Today is July 1, a big day in academic medical centers where hundreds of eager interns begin their ‘real’ jobs as doctors. Well, not ‘real’, really! They need to complete their residencies before getting ‘real’ real jobs!!
I thought it is a perfect day to review a recent article in Journal of American Medical Association journal: Training Physicians to Provide High-Value, Cost-Conscious Care- a Systematic Review by Lorette A. Stammen, MD and team. (JAMA. 2015;314(22):2384-2400.) Eighteen percent of the US GDP is spent on health care and there is a critical need to bend the cost curve while improving healthcare outcomes. Value in Healthcare = (Quality + Outcomes)/ Costs.
This study systematically reviewed previously done studies on different training strategies for physicians in order to improve value and cost-consciousness. Of the initial 2650 articles, 79 studies were relevant to this systematic review and included educational interventions on physicians to improve value of care. Majority of the studies were before-after study design while 14 were randomized controlled trials. The recipients of interventions were practicing physicians, residents and/ or medical students. Majority of the studies intervened on drug prescribing practices while some targeted better utilization of tests or implementation of evidence-based guidelines to improve care.
When they analyzed the components of the educational intervention used in each study and collated them into themes, they identified three key interventions that led to successful learning as evidenced by improved outcomes and decreased costs: 1. Effective knowledge transfer on topics such as general health economics, prices of health services, scientific evidence on guidelines, and patient preferences; 2. Feedback and facilitated reflection on past and current prescribing practices; and 3. A supportive environment with role models who deliver high-value cost-conscious care and a culture that reinforces these values. For example, in one study, internal medicine physicians were given a pocket card with costs of laboratory testing and asked to write these costs on the order form while ordering tests. Teaching sessions highlighting specific scientific evidence, e.g., a session on antibiotic choice, dose, route, and duration, were found to be highly effective. Providing feedback and stimulating reflection was helpful in allowing the physicians gain insight into their performance, with a goal to influence future practice. Clinical role models were found to be immensely helpful, both for modeling best practices as well as to create a high-value cost-conscious culture.
The greatest usefulness of this study is that it clearly identifies which components of educational interventions were successful. As one might imagine, this information has great application in designing educational interventions for physicians to achieve the goals of high-value cost-conscious care. I am definitely going to apply this information in my next project. I did wonder if all three of these key interventions had a synergistic effect in a healthcare system. I imagine they might.