reflections on IHE experiences offer insight into HVCCC. DESIGN: The authors conducted an applied thematic analysis of narrative reflective reports of GME trainees' IHE experiences to characterize their perceptions of HVCCC. PARTICIPANTS: The Mayo International Health Program (MIHP) supports residents and fellows from all specialties across all Mayo Clinic sites. We included 546 MIHP participants from 2001 to 2020. APPROACH: The authors collected post-elective narrative reports from all MIHP participants. Reflections were coded and themes were organized into model for transformative learning during IHEs, focusing on HVCCC. KEY RESULTS: GME trainees across 24 different medical specialties participated in IHEs in 73 different countries. Three components of transformative learning were identified: disorienting dilemma, critical reflection, and commitment to behavior change. Within the component of critical reflection, three topics related to HVCCC were identified: cost transparency, resource stewardship, and reduced fear of litigation. Transformation was demonstrated through reflection on future behavioral change, including cost-aware practice, stepwise approach to health care, and greater reliance on clinical skills. CONCLUSIONS: IHEs provide rich experiences for transformative learning and reflection on HVCCC. These experiences may help shape trainees' ideology of and commitment to HVCCC practices.

Student High Value Care Initiative: a Longitudinal Model for Student-Led Implementation and Scholarship.

BACKGROUND: Educating medical trainees to practice high value care is a critical component to improving quality of care and should be introduced at the beginning of medical education. AIM: To create a successful educational model that provides medical students and junior faculty with experiential learning in quality improvement and mentorship opportunities, and produce effective quality initiatives. SETTING: A tertiary medical center affiliated with a medical school in New York City. PARTICIPANTS: First year medical students, junior faculty in hospital medicine, and a senior faculty course director. PROGRAM DESCRIPTION: The Student High Value Care initiative is a longitudinal initiative comprised of six core elements: (1) project development, (2) value improvement curriculum, (3) mentorship, (4), Institutional support, (5) scholarship, and (6) student leadership. PROGRAM EVALUATION: During the first 3 years, 68 medical students and ten junior faculty participated in 10 quality improvement projects. Nine projects were successful in their measured outcomes, with statistically significant improvements. Nine had an abstract accepted to a regional or national meeting, and seven produced publications in peer-reviewed literature. DISCUSSION: In the first 3 years of the initiative, we successfully engaged medical students and junior faculty to create and support the implementation of successful quality improvement initiatives. Since that time, the program continues to offer meaningful mentorship and scholarship opportunities.

Predictors of patient satisfaction with Mohs micrographic surgery at time of surgery and 3 months postsurgery: A prospective cohort study.

BACKGROUND: Despite the importance of patient satisfaction in ensuring high-quality care, studies investigating patient satisfaction in Mohs micrographic surgery (MMS) are limited. OBJECTIVE: We investigated the factors associated with patient satisfaction in MMS for nonmelanoma skin cancer and how patient satisfaction changes in the postoperative period. METHODS: In this prospective cohort study including 100 patients, patient satisfaction surveys were administered at the time of surgery and at 3 months postsurgery. Sociodemographic characteristics, medical history, and surgical parameters were collected by chart review. Univariate linear and logistic regression models were created to examine these relationships. RESULTS: Decreased satisfaction was observed in patients requiring 3 or more MMS stages both at the time of surgery (P = .047) and at 3 months post-surgery (P = .0244). Patients with morning procedures ending after 1:00 pm had decreased satisfaction at the time of surgery (P = .019). A decrease in patient satisfaction between the time of surgery and 3 months postsurgery was observed in patients with surgical sites on the extremities (P = .036), larger preoperative lesion sizes (P = .012), and larger defect sizes (P = .033). LIMITATIONS: Single-institution data, self-selection bias, and recall bias. CONCLUSION: Patient satisfaction with MMS is impacted by numerous factors and remains dynamic over time.

Estimated cost-savings from optimizing use of inhaled medications for inpatients with obstructive lung disease.

CONCLUSIONS: Models representing transitions from all-nebulized to nebulizer-plus-MDI respiratory medications resulted in cost savings, largely from the reduction of labor cost of nebulizer administration with nebs-only treatment. Therefore, transitioning from nebs to MDIs can lead to cost savings and could allow greater opportunities for inhaler education.

Use of high- and low-value care among US adults by education levels.

BACKGROUND: Healthcare reform in the United States has focused on improving the value of health care, but there are some concerns about the inequitable delivery of value-based care. OBJECTIVE: We examine whether the receipt of high- and low-value care differs by education levels. METHODS: We employed a repeated cross-sectional study design using data from the 2010-2019 Medical Expenditure Panel Survey. Our outcomes included 8 high-value services across 3 categories and 9 low-value services across 3 categories. Our primary independent variable was education level: (i) no degree, (ii) high school diploma, and (iii) college graduate. We conducted a linear probability model while adjusting for individual-level characteristics and estimated the adjusted values of the outcomes for each education group. RESULTS: In almost all services, the use of high-value care was greater among more educated adults than less educated adults. Compared to those with no degree, those with a college degree were significantly more likely to receive all high-value services except for HbA1c measurement, ranging from blood pressure measurement (4.5 percentage points [95% CI: 3.9-5.1]) to colorectal cancer screening (15.6 percentage points [95% CI: 13.9-17.3]). However, there were no consistent patterns of the use of low-value care by education levels. CONCLUSION: Our findings suggest that more educated adults were more likely to receive high-value cancer screening, high-value diagnostic and preventive testing, and high-value diabetes care than less educated adults. These findings highlight the importance of implementing tailored policies to address education-based inequities in the delivery of high-value services in the United States.

The Use and Downstream Associations of Magnetic Resonance Imaging for Lateral Epicondylitis.

PURPOSE: Low-value imaging is associated with wasteful health care spending and patient harm. The routine use of magnetic resonance imaging (MRI) for the work-up of lateral epicondylitis is an example of low-value imaging. As such, our aim was to investigate the use of MRIs ordered for lateral epicondylitis, the characteristics of those undergoing an MRI, and the downstream associations of MRI with other care. METHODS: We identified patients aged ≥18 years with a diagnosis of lateral epicondylitis between 2010 and 2019 using a Humana claims database. We identified patients with a Current Procedural Terminology code corresponding to an elbow MRI. We analyzed the use and downstream treatment cascades in those undergoing MRI. Multivariable logistic regression models were used to assess the odds of undergoing an MRI, adjusting for age, sex, insurance type, and comorbidity index. Separate multivariable logistic regression analyses were used to determine the association between undergoing an MRI and the incidence of secondary outcomes (eg, receiving surgery). RESULTS: A total of 624,102 patients met the inclusion criteria. Of 8,209 (1.3%) patients undergoing MRI, 3,584 (44%) underwent it within 90 days after diagnosis. There was notable regional variation in MRI use. The MRIs were ordered most frequently by primary care specialties and for younger, female, commercially insured, and patients with more comorbidities. Performance of an MRI was associated with an increase in downstream treatments, including surgery (odds ratio [OR], 9.58 [9.12-10.07]), injection (OR, 2.90 [2.77-3.04]), therapy (OR, 1.81 [1.72-1.91]), and cost ($134 per patient). CONCLUSIONS: Although there is variation in the use of MRI for lateral epicondylitis and its use is associated with downstream effects, the routine use of MRI for the diagnosis of lateral epicondylitis is low. CLINICAL RELEVANCE: The routine use of MRI for lateral epicondylitis is low. Understanding interventions to minimize such low-value care in lateral epicondylitis can be used to inform improvement efforts to minimize low-value care for other conditions.

Implementation of an educational intervention to improve medical student cost awareness: a prospective cohort study.

BACKGROUND: In the context of rising healthcare costs, formal education on treatment-related financial hardship is lacking in many medical schools, leaving future physicians undereducated and unprepared to engage in high-value care. METHOD: We performed a prospective cohort study to characterize medical student knowledge regarding treatment-related financial hardship from 2019 to 2020 and 2020-2021, with the latter cohort receiving a targeted educational intervention to increase cost awareness. Using Kirkpatrick's four-level training evaluation model, survey data was analyzed to characterize the acceptability of the intervention and the impact of the intervention on student knowledge, attitudes, and self-reported preparedness to engage in cost-conscious care. RESULTS: Overall, N = 142 medical students completed the study survey; 61 (47.3%) in the non-intervention arm and 81 (66.4%) in the intervention arm. Of the 81 who completed the baseline survey in the intervention arm, 65 (80.2%) completed the immediate post-intervention survey and 39 (48.1%) completed the two-month post-intervention survey. Following the educational intervention, students reported a significantly increased understanding of common financial terms, access to cost-related resources, and level of comfort and preparedness in engaging in discussions around cost compared to their pre-intervention responses. The majority of participants (97.4%) reported that they would recommend the intervention to future students. A greater proportion of financially stressed students reported considering patient costs when making treatment decisions compared to their non-financially stressed peers. CONCLUSIONS: Targeted educational interventions to increase cost awareness have the potential to improve both medical student knowledge and preparedness to engage in cost-conscious care. Student financial stress may impact high-value care practices. Robust curricula on high-value care, including treatment-related financial hardship, should be formalized and universal within medical school training.

Prior Authorization in Total Joint Arthroplasty: A Survey of the American Association of Hip and Knee Surgeons Membership.

BACKGROUND: This study surveyed the impact that prior authorization has on the practices of total joint arthroplasty (TJA) members of the American Association of Hip and Knee Surgeons (AAHKS). METHODS: A 24-question survey was approved by the AAHKS Advocacy Committee and distributed to all 2,802 board-certified members of AAHKS. RESULTS: There were 353 survey responses (13%). Ninety-five percent of surgeons noted a 5-year increase in prior authorization. A majority (71%) of practices employ at least 1 staff member to exclusively work on prior authorization. Average time spent on prior authorization was 15 h/wk (range, 1 to 125) and average number of claims peer week was 18 (range, 1 to 250). Surgeries (99%) were the most common denial. These were denied because nonoperative treatment had not been tried (71%) or had not been attempted for enough time (67%). Most (57%) prior authorization processes rarely/never changed the treatment provided. Most (56%) indicated that prior authorization rarely/never followed evidence-based guidelines. A majority (93%) expressed high administrative burden as well as negative clinical outcomes (87%) due to prior authorization including delays to access care (96%) at least sometimes. DISCUSSION: Prior authorization has increased in the past 5 years resulting in high administrative burden. Prior authorizations were most common for TJA surgeries because certain nonoperative treatments were not attempted or not attempted for enough time. Surgeons indicated that prior authorization may be detrimental to high-value care and lead to potentially harmful delays in care without ultimately changing the management of the patient.

Skilled Nursing Facility Following Hip Fracture Arthroplasty Diminishes Care "Value".

BACKGROUND: Value is defined as outcome/cost. The purpose of this study was to analyze differences in the lengths of care, outcomes, and costs between skilled nursing facilities (SNFs) and home with health services (HHS) for patients treated with arthroplasty for femoral neck fracture (FNF). METHODS: Between October 2018 and September 2020, 192 patients eligible for the Comprehensive Care for Joint Replacement bundle program treated for a displaced FNF with total hip arthroplasty (THA) or hemiarthroplasty (HA) and discharged to SNF or HHS were analyzed for demographics, comorbidities, postoperative outcomes, costs of care, and discharge rehabilitation details. Variables were compared using chi-squared or t-tests as appropriate. There were 60 (31%) patients discharged to HHS (37% THA and 63% HA) and 132 (69%) patients discharged to SNF (14% THA and 86% HA). Patients discharged to SNF were older (P < .01), had lower Risk Assessment and Prediction Tool scores (P < .01), had higher comorbidity scores (P = .011), and had longer posthospitalization care (P < .01). RESULTS: There were no differences in rates of inpatient minor complications (P = .520), inpatient major complications (P = .119), Intensive Care Unit admissions (P = .193), or readmissions within 30 (P = .690) and 90 days (P = .176). Costs of care at a SNF were higher than HHS (P < .01). In multivariate regressions, a lower Risk Assessment and Prediction Tool score was associated with discharge to SNF (odds ratio 0.69, 95% confidence interval 0.58-0.83, P < .001). CONCLUSION: Among Comprehensive Care for Joint Replacement bundle patients treated for a displaced FNF with arthroplasty, discharge with HHS may be a more cost-effective option than discharge to a SNF that does not increase risk of readmission in medically appropriate patients.

AGA Technical Review on the Medical Management of Moderate to Severe Luminal and Perianal Fistulizing Crohn's Disease.

The incidence and prevalence of Crohn's disease (CD) is rising globally. Patients with moderate to severe CD are at high risk for needing surgery and hospitalization and for developing disease-related complications, corticosteroid dependence, and serious infections. Optimal management of outpatients with moderate to severe luminal and/or fistulizing (including perianal) CD often requires the use of immunomodulator (thiopurines, methotrexate) and/or biologic therapies, including tumor necrosis factor-α antagonists, vedolizumab, or ustekinumab, either as monotherapy or in combination (with immunomodulators) to mitigate these risks. Decisions about optimal drug therapy in moderate to severe CD are complex, with limited guidance on comparative efficacy and safety of different treatments, leading to considerable practice variability. Since the last iteration of these guidelines published in 2013, significant advances have been made in the field, including the regulatory approval of 2 new biologic agents, vedolizumab and ustekinumab. Therefore, the American Gastroenterological Association prioritized updating clinical guidelines on this topic. To inform the clinical guidelines, this technical review was completed in accordance with the GRADE (Grading of Recommendations Assessment, Development and Evaluation) framework. The review addressed the following focused questions (in adult outpatients with moderate to severe luminal CD): overall and comparative efficacy of different medications for induction and maintenance of remission in patients with or without prior exposure to tumor necrosis factor-α antagonists, comparative efficacy and safety of biologic monotherapy vs combination therapy with immunomodulators, comparative efficacy of a top-down (upfront use of biologics and/or immunomodulator therapy) vs step-up treatment strategy (acceleration to biologic and/or immunomodulator therapy only after failure of mesalamine), and the role of corticosteroids and mesalamine for induction and/or maintenance of remission. Finally, in adult outpatients with moderate to severe fistulizing CD, this review addressed the efficacy of pharmacologic interventions for achieving fistula and the role of adjunctive antibiotics without clear evidence of active infection.

The Association of the First Surge of the COVID-19 Pandemic with the High- and Low-Value Outpatient Care Delivered to Adults in the USA.

BACKGROUND: The first surge of the COVID-19 pandemic entirely altered healthcare delivery. Whether this also altered the receipt of high- and low-value care is unknown. OBJECTIVE: To test the association between the April through June 2020 surge of COVID-19 and various high- and low-value care measures to determine how the delivery of care changed. DESIGN: Difference in differences analysis, examining the difference in quality measures between the April through June 2020 surge quarter and the January through March 2020 quarter with the same 2 quarters' difference the year prior. PARTICIPANTS: Adults in the MarketScan® Commercial Database and Medicare Supplemental Database. MAIN MEASURES: Fifteen low-value and 16 high-value quality measures aggregated into 8 clinical quality composites (4 of these low-value). KEY RESULTS: We analyzed 9,352,569 adults. Mean age was 44 years (SD, 15.03), 52% were female, and 75% were employed. Receipt of nearly every type of low-value care decreased during the surge. For example, low-value cancer screening decreased 0.86% (95% CI, -1.03 to -0.69). Use of opioid medications for back and neck pain (DiD +0.94 [95% CI, +0.82 to +1.07]) and use of opioid medications for headache (DiD +0.38 [95% CI, 0.07 to 0.69]) were the only two measures to increase. Nearly all high-value care measures also decreased. For example, high-value diabetes care decreased 9.75% (95% CI, -10.79 to -8.71). CONCLUSIONS: The first COVID-19 surge was associated with receipt of less low-value care and substantially less high-value care for most measures, with the notable exception of increases in low-value opioid use.

No Time to Waste: An Appraisal of Value at the End of Life.

OBJECTIVES: The use of economic evaluations of end-of-life interventions may be limited by an incomplete appreciation of how patients and society perceive value at end of life. The objective of this study was to evaluate how patients, caregivers, and society value gains in quantity of life and quality of life (QOL) at the end of life. The validity of the assumptions underlying the use of the quality-adjusted life-years (QALY) as a measure of preferences at end of life was also examined. METHODS: MEDLINE, Embase, CINAHL, PsycINFO, and PubMed were searched from inception to February 22, 2021. Original research studies reporting empirical data on healthcare priority setting at end of life were included. There was no restriction on the use of either quantitative or qualitative methods. Two reviewers independently screened, selected, and extracted data from studies. Narrative synthesis was conducted for all included studies. The primary outcomes were the value of gains in quantity of life and the value of gains in QOL at end of life. RESULTS: A total of 51 studies involving 53 981 participants reported that gains in QOL were generally preferred over quantity of life at the end of life across stakeholder groups. Several violations of the underlying assumptions of the QALY to measure preferences at the end of life were observed. CONCLUSIONS: Most patients, caregivers, and members of the general public prioritize gains in QOL over marginal gains in life prolongation at the end of life. These findings suggest that policy evaluations of end-of-life interventions should favor those that improve QOL. QALYs may be an inadequate measure of preferences for end-of-life care thereby limiting their use in formal economic evaluations of end-of-life interventions.

An Analysis of 5 Years of Randomized Trials in Gastroenterology and Hepatology Reveals 52 Medical Reversals.

BACKGROUND AND AIMS: One manifestation of low-value medical practice is the medical reversal, a practice in widespread use that, once subjected to a randomized controlled trial (RCT), is found to be no better-or worse-than a prior established standard of care. We aimed to determine the prevalence of medical reversals in gastroenterology (GI) journals and characterize these reversals. METHODS: We searched the American Journal of Gastroenterology, Clinical Gastroenterology and Hepatology, Gastroenterology, Gut, Hepatology, and the Journal of Hepatology, reviewing studies published in 2015-2019. We identified RCTs that tested an established clinical practice and produced negative results, considered tentative reversals. Any systematic review or meta-analysis that included the article was categorized as confirming the reversal, refuting the reversal, or providing insufficient data. RESULTS: During the 5-year period, we identified 5,898 original articles, of which 212 tested an established practice and 52 were categorized as unrefuted medical reversals (25% of articles testing standard of care). Of the reversals, 21 (40%) tested procedures and devices, 15 (29%) tested medications, and 8 (15%) tested vitamins/supplements/diet. Twenty-three (44%) considered the alimentary tract, 12 (23%) considered the liver, pancreas, or biliary tract, and 17 (33%) considered endoscopy. Thirty-eight (73%) were funded exclusively by non-industry sources. CONCLUSION: This review reveals a total of 52 reversals across all subfields of GI and medical, procedural, screening, and diagnostic interventions, occurring in 25% of randomized trials testing an established practice. More research is needed to determine the optimal way to engage stakeholders and remove reversed practices from medical care.

Doctors as Resource Stewards? Translating High-Value, Cost-Conscious Care to the Consulting Room.

After many policy attempts to tackle the persistent rise in the costs of health care, physicians are increasingly seen as potentially effective resource stewards. Frameworks including the quadruple aim, value-based health care and choosing wisely underline the importance of positive engagement of the health care workforce in reinventing the system-paving the way to real affordability by defining the right care. Current programmes focus on educating future doctors to provide 'high-value, cost-conscious care' (HVCCC), which proponents believe is the future of sustainable medical practice. Such programmes, which aim to extend population-level allocation concerns to interactions between an individual doctor and patient, have generated lively debates about the ethics of expanding doctors' professional accountability. To empirically ground this discussion, we conducted a qualitative interview study to examine what happens when resource stewardship responsibilities are extended to the consulting room. Attempts to deliver HVCCC were found to involve inevitable trade-offs between benefits to the individual patient and (social) costs, medical uncertainty and efficiency, and between resource stewardship and trust. Physicians reconcile this by justifying good-value care in terms of what is in the best interest of individual patients-redefining the currency of value from monetary costs to a patient's quality of life, and cost-conscious care as reflective medical practice. Micro-level resource stewardship thus becomes a matter of working reflexively and reducing wasteful forms of care, rather than of making difficult choices about resource allocation.

Frequency and yield of blood cultures for observation patients with skin and soft tissue infections.

OBJECTIVES: 1) To measure frequency and yield of blood cultures obtained for observation status adult patients with skin and soft tissue infection (SSTI), 2) describe how often blood cultures were performed according to Infectious Diseases Society of America (IDSA) SSTI guideline indications, 3) identify proportion of patients meeting Center for Medicare Services (CMS) sepsis criteria. DESIGN: Retrospective cohort. SETTING: Tertiary academic center. PATIENTS: Consecutive adult observation status patients hospitalized with SSTI between July 2017 and July 2018. METHODS: We measured the proportion and results of blood cultures obtained among the study cohort and proportion of obtained cultures that satisfied IDSA indications. RESULTS: We identified 132 observation status patients with SSTI during the study period; 67 (50.8%) had blood cultures drawn. Only 14 (10.6%) patients met IDSA indications for culture; 51 (38.%) met Center for Medicare Services definition for sepsis. We identified two (3.0%) cases of bacteremia and two (3.0%) cases of skin bacteria contamination. In multivariable analysis, only temperature > 38 °C (OR 3.84, 95%CI 1.09-13.60) and white race (OR 2.71, 95%CI 1.21-6.20) were associated with blood culture obtainment; neither meeting IDSA SSTI guideline indications nor meeting CMS sepsis criteria was associated with culture. CONCLUSIONS: Among observation status patients with SSTI, over half had blood cultures drawn, though 10% satisfied guideline indications for culture. The proportion of cultures with bacterial growth was low and yielded as many skin contaminants as cases of bacteremia. Our study highlights the need for further quality improvement efforts to reduce unnecessary blood cultures in routine SSTI cases.

A stepped-wedge randomised controlled trial assessing the implementation, effectiveness and cost-consequences of the EDDIE+ hospital avoidance program in 12 residential aged care homes: study protocol.

BACKGROUND: Older people living in residential aged care homes experience frequent emergency transfers to hospital. These events are associated with risks of hospital acquired complications and invasive treatments or interventions. Evidence suggests that some hospital transfers may be unnecessary or avoidable. The Early Detection of Deterioration in Elderly residents (EDDIE) program is a multi-component intervention aimed at reducing unnecessary hospital admissions from residential aged care homes by empowering nursing and care staff to detect and manage early signs of resident deterioration. This study aims to implement and evaluate the program in a multi-site randomised study in Queensland, Australia. METHODS: A stepped-wedge randomised controlled trial will be conducted at 12 residential aged care homes over 58 weeks. The program has four components: education and training, decision support tools, diagnostic equipment, and implementation facilitation with clinical systems support. The integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework will be used to guide the program implementation and process evaluation. The primary outcome measure will be the number of hospital bed days used by residents, with secondary outcomes assessing emergency department transfer rates, admission rates, length of stay, family awareness and experience, staff self-efficacy and costs of both implementation and health service use. A process evaluation will assess the extent and fidelity of program implementation, mechanisms of impact and the contextual barriers and enablers. DISCUSSION: The intervention is expected to improve outcomes by reducing unnecessary hospital transfers. Fewer hospital transfers and admissions will release resources for other patients with potentially greater needs. Residential aged care home staff might benefit from feelings of empowerment in their ability to proactively manage early signs of resident deterioration. The process evaluation will be useful for supporting wider implementation of this intervention and other similar initiatives. TRIAL REGISTRATION: The trial is prospectively registered with the Australia New Zealand Clinical Trial Registry ( ACTRN12620000507987 , registered 23/04/2020).

Defining value in health care: a scoping review of the literature.

BACKGROUND: As health-care spending rises internationally, policymakers have increasingly begun to look to improve health-care value. However, the precise definition of health-care value remains ambiguous. METHODS: We conducted a scoping review of the literature to understand how value has been defined in the context of health care. We searched PubMed, Embase, Google Scholar, PolicyFile and Scopus between February and March 2020 to identify articles eligible for inclusion. Publications that defined value (including high or low value) using an element of cost and an element of outcomes were included in this review. No restrictions were placed on the date of publication. Articles were limited to those published in English. RESULTS: Out of 1750 publications screened, 46 met inclusion criteria. Among the 46 included articles, 22 focused on overall value, 19 on low value and 5 on high value. We developed a framework to categorize definitions based on three core domains: components, perspective and scope. Differences across these three domains contributed to significant variations in definitions of value. CONCLUSIONS: How value is defined has the potential to influence measurement and intervention strategies in meaningful ways. To effectively improve value in health-care systems, we must understand what is meant by value and the merits of different definitions.