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A practical framework for understanding and reducing medical overuse: Conceptualizing overuse through the patient-clinician interaction
Medical services overuse is the provision of healthcare services for which there is no medical basis or for which harms equal or exceed benefits.1 This overuse drives poor-quality care and unnecessary cost.2,3 The high prevalence of overuse is recognized by patients,4 clinicians,5 and policymakers.6 Initiatives to reduce overuse have targeted physicians,7 the public,8 and medical educators9,10 but have had limited impact.11,12 Few studies have addressed methods for reducing overuse, and de-implementation of nonbeneficial practices has proved challenging.1,13,14 Models for reducing overuse are only theoretical15 or are focused on administrative decisions.16,17 We think a practical framework is needed. We used an iterative process, informed by expert opinion and discussion, to design such a framework.
METHODS
The authors, who have expertise in overuse, value, medical education, evidence-based medicine, and implementation science, reviewed related conceptual frameworks18 and evidence regarding drivers of overuse. We organized these drivers into domains to create a draft framework, which we presented at Preventing Overdiagnosis 2015, a meeting of clinicians, patients, and policymakers interested in overuse. We incorporated feedback from meeting attendees to modify framework domains, and we performed structured searches (using key words in Pubmed) to explore, and estimate the strength of, evidence supporting items within each domain. We rated supporting evidence as strong (studies found a clear correlation between a factor and overuse), moderate (evidence suggests such a correlation or demonstrates a correlation between a particular factor and utilization but not overuse per se), weak (only indirect evidence exists), or absent (no studies identified evaluating a particular factor). All authors reached consensus on ratings.
Framework Principles and Evidence
Patient-centered definition of overuse. During framework development, defining clinical appropriateness emerged as the primary challenge to identifying and reducing overuse. Although some care generally is appropriate based on strong evidence of benefit, and some is inappropriate given a clear lack of benefit or harm, much care is of unclear or variable benefit. Practice guidelines can help identify overuse, but their utility may be limited by lack of evidence in specific clinical situations,19 and their recommendations may apply poorly to an individual patient. This presents challenges to using guidelines to identify and reduce overuse.
Despite limitations, the scope of overuse has been estimated by applying broad, often guideline-based, criteria for care appropriateness to administrative data.20 Unfortunately, these estimates provide little direction to clinicians and patients partnering to make usage decisions. During framework development, we identified the importance of a patient-level, patient-specific definition of overuse. This approach reinforces the importance of meeting patient needs while standardizing treatments to reduce overuse. A patient-centered approach may also assist professional societies and advocacy groups in developing actionable campaigns and may uncover evidence gaps.
Centrality of patient-clinician interaction. During framework development, the patient–clinician interaction emerged as the nexus through which drivers of overuse exert influence. The centrality of this interaction has been demonstrated in studies of the relationship between care continuity and overuse21 or utilization,22,23 by evidence that communication and patient–clinician relationships affect utilization,24 and by the observation that clinician training in shared decision-making reduces overuse.25 A patient-centered framework assumes that, at least in the weighing of clinically reasonable options, a patient-centered approach optimizes outcomes for that patient.
Incorporating drivers of overuse. We incorporated drivers of overuse into domains and related them to the patient–clinician interaction.26 Domains included the culture of healthcare consumption, patient factors and experiences, the practice environment, the culture of professional medicine, and clinician attitudes and beliefs.
We characterized the evidence illustrating how drivers within each domain influence healthcare use. The evidence for each domain is listed in Table 1.
RESULTS
The final framework is shown in the Figure. Within the healthcare system, patients are influenced by the culture of healthcare consumption, which varies within and among countries.27 Clinicians are influenced by the culture of medical care, which varies by practice setting,28 and by their training environment.29 Both clinicians and patients are influenced by the practice environment and by personal experiences. Ultimately, clinical decisions occur within the specific patient–clinician interaction.24 Table 1 lists each domain’s components, likely impact on overuse, and estimated strength of supporting evidence. Interventions can be conceptualized within appropriate domains or through the interaction between patient and clinician.
DISCUSSION
We developed a novel and practical conceptual framework for characterizing drivers of overuse and potential intervention points. To our knowledge, this is the first framework incorporating a patient-specific approach to overuse and emphasizing the patient–clinician interaction. Key strengths of framework development are inclusion of a range of perspectives and characterization of the evidence within each domain. Limitations include lack of a formal systematic review and broad, qualitative assessments of evidence strength. However, we believe this framework provides an important conceptual foundation for the study of overuse and interventions to reduce overuse.
Framework Applications
This framework, which highlights the many drivers of overuse, can facilitate understanding of overuse and help conceptualize change, prioritize research goals, and inform specific interventions. For policymakers, the framework can inform efforts to reduce overuse by emphasizing the need for complex interventions and by clarifying the likely impact of interventions targeting specific domains. Similarly, for clinicians and quality improvement professionals, the framework can ground root cause analyses of overuse-related problems and inform allocation of limited resources. Finally, the relatively weak evidence on the role of most acknowledged drivers of overuse suggests an important research agenda. Specifically, several pressing needs have been identified: defining relevant physician and patient cultural factors, investigating interventions to impact culture, defining practice environment features that optimize care appropriateness, and describing specific patient–clinician interaction practices that minimize overuse while providing needed care.
Targeting Interventions
Domains within the framework are influenced by different types of interventions, and different stakeholders may target different domains. For example:
- The culture of healthcare consumption may be influenced through public education (eg, Choosing Wisely® patient resources)30-32 and public health campaigns.
- The practice environment may be influenced by initiatives to align clinician incentives,33 team care,34 electronic health record interventions,35 and improved access.36
- Clinician attitudes and beliefs may be influenced by audit and feedback,37-40 reflection,41 role modeling,42 and education.43-45
- Patient attitudes and beliefs may be influenced by education, access to price and quality information, and increased engagement in care.46,47
- For clinicians, the patient–clinician interaction can be improved through training in communication and shared decision-making,25 through access to information (eg, costs) that can be easily shared with patients,48,49 and through novel visit structures (eg, scribes).50
- On the patient side, this interaction can be optimized with improved access (eg, through telemedicine)51,52 or with patient empowerment during hospitalization.
- The culture of medicine is difficult to influence. Change likely will occur through:
○ Regulatory interventions (eg, Transforming Clinical Practice Initiative of Center for Medicare & Medicaid Innovation).
○ Educational initiatives (eg, high-value care curricula of Alliance for Academic Internal Medicine/American College of Physicians53).
○ Medical journal features (eg, “Less Is More” in JAMA Internal Medicine54 and “Things We Do for No Reason” in Journal of Hospital Medicine).
○ Professional organizations (eg, Choosing Wisely®).
As organizations implement quality improvement initiatives to reduce overuse of services, the framework can be used to target interventions to relevant domains. For example, a hospital leader who wants to reduce opioid prescribing may use the framework to identify the factors that encourage prescribing in each domain—poor understanding of pain treatment (a clinician factor), desire for early discharge encouraging overly aggressive pain management (an environmental factor), patient demand for opioids combined with poor understanding of harms (patient factors), and poor communication regarding pain (a patient–clinician interaction factor). Although not all relevant factors can be addressed, their classification by domain facilitates intervention, in this case perhaps leading to a focus on clinician and patient education on opioids and development of a practical communication tool that targets 3 domains. Table 2 lists ways in which the framework informs approaches to this and other overused services in the hospital setting. Note that some drivers can be acknowledged without identifying targeted interventions.
Moving Forward
Through a multi-stakeholder iterative process, we developed a practical framework for understanding medical overuse and interventions to reduce it. Centered on the patient–clinician interaction, this framework explains overuse as the product of medical and patient culture, the practice environment and incentives, and other clinician and patient factors. Ultimately, care is implemented during the patient–clinician interaction, though few interventions to reduce overuse have focused on that domain.
Conceptualizing overuse through the patient–clinician interaction maintains focus on patients while promoting population health that is both better and lower in cost. This framework can guide interventions to reduce overuse in important parts of the healthcare system while ensuring the final goal of high-quality individualized patient care.
Acknowledgments
The authors thank Valerie Pocus for helping with the artistic design of Framework. An early version of Framework was presented at the 2015 Preventing Overdiagnosis meeting in Bethesda, Maryland.
Disclosures
Dr. Morgan received research support from the VA Health Services Research (CRE 12-307), Agency for Healthcare Research and Quality (AHRQ) (K08- HS18111). Dr. Leppin’s work was supported by CTSA Grant Number UL1 TR000135 from the National Center for Advancing Translational Sciences, a component of the National Institutes of Health (NIH). Dr. Korenstein’s work on this paper was supported by a Cancer Center Support Grant from the National Cancer Institute to Memorial Sloan Kettering Cancer Center (award number P30 CA008748). Dr. Morgan provided a self-developed lecture in a 3M-sponsored series on hospital epidemiology and has received honoraria for serving as a book and journal editor for Springer Publishing. Dr. Smith is employed by the American College of Physicians and owns stock in Merck, where her husband is employed. The other authors report no potential conflicts of interest.
1. Morgan DJ, Brownlee S, Leppin AL, et al. Setting a research agenda for medical overuse. BMJ. 2015;351:h4534. PubMed
2. Hood VL, Weinberger SE. High value, cost-conscious care: an international imperative. Eur J Intern Med. 2012;23(6):495-498. PubMed
3. Korenstein D, Falk R, Howell EA, Bishop T, Keyhani S. Overuse of health care services in the United States: an understudied problem. Arch Intern Med. 2012;172(2):171-178. PubMed
4. How SKH, Shih A, Lau J, Schoen C. Public Views on U.S. Health System Organization: A Call for New Directions. http://www.commonwealthfund.org/publications/data-briefs/2008/aug/public-views-on-u-s--health-system-organization--a-call-for-new-directions. Published August 1, 2008. Accessed December 11, 2015.
5. Sirovich BE, Woloshin S, Schwartz LM. Too little? Too much? Primary care physicians’ views on US health care: a brief report. Arch Intern Med. 2011;171(17):1582-1585. PubMed
6. Joint Commission, American Medical Association–Convened Physician Consortium for Performance Improvement. Proceedings From the National Summit on Overuse. https://www.jointcommission.org/assets/1/6/National_Summit_Overuse.pdf. Published September 24, 2012. Accessed July 8, 2016.
7. Cassel CK, Guest JA. Choosing Wisely: helping physicians and patients make smart decisions about their care. JAMA. 2012;307(17):1801-1802. PubMed
8. Wolfson D, Santa J, Slass L. Engaging physicians and consumers in conversations about treatment overuse and waste: a short history of the Choosing Wisely campaign. Acad Med. 2014;89(7):990-995. PubMed
9. Smith CD, Levinson WS. A commitment to high-value care education from the internal medicine community. Ann Int Med. 2015;162(9):639-640. PubMed
10. Korenstein D, Kale M, Levinson W. Teaching value in academic environments: shifting the ivory tower. JAMA. 2013;310(16):1671-1672. PubMed
11. Kale MS, Bishop TF, Federman AD, Keyhani S. Trends in the overuse of ambulatory health care services in the United States. JAMA Intern Med. 2013;173(2):142-148. PubMed
12. Rosenberg A, Agiro A, Gottlieb M, et al. Early trends among seven recommendations from the Choosing Wisely campaign. JAMA Intern Med. 2015;175(12):1913-1920. PubMed
13. Prasad V, Ioannidis JP. Evidence-based de-implementation for contradicted, unproven, and aspiring healthcare practices. Implement Sci. 2014;9:1. PubMed
14. Ubel PA, Asch DA. Creating value in health by understanding and overcoming resistance to de-innovation. Health Aff (Millwood). 2015;34(2):239-244. PubMed
15. Powell AA, Bloomfield HE, Burgess DJ, Wilt TJ, Partin MR. A conceptual framework for understanding and reducing overuse by primary care providers. Med Care Res Rev. 2013;70(5):451-472. PubMed
16. Nassery N, Segal JB, Chang E, Bridges JF. Systematic overuse of healthcare services: a conceptual model. Appl Health Econ Health Policy. 2015;13(1):1-6. PubMed
17. Segal JB, Nassery N, Chang HY, Chang E, Chan K, Bridges JF. An index for measuring overuse of health care resources with Medicare claims. Med Care. 2015;53(3):230-236. PubMed
18. Reschovsky JD, Rich EC, Lake TK. Factors contributing to variations in physicians’ use of evidence at the point of care: a conceptual model. J Gen Intern Med. 2015;30(suppl 3):S555-S561. PubMed
19. Feinstein AR, Horwitz RI. Problems in the “evidence” of “evidence-based medicine.” Am J Med. 1997;103(6):529-535. PubMed
20. Makarov DV, Soulos PR, Gold HT, et al. Regional-level correlations in inappropriate imaging rates for prostate and breast cancers: potential implications for the Choosing Wisely campaign. JAMA Oncol. 2015;1(2):185-194. PubMed
21. Romano MJ, Segal JB, Pollack CE. The association between continuity of care and the overuse of medical procedures. JAMA Intern Med. 2015;175(7):1148-1154. PubMed
22. Bayliss EA, Ellis JL, Shoup JA, Zeng C, McQuillan DB, Steiner JF. Effect of continuity of care on hospital utilization for seniors with multiple medical conditions in an integrated health care system. Ann Fam Med. 2015;13(2):123-129. PubMed
23. Chaiyachati KH, Gordon K, Long T, et al. Continuity in a VA patient-centered medical home reduces emergency department visits. PloS One. 2014;9(5):e96356. PubMed
24. Underhill ML, Kiviniemi MT. The association of perceived provider-patient communication and relationship quality with colorectal cancer screening. Health Educ Behav. 2012;39(5):555-563. PubMed
25. Legare F, Labrecque M, Cauchon M, Castel J, Turcotte S, Grimshaw J. Training family physicians in shared decision-making to reduce the overuse of antibiotics in acute respiratory infections: a cluster randomized trial. CMAJ. 2012;184(13):E726-E734. PubMed
26. PerryUndum Research/Communication; for ABIM Foundation. Unnecessary Tests and Procedures in the Health Care System: What Physicians Say About the Problem, the Causes, and the Solutions: Results From a National Survey of Physicians. http://www.choosingwisely.org/wp-content/uploads/2015/04/Final-Choosing-Wisely-Survey-Report.pdf. Published May 1, 2014. Accessed July 8, 2016.
27. Corallo AN, Croxford R, Goodman DC, Bryan EL, Srivastava D, Stukel TA. A systematic review of medical practice variation in OECD countries. Health Policy. 2014;114(1):5-14. PubMed
28. Cutler D, Skinner JS, Stern AD, Wennberg DE. Physician Beliefs and Patient Preferences: A New Look at Regional Variation in Health Care Spending. NBER Working Paper No. 19320. Cambridge, MA: National Bureau of Economic Research; 2013. http://www.nber.org/papers/w19320. Published August 2013. Accessed July 8, 2016.
29. Sirovich BE, Lipner RS, Johnston M, Holmboe ES. The association between residency training and internists’ ability to practice conservatively. JAMA Intern Med. 2014;174(10):1640-1648. PubMed
30. Huttner B, Goossens H, Verheij T, Harbarth S. Characteristics and outcomes of public campaigns aimed at improving the use of antibiotics in outpatients in high-income countries. Lancet Infect Dis. 2010;10(1):17-31. PubMed
31. Perz JF, Craig AS, Coffey CS, et al. Changes in antibiotic prescribing for children after a community-wide campaign. JAMA. 2002;287(23):3103-3109. PubMed
32. Sabuncu E, David J, Bernede-Bauduin C, et al. Significant reduction of antibiotic use in the community after a nationwide campaign in France, 2002-2007. PLoS Med. 2009;6(6):e1000084. PubMed
33. Flodgren G, Eccles MP, Shepperd S, Scott A, Parmelli E, Beyer FR. An overview of reviews evaluating the effectiveness of financial incentives in changing healthcare professional behaviours and patient outcomes. Cochrane Database Syst Rev. 2011;(7):CD009255. PubMed
34. Yoon J, Rose DE, Canelo I, et al. Medical home features of VHA primary care clinics and avoidable hospitalizations. J Gen Intern Med. 2013;28(9):1188-1194. PubMed
35. Gonzales R, Anderer T, McCulloch CE, et al. A cluster randomized trial of decision support strategies for reducing antibiotic use in acute bronchitis. JAMA Intern Med. 2013;173(4):267-273. PubMed
36. Davis MM, Balasubramanian BA, Cifuentes M, et al. Clinician staffing, scheduling, and engagement strategies among primary care practices delivering integrated care. J Am Board Fam Med. 2015;28(suppl 1):S32-S40. PubMed
37. Dine CJ, Miller J, Fuld A, Bellini LM, Iwashyna TJ. Educating physicians-in-training about resource utilization and their own outcomes of care in the inpatient setting. J Grad Med Educ. 2010;2(2):175-180. PubMed
38. Elligsen M, Walker SA, Pinto R, et al. Audit and feedback to reduce broad-spectrum antibiotic use among intensive care unit patients: a controlled interrupted time series analysis. Infect Control Hosp Epidemiol. 2012;33(4):354-361. PubMed
39. Gerber JS, Prasad PA, Fiks AG, et al. Effect of an outpatient antimicrobial stewardship intervention on broad-spectrum antibiotic prescribing by primary care pediatricians: a randomized trial. JAMA. 2013;309(22):2345-2352. PubMed
40. Taggart LR, Leung E, Muller MP, Matukas LM, Daneman N. Differential outcome of an antimicrobial stewardship audit and feedback program in two intensive care units: a controlled interrupted time series study. BMC Infect Dis. 2015;15:480. PubMed
41. Hughes DR, Sunshine JH, Bhargavan M, Forman H. Physician self-referral for imaging and the cost of chronic care for Medicare beneficiaries. Med Care. 2011;49(9):857-864. PubMed
42. Ryskina KL, Pesko MF, Gossey JT, Caesar EP, Bishop TF. Brand name statin prescribing in a resident ambulatory practice: implications for teaching cost-conscious medicine. J Grad Med Educ. 2014;6(3):484-488. PubMed
43. Bhatia RS, Milford CE, Picard MH, Weiner RB. An educational intervention reduces the rate of inappropriate echocardiograms on an inpatient medical service. JACC Cardiovasc Imaging. 2013;6(5):545-555. PubMed
44. Grimshaw JM, Thomas RE, MacLennan G, et al. Effectiveness and efficiency of guideline dissemination and implementation strategies. Health Technol Assess. 2004;8(6):iii-iv, 1-72. PubMed
45. Wilson I, Cowin LS, Johnson M, Young H. Professional identity in medical students: pedagogical challenges to medical education. Teach Learn Med. 2013;25(4):369-373. PubMed
46. Berger Z, Flickinger TE, Pfoh E, Martinez KA, Dy SM. Promoting engagement by patients and families to reduce adverse events in acute care settings: a systematic review. BMJ Qual Saf. 2014;23(7):548-555. PubMed
47. Dykes PC, Stade D, Chang F, et al. Participatory design and development of a patient-centered toolkit to engage hospitalized patients and care partners in their plan of care. AMIA Annu Symp Proc. 2014;2014:486-495. PubMed
48. Coxeter P, Del Mar CB, McGregor L, Beller EM, Hoffmann TC. Interventions to facilitate shared decision making to address antibiotic use for acute respiratory infections in primary care. Cochrane Database Syst Rev. 2015;(11):CD010907. PubMed
49. Stacey D, Legare F, Col NF, et al. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev. 2014;(1):CD001431. PubMed
50. Bank AJ, Gage RM. Annual impact of scribes on physician productivity and revenue in a cardiology clinic. Clinicoecon Outcomes Res. 2015;7:489-495. PubMed
51. Lyles CR, Sarkar U, Schillinger D, et al. Refilling medications through an online patient portal: consistent improvements in adherence across racial/ethnic groups. J Am Med Inform Assoc. 2016;23(e1):e28-e33. PubMed
52. Kruse CS, Bolton K, Freriks G. The effect of patient portals on quality outcomes and its implications to meaningful use: a systematic review. J Med Internet Res. 2015;17(2):e44. PubMed
53. Smith CD. Teaching high-value, cost-conscious care to residents: the Alliance for Academic Internal Medicine-American College of Physicians curriculum. Ann Intern Med. 2012;157(4):284-286. PubMed
54. Redberg RF. Less is more. Arch Intern Med. 2010;170(7):584. PubMed
65. Birkmeyer JD, Reames BN, McCulloch P, Carr AJ, Campbell WB, Wennberg JE. Understanding of regional variation in the use of surgery. Lancet. 2013;382(9898):1121-1129. PubMed
66. Pearson SD, Goldman L, Orav EJ, et al. Triage decisions for emergency department patients with chest pain: do physicians’ risk attitudes make the difference? J Gen Intern Med. 1995;10(10):557-564. PubMed
67. Tubbs EP, Elrod JA, Flum DR. Risk taking and tolerance of uncertainty: implications for surgeons. J Surg Res. 2006;131(1):1-6. PubMed
68. Zaat JO, van Eijk JT. General practitioners’ uncertainty, risk preference, and use of laboratory tests. Med Care. 1992;30(9):846-854. PubMed
69. Barnato AE, Tate JA, Rodriguez KL, Zickmund SL, Arnold RM. Norms of decision making in the ICU: a case study of two academic medical centers at the extremes of end-of-life treatment intensity. Intensive Care Med. 2012;38(11):1886-1896. PubMed
70. Fisher ES, Wennberg JE, Stukel TA, et al. Associations among hospital capacity, utilization, and mortality of US Medicare beneficiaries, controlling for sociodemographic factors. Health Serv Res. 2000;34(6):1351-1362. PubMed
71. Yasaitis LC, Bynum JP, Skinner JS. Association between physician supply, local practice norms, and outpatient visit rates. Med Care. 2013;51(6):524-531. PubMed
72. Chen C, Petterson S, Phillips R, Bazemore A, Mullan F. Spending patterns in region of residency training and subsequent expenditures for care provided by practicing physicians for Medicare beneficiaries. JAMA. 2014;312(22):2385-2393. PubMed
73. Ryskina KL, Smith CD, Weissman A, et al. U.S. internal medicine residents’ knowledge and practice of high-value care: a national survey. Acad Med. 2015;90(10):1373-1379. PubMed
74. Khullar D, Chokshi DA, Kocher R, et al. Behavioral economics and physician compensation—promise and challenges. N Engl J Med. 2015;372(24):2281-2283. PubMed
75. Landon BE, Reschovsky J, Reed M, Blumenthal D. Personal, organizational, and market level influences on physicians’ practice patterns: results of a national survey of primary care physicians. Med Care. 2001;39(8):889-905. PubMed
76. Fanari Z, Abraham N, Kolm P, et al. Aggressive measures to decrease “door to balloon” time and incidence of unnecessary cardiac catheterization: potential risks and role of quality improvement. Mayo Clin Proc. 2015;90(12):1614-1622. PubMed
77. Kerr EA, Lucatorto MA, Holleman R, Hogan MM, Klamerus ML, Hofer TP. Monitoring performance for blood pressure management among patients with diabetes mellitus: too much of a good thing? Arch Intern Med. 2012;172(12):938-945. PubMed
78. Verhofstede R, Smets T, Cohen J, Costantini M, Van Den Noortgate N, Deliens L. Implementing the care programme for the last days of life in an acute geriatric hospital ward: a phase 2 mixed method study. BMC Palliat Care. 2016;15:27. PubMed
Medical services overuse is the provision of healthcare services for which there is no medical basis or for which harms equal or exceed benefits.1 This overuse drives poor-quality care and unnecessary cost.2,3 The high prevalence of overuse is recognized by patients,4 clinicians,5 and policymakers.6 Initiatives to reduce overuse have targeted physicians,7 the public,8 and medical educators9,10 but have had limited impact.11,12 Few studies have addressed methods for reducing overuse, and de-implementation of nonbeneficial practices has proved challenging.1,13,14 Models for reducing overuse are only theoretical15 or are focused on administrative decisions.16,17 We think a practical framework is needed. We used an iterative process, informed by expert opinion and discussion, to design such a framework.
METHODS
The authors, who have expertise in overuse, value, medical education, evidence-based medicine, and implementation science, reviewed related conceptual frameworks18 and evidence regarding drivers of overuse. We organized these drivers into domains to create a draft framework, which we presented at Preventing Overdiagnosis 2015, a meeting of clinicians, patients, and policymakers interested in overuse. We incorporated feedback from meeting attendees to modify framework domains, and we performed structured searches (using key words in Pubmed) to explore, and estimate the strength of, evidence supporting items within each domain. We rated supporting evidence as strong (studies found a clear correlation between a factor and overuse), moderate (evidence suggests such a correlation or demonstrates a correlation between a particular factor and utilization but not overuse per se), weak (only indirect evidence exists), or absent (no studies identified evaluating a particular factor). All authors reached consensus on ratings.
Framework Principles and Evidence
Patient-centered definition of overuse. During framework development, defining clinical appropriateness emerged as the primary challenge to identifying and reducing overuse. Although some care generally is appropriate based on strong evidence of benefit, and some is inappropriate given a clear lack of benefit or harm, much care is of unclear or variable benefit. Practice guidelines can help identify overuse, but their utility may be limited by lack of evidence in specific clinical situations,19 and their recommendations may apply poorly to an individual patient. This presents challenges to using guidelines to identify and reduce overuse.
Despite limitations, the scope of overuse has been estimated by applying broad, often guideline-based, criteria for care appropriateness to administrative data.20 Unfortunately, these estimates provide little direction to clinicians and patients partnering to make usage decisions. During framework development, we identified the importance of a patient-level, patient-specific definition of overuse. This approach reinforces the importance of meeting patient needs while standardizing treatments to reduce overuse. A patient-centered approach may also assist professional societies and advocacy groups in developing actionable campaigns and may uncover evidence gaps.
Centrality of patient-clinician interaction. During framework development, the patient–clinician interaction emerged as the nexus through which drivers of overuse exert influence. The centrality of this interaction has been demonstrated in studies of the relationship between care continuity and overuse21 or utilization,22,23 by evidence that communication and patient–clinician relationships affect utilization,24 and by the observation that clinician training in shared decision-making reduces overuse.25 A patient-centered framework assumes that, at least in the weighing of clinically reasonable options, a patient-centered approach optimizes outcomes for that patient.
Incorporating drivers of overuse. We incorporated drivers of overuse into domains and related them to the patient–clinician interaction.26 Domains included the culture of healthcare consumption, patient factors and experiences, the practice environment, the culture of professional medicine, and clinician attitudes and beliefs.
We characterized the evidence illustrating how drivers within each domain influence healthcare use. The evidence for each domain is listed in Table 1.
RESULTS
The final framework is shown in the Figure. Within the healthcare system, patients are influenced by the culture of healthcare consumption, which varies within and among countries.27 Clinicians are influenced by the culture of medical care, which varies by practice setting,28 and by their training environment.29 Both clinicians and patients are influenced by the practice environment and by personal experiences. Ultimately, clinical decisions occur within the specific patient–clinician interaction.24 Table 1 lists each domain’s components, likely impact on overuse, and estimated strength of supporting evidence. Interventions can be conceptualized within appropriate domains or through the interaction between patient and clinician.
DISCUSSION
We developed a novel and practical conceptual framework for characterizing drivers of overuse and potential intervention points. To our knowledge, this is the first framework incorporating a patient-specific approach to overuse and emphasizing the patient–clinician interaction. Key strengths of framework development are inclusion of a range of perspectives and characterization of the evidence within each domain. Limitations include lack of a formal systematic review and broad, qualitative assessments of evidence strength. However, we believe this framework provides an important conceptual foundation for the study of overuse and interventions to reduce overuse.
Framework Applications
This framework, which highlights the many drivers of overuse, can facilitate understanding of overuse and help conceptualize change, prioritize research goals, and inform specific interventions. For policymakers, the framework can inform efforts to reduce overuse by emphasizing the need for complex interventions and by clarifying the likely impact of interventions targeting specific domains. Similarly, for clinicians and quality improvement professionals, the framework can ground root cause analyses of overuse-related problems and inform allocation of limited resources. Finally, the relatively weak evidence on the role of most acknowledged drivers of overuse suggests an important research agenda. Specifically, several pressing needs have been identified: defining relevant physician and patient cultural factors, investigating interventions to impact culture, defining practice environment features that optimize care appropriateness, and describing specific patient–clinician interaction practices that minimize overuse while providing needed care.
Targeting Interventions
Domains within the framework are influenced by different types of interventions, and different stakeholders may target different domains. For example:
- The culture of healthcare consumption may be influenced through public education (eg, Choosing Wisely® patient resources)30-32 and public health campaigns.
- The practice environment may be influenced by initiatives to align clinician incentives,33 team care,34 electronic health record interventions,35 and improved access.36
- Clinician attitudes and beliefs may be influenced by audit and feedback,37-40 reflection,41 role modeling,42 and education.43-45
- Patient attitudes and beliefs may be influenced by education, access to price and quality information, and increased engagement in care.46,47
- For clinicians, the patient–clinician interaction can be improved through training in communication and shared decision-making,25 through access to information (eg, costs) that can be easily shared with patients,48,49 and through novel visit structures (eg, scribes).50
- On the patient side, this interaction can be optimized with improved access (eg, through telemedicine)51,52 or with patient empowerment during hospitalization.
- The culture of medicine is difficult to influence. Change likely will occur through:
○ Regulatory interventions (eg, Transforming Clinical Practice Initiative of Center for Medicare & Medicaid Innovation).
○ Educational initiatives (eg, high-value care curricula of Alliance for Academic Internal Medicine/American College of Physicians53).
○ Medical journal features (eg, “Less Is More” in JAMA Internal Medicine54 and “Things We Do for No Reason” in Journal of Hospital Medicine).
○ Professional organizations (eg, Choosing Wisely®).
As organizations implement quality improvement initiatives to reduce overuse of services, the framework can be used to target interventions to relevant domains. For example, a hospital leader who wants to reduce opioid prescribing may use the framework to identify the factors that encourage prescribing in each domain—poor understanding of pain treatment (a clinician factor), desire for early discharge encouraging overly aggressive pain management (an environmental factor), patient demand for opioids combined with poor understanding of harms (patient factors), and poor communication regarding pain (a patient–clinician interaction factor). Although not all relevant factors can be addressed, their classification by domain facilitates intervention, in this case perhaps leading to a focus on clinician and patient education on opioids and development of a practical communication tool that targets 3 domains. Table 2 lists ways in which the framework informs approaches to this and other overused services in the hospital setting. Note that some drivers can be acknowledged without identifying targeted interventions.
Moving Forward
Through a multi-stakeholder iterative process, we developed a practical framework for understanding medical overuse and interventions to reduce it. Centered on the patient–clinician interaction, this framework explains overuse as the product of medical and patient culture, the practice environment and incentives, and other clinician and patient factors. Ultimately, care is implemented during the patient–clinician interaction, though few interventions to reduce overuse have focused on that domain.
Conceptualizing overuse through the patient–clinician interaction maintains focus on patients while promoting population health that is both better and lower in cost. This framework can guide interventions to reduce overuse in important parts of the healthcare system while ensuring the final goal of high-quality individualized patient care.
Acknowledgments
The authors thank Valerie Pocus for helping with the artistic design of Framework. An early version of Framework was presented at the 2015 Preventing Overdiagnosis meeting in Bethesda, Maryland.
Disclosures
Dr. Morgan received research support from the VA Health Services Research (CRE 12-307), Agency for Healthcare Research and Quality (AHRQ) (K08- HS18111). Dr. Leppin’s work was supported by CTSA Grant Number UL1 TR000135 from the National Center for Advancing Translational Sciences, a component of the National Institutes of Health (NIH). Dr. Korenstein’s work on this paper was supported by a Cancer Center Support Grant from the National Cancer Institute to Memorial Sloan Kettering Cancer Center (award number P30 CA008748). Dr. Morgan provided a self-developed lecture in a 3M-sponsored series on hospital epidemiology and has received honoraria for serving as a book and journal editor for Springer Publishing. Dr. Smith is employed by the American College of Physicians and owns stock in Merck, where her husband is employed. The other authors report no potential conflicts of interest.
Medical services overuse is the provision of healthcare services for which there is no medical basis or for which harms equal or exceed benefits.1 This overuse drives poor-quality care and unnecessary cost.2,3 The high prevalence of overuse is recognized by patients,4 clinicians,5 and policymakers.6 Initiatives to reduce overuse have targeted physicians,7 the public,8 and medical educators9,10 but have had limited impact.11,12 Few studies have addressed methods for reducing overuse, and de-implementation of nonbeneficial practices has proved challenging.1,13,14 Models for reducing overuse are only theoretical15 or are focused on administrative decisions.16,17 We think a practical framework is needed. We used an iterative process, informed by expert opinion and discussion, to design such a framework.
METHODS
The authors, who have expertise in overuse, value, medical education, evidence-based medicine, and implementation science, reviewed related conceptual frameworks18 and evidence regarding drivers of overuse. We organized these drivers into domains to create a draft framework, which we presented at Preventing Overdiagnosis 2015, a meeting of clinicians, patients, and policymakers interested in overuse. We incorporated feedback from meeting attendees to modify framework domains, and we performed structured searches (using key words in Pubmed) to explore, and estimate the strength of, evidence supporting items within each domain. We rated supporting evidence as strong (studies found a clear correlation between a factor and overuse), moderate (evidence suggests such a correlation or demonstrates a correlation between a particular factor and utilization but not overuse per se), weak (only indirect evidence exists), or absent (no studies identified evaluating a particular factor). All authors reached consensus on ratings.
Framework Principles and Evidence
Patient-centered definition of overuse. During framework development, defining clinical appropriateness emerged as the primary challenge to identifying and reducing overuse. Although some care generally is appropriate based on strong evidence of benefit, and some is inappropriate given a clear lack of benefit or harm, much care is of unclear or variable benefit. Practice guidelines can help identify overuse, but their utility may be limited by lack of evidence in specific clinical situations,19 and their recommendations may apply poorly to an individual patient. This presents challenges to using guidelines to identify and reduce overuse.
Despite limitations, the scope of overuse has been estimated by applying broad, often guideline-based, criteria for care appropriateness to administrative data.20 Unfortunately, these estimates provide little direction to clinicians and patients partnering to make usage decisions. During framework development, we identified the importance of a patient-level, patient-specific definition of overuse. This approach reinforces the importance of meeting patient needs while standardizing treatments to reduce overuse. A patient-centered approach may also assist professional societies and advocacy groups in developing actionable campaigns and may uncover evidence gaps.
Centrality of patient-clinician interaction. During framework development, the patient–clinician interaction emerged as the nexus through which drivers of overuse exert influence. The centrality of this interaction has been demonstrated in studies of the relationship between care continuity and overuse21 or utilization,22,23 by evidence that communication and patient–clinician relationships affect utilization,24 and by the observation that clinician training in shared decision-making reduces overuse.25 A patient-centered framework assumes that, at least in the weighing of clinically reasonable options, a patient-centered approach optimizes outcomes for that patient.
Incorporating drivers of overuse. We incorporated drivers of overuse into domains and related them to the patient–clinician interaction.26 Domains included the culture of healthcare consumption, patient factors and experiences, the practice environment, the culture of professional medicine, and clinician attitudes and beliefs.
We characterized the evidence illustrating how drivers within each domain influence healthcare use. The evidence for each domain is listed in Table 1.
RESULTS
The final framework is shown in the Figure. Within the healthcare system, patients are influenced by the culture of healthcare consumption, which varies within and among countries.27 Clinicians are influenced by the culture of medical care, which varies by practice setting,28 and by their training environment.29 Both clinicians and patients are influenced by the practice environment and by personal experiences. Ultimately, clinical decisions occur within the specific patient–clinician interaction.24 Table 1 lists each domain’s components, likely impact on overuse, and estimated strength of supporting evidence. Interventions can be conceptualized within appropriate domains or through the interaction between patient and clinician.
DISCUSSION
We developed a novel and practical conceptual framework for characterizing drivers of overuse and potential intervention points. To our knowledge, this is the first framework incorporating a patient-specific approach to overuse and emphasizing the patient–clinician interaction. Key strengths of framework development are inclusion of a range of perspectives and characterization of the evidence within each domain. Limitations include lack of a formal systematic review and broad, qualitative assessments of evidence strength. However, we believe this framework provides an important conceptual foundation for the study of overuse and interventions to reduce overuse.
Framework Applications
This framework, which highlights the many drivers of overuse, can facilitate understanding of overuse and help conceptualize change, prioritize research goals, and inform specific interventions. For policymakers, the framework can inform efforts to reduce overuse by emphasizing the need for complex interventions and by clarifying the likely impact of interventions targeting specific domains. Similarly, for clinicians and quality improvement professionals, the framework can ground root cause analyses of overuse-related problems and inform allocation of limited resources. Finally, the relatively weak evidence on the role of most acknowledged drivers of overuse suggests an important research agenda. Specifically, several pressing needs have been identified: defining relevant physician and patient cultural factors, investigating interventions to impact culture, defining practice environment features that optimize care appropriateness, and describing specific patient–clinician interaction practices that minimize overuse while providing needed care.
Targeting Interventions
Domains within the framework are influenced by different types of interventions, and different stakeholders may target different domains. For example:
- The culture of healthcare consumption may be influenced through public education (eg, Choosing Wisely® patient resources)30-32 and public health campaigns.
- The practice environment may be influenced by initiatives to align clinician incentives,33 team care,34 electronic health record interventions,35 and improved access.36
- Clinician attitudes and beliefs may be influenced by audit and feedback,37-40 reflection,41 role modeling,42 and education.43-45
- Patient attitudes and beliefs may be influenced by education, access to price and quality information, and increased engagement in care.46,47
- For clinicians, the patient–clinician interaction can be improved through training in communication and shared decision-making,25 through access to information (eg, costs) that can be easily shared with patients,48,49 and through novel visit structures (eg, scribes).50
- On the patient side, this interaction can be optimized with improved access (eg, through telemedicine)51,52 or with patient empowerment during hospitalization.
- The culture of medicine is difficult to influence. Change likely will occur through:
○ Regulatory interventions (eg, Transforming Clinical Practice Initiative of Center for Medicare & Medicaid Innovation).
○ Educational initiatives (eg, high-value care curricula of Alliance for Academic Internal Medicine/American College of Physicians53).
○ Medical journal features (eg, “Less Is More” in JAMA Internal Medicine54 and “Things We Do for No Reason” in Journal of Hospital Medicine).
○ Professional organizations (eg, Choosing Wisely®).
As organizations implement quality improvement initiatives to reduce overuse of services, the framework can be used to target interventions to relevant domains. For example, a hospital leader who wants to reduce opioid prescribing may use the framework to identify the factors that encourage prescribing in each domain—poor understanding of pain treatment (a clinician factor), desire for early discharge encouraging overly aggressive pain management (an environmental factor), patient demand for opioids combined with poor understanding of harms (patient factors), and poor communication regarding pain (a patient–clinician interaction factor). Although not all relevant factors can be addressed, their classification by domain facilitates intervention, in this case perhaps leading to a focus on clinician and patient education on opioids and development of a practical communication tool that targets 3 domains. Table 2 lists ways in which the framework informs approaches to this and other overused services in the hospital setting. Note that some drivers can be acknowledged without identifying targeted interventions.
Moving Forward
Through a multi-stakeholder iterative process, we developed a practical framework for understanding medical overuse and interventions to reduce it. Centered on the patient–clinician interaction, this framework explains overuse as the product of medical and patient culture, the practice environment and incentives, and other clinician and patient factors. Ultimately, care is implemented during the patient–clinician interaction, though few interventions to reduce overuse have focused on that domain.
Conceptualizing overuse through the patient–clinician interaction maintains focus on patients while promoting population health that is both better and lower in cost. This framework can guide interventions to reduce overuse in important parts of the healthcare system while ensuring the final goal of high-quality individualized patient care.
Acknowledgments
The authors thank Valerie Pocus for helping with the artistic design of Framework. An early version of Framework was presented at the 2015 Preventing Overdiagnosis meeting in Bethesda, Maryland.
Disclosures
Dr. Morgan received research support from the VA Health Services Research (CRE 12-307), Agency for Healthcare Research and Quality (AHRQ) (K08- HS18111). Dr. Leppin’s work was supported by CTSA Grant Number UL1 TR000135 from the National Center for Advancing Translational Sciences, a component of the National Institutes of Health (NIH). Dr. Korenstein’s work on this paper was supported by a Cancer Center Support Grant from the National Cancer Institute to Memorial Sloan Kettering Cancer Center (award number P30 CA008748). Dr. Morgan provided a self-developed lecture in a 3M-sponsored series on hospital epidemiology and has received honoraria for serving as a book and journal editor for Springer Publishing. Dr. Smith is employed by the American College of Physicians and owns stock in Merck, where her husband is employed. The other authors report no potential conflicts of interest.
1. Morgan DJ, Brownlee S, Leppin AL, et al. Setting a research agenda for medical overuse. BMJ. 2015;351:h4534. PubMed
2. Hood VL, Weinberger SE. High value, cost-conscious care: an international imperative. Eur J Intern Med. 2012;23(6):495-498. PubMed
3. Korenstein D, Falk R, Howell EA, Bishop T, Keyhani S. Overuse of health care services in the United States: an understudied problem. Arch Intern Med. 2012;172(2):171-178. PubMed
4. How SKH, Shih A, Lau J, Schoen C. Public Views on U.S. Health System Organization: A Call for New Directions. http://www.commonwealthfund.org/publications/data-briefs/2008/aug/public-views-on-u-s--health-system-organization--a-call-for-new-directions. Published August 1, 2008. Accessed December 11, 2015.
5. Sirovich BE, Woloshin S, Schwartz LM. Too little? Too much? Primary care physicians’ views on US health care: a brief report. Arch Intern Med. 2011;171(17):1582-1585. PubMed
6. Joint Commission, American Medical Association–Convened Physician Consortium for Performance Improvement. Proceedings From the National Summit on Overuse. https://www.jointcommission.org/assets/1/6/National_Summit_Overuse.pdf. Published September 24, 2012. Accessed July 8, 2016.
7. Cassel CK, Guest JA. Choosing Wisely: helping physicians and patients make smart decisions about their care. JAMA. 2012;307(17):1801-1802. PubMed
8. Wolfson D, Santa J, Slass L. Engaging physicians and consumers in conversations about treatment overuse and waste: a short history of the Choosing Wisely campaign. Acad Med. 2014;89(7):990-995. PubMed
9. Smith CD, Levinson WS. A commitment to high-value care education from the internal medicine community. Ann Int Med. 2015;162(9):639-640. PubMed
10. Korenstein D, Kale M, Levinson W. Teaching value in academic environments: shifting the ivory tower. JAMA. 2013;310(16):1671-1672. PubMed
11. Kale MS, Bishop TF, Federman AD, Keyhani S. Trends in the overuse of ambulatory health care services in the United States. JAMA Intern Med. 2013;173(2):142-148. PubMed
12. Rosenberg A, Agiro A, Gottlieb M, et al. Early trends among seven recommendations from the Choosing Wisely campaign. JAMA Intern Med. 2015;175(12):1913-1920. PubMed
13. Prasad V, Ioannidis JP. Evidence-based de-implementation for contradicted, unproven, and aspiring healthcare practices. Implement Sci. 2014;9:1. PubMed
14. Ubel PA, Asch DA. Creating value in health by understanding and overcoming resistance to de-innovation. Health Aff (Millwood). 2015;34(2):239-244. PubMed
15. Powell AA, Bloomfield HE, Burgess DJ, Wilt TJ, Partin MR. A conceptual framework for understanding and reducing overuse by primary care providers. Med Care Res Rev. 2013;70(5):451-472. PubMed
16. Nassery N, Segal JB, Chang E, Bridges JF. Systematic overuse of healthcare services: a conceptual model. Appl Health Econ Health Policy. 2015;13(1):1-6. PubMed
17. Segal JB, Nassery N, Chang HY, Chang E, Chan K, Bridges JF. An index for measuring overuse of health care resources with Medicare claims. Med Care. 2015;53(3):230-236. PubMed
18. Reschovsky JD, Rich EC, Lake TK. Factors contributing to variations in physicians’ use of evidence at the point of care: a conceptual model. J Gen Intern Med. 2015;30(suppl 3):S555-S561. PubMed
19. Feinstein AR, Horwitz RI. Problems in the “evidence” of “evidence-based medicine.” Am J Med. 1997;103(6):529-535. PubMed
20. Makarov DV, Soulos PR, Gold HT, et al. Regional-level correlations in inappropriate imaging rates for prostate and breast cancers: potential implications for the Choosing Wisely campaign. JAMA Oncol. 2015;1(2):185-194. PubMed
21. Romano MJ, Segal JB, Pollack CE. The association between continuity of care and the overuse of medical procedures. JAMA Intern Med. 2015;175(7):1148-1154. PubMed
22. Bayliss EA, Ellis JL, Shoup JA, Zeng C, McQuillan DB, Steiner JF. Effect of continuity of care on hospital utilization for seniors with multiple medical conditions in an integrated health care system. Ann Fam Med. 2015;13(2):123-129. PubMed
23. Chaiyachati KH, Gordon K, Long T, et al. Continuity in a VA patient-centered medical home reduces emergency department visits. PloS One. 2014;9(5):e96356. PubMed
24. Underhill ML, Kiviniemi MT. The association of perceived provider-patient communication and relationship quality with colorectal cancer screening. Health Educ Behav. 2012;39(5):555-563. PubMed
25. Legare F, Labrecque M, Cauchon M, Castel J, Turcotte S, Grimshaw J. Training family physicians in shared decision-making to reduce the overuse of antibiotics in acute respiratory infections: a cluster randomized trial. CMAJ. 2012;184(13):E726-E734. PubMed
26. PerryUndum Research/Communication; for ABIM Foundation. Unnecessary Tests and Procedures in the Health Care System: What Physicians Say About the Problem, the Causes, and the Solutions: Results From a National Survey of Physicians. http://www.choosingwisely.org/wp-content/uploads/2015/04/Final-Choosing-Wisely-Survey-Report.pdf. Published May 1, 2014. Accessed July 8, 2016.
27. Corallo AN, Croxford R, Goodman DC, Bryan EL, Srivastava D, Stukel TA. A systematic review of medical practice variation in OECD countries. Health Policy. 2014;114(1):5-14. PubMed
28. Cutler D, Skinner JS, Stern AD, Wennberg DE. Physician Beliefs and Patient Preferences: A New Look at Regional Variation in Health Care Spending. NBER Working Paper No. 19320. Cambridge, MA: National Bureau of Economic Research; 2013. http://www.nber.org/papers/w19320. Published August 2013. Accessed July 8, 2016.
29. Sirovich BE, Lipner RS, Johnston M, Holmboe ES. The association between residency training and internists’ ability to practice conservatively. JAMA Intern Med. 2014;174(10):1640-1648. PubMed
30. Huttner B, Goossens H, Verheij T, Harbarth S. Characteristics and outcomes of public campaigns aimed at improving the use of antibiotics in outpatients in high-income countries. Lancet Infect Dis. 2010;10(1):17-31. PubMed
31. Perz JF, Craig AS, Coffey CS, et al. Changes in antibiotic prescribing for children after a community-wide campaign. JAMA. 2002;287(23):3103-3109. PubMed
32. Sabuncu E, David J, Bernede-Bauduin C, et al. Significant reduction of antibiotic use in the community after a nationwide campaign in France, 2002-2007. PLoS Med. 2009;6(6):e1000084. PubMed
33. Flodgren G, Eccles MP, Shepperd S, Scott A, Parmelli E, Beyer FR. An overview of reviews evaluating the effectiveness of financial incentives in changing healthcare professional behaviours and patient outcomes. Cochrane Database Syst Rev. 2011;(7):CD009255. PubMed
34. Yoon J, Rose DE, Canelo I, et al. Medical home features of VHA primary care clinics and avoidable hospitalizations. J Gen Intern Med. 2013;28(9):1188-1194. PubMed
35. Gonzales R, Anderer T, McCulloch CE, et al. A cluster randomized trial of decision support strategies for reducing antibiotic use in acute bronchitis. JAMA Intern Med. 2013;173(4):267-273. PubMed
36. Davis MM, Balasubramanian BA, Cifuentes M, et al. Clinician staffing, scheduling, and engagement strategies among primary care practices delivering integrated care. J Am Board Fam Med. 2015;28(suppl 1):S32-S40. PubMed
37. Dine CJ, Miller J, Fuld A, Bellini LM, Iwashyna TJ. Educating physicians-in-training about resource utilization and their own outcomes of care in the inpatient setting. J Grad Med Educ. 2010;2(2):175-180. PubMed
38. Elligsen M, Walker SA, Pinto R, et al. Audit and feedback to reduce broad-spectrum antibiotic use among intensive care unit patients: a controlled interrupted time series analysis. Infect Control Hosp Epidemiol. 2012;33(4):354-361. PubMed
39. Gerber JS, Prasad PA, Fiks AG, et al. Effect of an outpatient antimicrobial stewardship intervention on broad-spectrum antibiotic prescribing by primary care pediatricians: a randomized trial. JAMA. 2013;309(22):2345-2352. PubMed
40. Taggart LR, Leung E, Muller MP, Matukas LM, Daneman N. Differential outcome of an antimicrobial stewardship audit and feedback program in two intensive care units: a controlled interrupted time series study. BMC Infect Dis. 2015;15:480. PubMed
41. Hughes DR, Sunshine JH, Bhargavan M, Forman H. Physician self-referral for imaging and the cost of chronic care for Medicare beneficiaries. Med Care. 2011;49(9):857-864. PubMed
42. Ryskina KL, Pesko MF, Gossey JT, Caesar EP, Bishop TF. Brand name statin prescribing in a resident ambulatory practice: implications for teaching cost-conscious medicine. J Grad Med Educ. 2014;6(3):484-488. PubMed
43. Bhatia RS, Milford CE, Picard MH, Weiner RB. An educational intervention reduces the rate of inappropriate echocardiograms on an inpatient medical service. JACC Cardiovasc Imaging. 2013;6(5):545-555. PubMed
44. Grimshaw JM, Thomas RE, MacLennan G, et al. Effectiveness and efficiency of guideline dissemination and implementation strategies. Health Technol Assess. 2004;8(6):iii-iv, 1-72. PubMed
45. Wilson I, Cowin LS, Johnson M, Young H. Professional identity in medical students: pedagogical challenges to medical education. Teach Learn Med. 2013;25(4):369-373. PubMed
46. Berger Z, Flickinger TE, Pfoh E, Martinez KA, Dy SM. Promoting engagement by patients and families to reduce adverse events in acute care settings: a systematic review. BMJ Qual Saf. 2014;23(7):548-555. PubMed
47. Dykes PC, Stade D, Chang F, et al. Participatory design and development of a patient-centered toolkit to engage hospitalized patients and care partners in their plan of care. AMIA Annu Symp Proc. 2014;2014:486-495. PubMed
48. Coxeter P, Del Mar CB, McGregor L, Beller EM, Hoffmann TC. Interventions to facilitate shared decision making to address antibiotic use for acute respiratory infections in primary care. Cochrane Database Syst Rev. 2015;(11):CD010907. PubMed
49. Stacey D, Legare F, Col NF, et al. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev. 2014;(1):CD001431. PubMed
50. Bank AJ, Gage RM. Annual impact of scribes on physician productivity and revenue in a cardiology clinic. Clinicoecon Outcomes Res. 2015;7:489-495. PubMed
51. Lyles CR, Sarkar U, Schillinger D, et al. Refilling medications through an online patient portal: consistent improvements in adherence across racial/ethnic groups. J Am Med Inform Assoc. 2016;23(e1):e28-e33. PubMed
52. Kruse CS, Bolton K, Freriks G. The effect of patient portals on quality outcomes and its implications to meaningful use: a systematic review. J Med Internet Res. 2015;17(2):e44. PubMed
53. Smith CD. Teaching high-value, cost-conscious care to residents: the Alliance for Academic Internal Medicine-American College of Physicians curriculum. Ann Intern Med. 2012;157(4):284-286. PubMed
54. Redberg RF. Less is more. Arch Intern Med. 2010;170(7):584. PubMed
65. Birkmeyer JD, Reames BN, McCulloch P, Carr AJ, Campbell WB, Wennberg JE. Understanding of regional variation in the use of surgery. Lancet. 2013;382(9898):1121-1129. PubMed
66. Pearson SD, Goldman L, Orav EJ, et al. Triage decisions for emergency department patients with chest pain: do physicians’ risk attitudes make the difference? J Gen Intern Med. 1995;10(10):557-564. PubMed
67. Tubbs EP, Elrod JA, Flum DR. Risk taking and tolerance of uncertainty: implications for surgeons. J Surg Res. 2006;131(1):1-6. PubMed
68. Zaat JO, van Eijk JT. General practitioners’ uncertainty, risk preference, and use of laboratory tests. Med Care. 1992;30(9):846-854. PubMed
69. Barnato AE, Tate JA, Rodriguez KL, Zickmund SL, Arnold RM. Norms of decision making in the ICU: a case study of two academic medical centers at the extremes of end-of-life treatment intensity. Intensive Care Med. 2012;38(11):1886-1896. PubMed
70. Fisher ES, Wennberg JE, Stukel TA, et al. Associations among hospital capacity, utilization, and mortality of US Medicare beneficiaries, controlling for sociodemographic factors. Health Serv Res. 2000;34(6):1351-1362. PubMed
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72. Chen C, Petterson S, Phillips R, Bazemore A, Mullan F. Spending patterns in region of residency training and subsequent expenditures for care provided by practicing physicians for Medicare beneficiaries. JAMA. 2014;312(22):2385-2393. PubMed
73. Ryskina KL, Smith CD, Weissman A, et al. U.S. internal medicine residents’ knowledge and practice of high-value care: a national survey. Acad Med. 2015;90(10):1373-1379. PubMed
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77. Kerr EA, Lucatorto MA, Holleman R, Hogan MM, Klamerus ML, Hofer TP. Monitoring performance for blood pressure management among patients with diabetes mellitus: too much of a good thing? Arch Intern Med. 2012;172(12):938-945. PubMed
78. Verhofstede R, Smets T, Cohen J, Costantini M, Van Den Noortgate N, Deliens L. Implementing the care programme for the last days of life in an acute geriatric hospital ward: a phase 2 mixed method study. BMC Palliat Care. 2016;15:27. PubMed
1. Morgan DJ, Brownlee S, Leppin AL, et al. Setting a research agenda for medical overuse. BMJ. 2015;351:h4534. PubMed
2. Hood VL, Weinberger SE. High value, cost-conscious care: an international imperative. Eur J Intern Med. 2012;23(6):495-498. PubMed
3. Korenstein D, Falk R, Howell EA, Bishop T, Keyhani S. Overuse of health care services in the United States: an understudied problem. Arch Intern Med. 2012;172(2):171-178. PubMed
4. How SKH, Shih A, Lau J, Schoen C. Public Views on U.S. Health System Organization: A Call for New Directions. http://www.commonwealthfund.org/publications/data-briefs/2008/aug/public-views-on-u-s--health-system-organization--a-call-for-new-directions. Published August 1, 2008. Accessed December 11, 2015.
5. Sirovich BE, Woloshin S, Schwartz LM. Too little? Too much? Primary care physicians’ views on US health care: a brief report. Arch Intern Med. 2011;171(17):1582-1585. PubMed
6. Joint Commission, American Medical Association–Convened Physician Consortium for Performance Improvement. Proceedings From the National Summit on Overuse. https://www.jointcommission.org/assets/1/6/National_Summit_Overuse.pdf. Published September 24, 2012. Accessed July 8, 2016.
7. Cassel CK, Guest JA. Choosing Wisely: helping physicians and patients make smart decisions about their care. JAMA. 2012;307(17):1801-1802. PubMed
8. Wolfson D, Santa J, Slass L. Engaging physicians and consumers in conversations about treatment overuse and waste: a short history of the Choosing Wisely campaign. Acad Med. 2014;89(7):990-995. PubMed
9. Smith CD, Levinson WS. A commitment to high-value care education from the internal medicine community. Ann Int Med. 2015;162(9):639-640. PubMed
10. Korenstein D, Kale M, Levinson W. Teaching value in academic environments: shifting the ivory tower. JAMA. 2013;310(16):1671-1672. PubMed
11. Kale MS, Bishop TF, Federman AD, Keyhani S. Trends in the overuse of ambulatory health care services in the United States. JAMA Intern Med. 2013;173(2):142-148. PubMed
12. Rosenberg A, Agiro A, Gottlieb M, et al. Early trends among seven recommendations from the Choosing Wisely campaign. JAMA Intern Med. 2015;175(12):1913-1920. PubMed
13. Prasad V, Ioannidis JP. Evidence-based de-implementation for contradicted, unproven, and aspiring healthcare practices. Implement Sci. 2014;9:1. PubMed
14. Ubel PA, Asch DA. Creating value in health by understanding and overcoming resistance to de-innovation. Health Aff (Millwood). 2015;34(2):239-244. PubMed
15. Powell AA, Bloomfield HE, Burgess DJ, Wilt TJ, Partin MR. A conceptual framework for understanding and reducing overuse by primary care providers. Med Care Res Rev. 2013;70(5):451-472. PubMed
16. Nassery N, Segal JB, Chang E, Bridges JF. Systematic overuse of healthcare services: a conceptual model. Appl Health Econ Health Policy. 2015;13(1):1-6. PubMed
17. Segal JB, Nassery N, Chang HY, Chang E, Chan K, Bridges JF. An index for measuring overuse of health care resources with Medicare claims. Med Care. 2015;53(3):230-236. PubMed
18. Reschovsky JD, Rich EC, Lake TK. Factors contributing to variations in physicians’ use of evidence at the point of care: a conceptual model. J Gen Intern Med. 2015;30(suppl 3):S555-S561. PubMed
19. Feinstein AR, Horwitz RI. Problems in the “evidence” of “evidence-based medicine.” Am J Med. 1997;103(6):529-535. PubMed
20. Makarov DV, Soulos PR, Gold HT, et al. Regional-level correlations in inappropriate imaging rates for prostate and breast cancers: potential implications for the Choosing Wisely campaign. JAMA Oncol. 2015;1(2):185-194. PubMed
21. Romano MJ, Segal JB, Pollack CE. The association between continuity of care and the overuse of medical procedures. JAMA Intern Med. 2015;175(7):1148-1154. PubMed
22. Bayliss EA, Ellis JL, Shoup JA, Zeng C, McQuillan DB, Steiner JF. Effect of continuity of care on hospital utilization for seniors with multiple medical conditions in an integrated health care system. Ann Fam Med. 2015;13(2):123-129. PubMed
23. Chaiyachati KH, Gordon K, Long T, et al. Continuity in a VA patient-centered medical home reduces emergency department visits. PloS One. 2014;9(5):e96356. PubMed
24. Underhill ML, Kiviniemi MT. The association of perceived provider-patient communication and relationship quality with colorectal cancer screening. Health Educ Behav. 2012;39(5):555-563. PubMed
25. Legare F, Labrecque M, Cauchon M, Castel J, Turcotte S, Grimshaw J. Training family physicians in shared decision-making to reduce the overuse of antibiotics in acute respiratory infections: a cluster randomized trial. CMAJ. 2012;184(13):E726-E734. PubMed
26. PerryUndum Research/Communication; for ABIM Foundation. Unnecessary Tests and Procedures in the Health Care System: What Physicians Say About the Problem, the Causes, and the Solutions: Results From a National Survey of Physicians. http://www.choosingwisely.org/wp-content/uploads/2015/04/Final-Choosing-Wisely-Survey-Report.pdf. Published May 1, 2014. Accessed July 8, 2016.
27. Corallo AN, Croxford R, Goodman DC, Bryan EL, Srivastava D, Stukel TA. A systematic review of medical practice variation in OECD countries. Health Policy. 2014;114(1):5-14. PubMed
28. Cutler D, Skinner JS, Stern AD, Wennberg DE. Physician Beliefs and Patient Preferences: A New Look at Regional Variation in Health Care Spending. NBER Working Paper No. 19320. Cambridge, MA: National Bureau of Economic Research; 2013. http://www.nber.org/papers/w19320. Published August 2013. Accessed July 8, 2016.
29. Sirovich BE, Lipner RS, Johnston M, Holmboe ES. The association between residency training and internists’ ability to practice conservatively. JAMA Intern Med. 2014;174(10):1640-1648. PubMed
30. Huttner B, Goossens H, Verheij T, Harbarth S. Characteristics and outcomes of public campaigns aimed at improving the use of antibiotics in outpatients in high-income countries. Lancet Infect Dis. 2010;10(1):17-31. PubMed
31. Perz JF, Craig AS, Coffey CS, et al. Changes in antibiotic prescribing for children after a community-wide campaign. JAMA. 2002;287(23):3103-3109. PubMed
32. Sabuncu E, David J, Bernede-Bauduin C, et al. Significant reduction of antibiotic use in the community after a nationwide campaign in France, 2002-2007. PLoS Med. 2009;6(6):e1000084. PubMed
33. Flodgren G, Eccles MP, Shepperd S, Scott A, Parmelli E, Beyer FR. An overview of reviews evaluating the effectiveness of financial incentives in changing healthcare professional behaviours and patient outcomes. Cochrane Database Syst Rev. 2011;(7):CD009255. PubMed
34. Yoon J, Rose DE, Canelo I, et al. Medical home features of VHA primary care clinics and avoidable hospitalizations. J Gen Intern Med. 2013;28(9):1188-1194. PubMed
35. Gonzales R, Anderer T, McCulloch CE, et al. A cluster randomized trial of decision support strategies for reducing antibiotic use in acute bronchitis. JAMA Intern Med. 2013;173(4):267-273. PubMed
36. Davis MM, Balasubramanian BA, Cifuentes M, et al. Clinician staffing, scheduling, and engagement strategies among primary care practices delivering integrated care. J Am Board Fam Med. 2015;28(suppl 1):S32-S40. PubMed
37. Dine CJ, Miller J, Fuld A, Bellini LM, Iwashyna TJ. Educating physicians-in-training about resource utilization and their own outcomes of care in the inpatient setting. J Grad Med Educ. 2010;2(2):175-180. PubMed
38. Elligsen M, Walker SA, Pinto R, et al. Audit and feedback to reduce broad-spectrum antibiotic use among intensive care unit patients: a controlled interrupted time series analysis. Infect Control Hosp Epidemiol. 2012;33(4):354-361. PubMed
39. Gerber JS, Prasad PA, Fiks AG, et al. Effect of an outpatient antimicrobial stewardship intervention on broad-spectrum antibiotic prescribing by primary care pediatricians: a randomized trial. JAMA. 2013;309(22):2345-2352. PubMed
40. Taggart LR, Leung E, Muller MP, Matukas LM, Daneman N. Differential outcome of an antimicrobial stewardship audit and feedback program in two intensive care units: a controlled interrupted time series study. BMC Infect Dis. 2015;15:480. PubMed
41. Hughes DR, Sunshine JH, Bhargavan M, Forman H. Physician self-referral for imaging and the cost of chronic care for Medicare beneficiaries. Med Care. 2011;49(9):857-864. PubMed
42. Ryskina KL, Pesko MF, Gossey JT, Caesar EP, Bishop TF. Brand name statin prescribing in a resident ambulatory practice: implications for teaching cost-conscious medicine. J Grad Med Educ. 2014;6(3):484-488. PubMed
43. Bhatia RS, Milford CE, Picard MH, Weiner RB. An educational intervention reduces the rate of inappropriate echocardiograms on an inpatient medical service. JACC Cardiovasc Imaging. 2013;6(5):545-555. PubMed
44. Grimshaw JM, Thomas RE, MacLennan G, et al. Effectiveness and efficiency of guideline dissemination and implementation strategies. Health Technol Assess. 2004;8(6):iii-iv, 1-72. PubMed
45. Wilson I, Cowin LS, Johnson M, Young H. Professional identity in medical students: pedagogical challenges to medical education. Teach Learn Med. 2013;25(4):369-373. PubMed
46. Berger Z, Flickinger TE, Pfoh E, Martinez KA, Dy SM. Promoting engagement by patients and families to reduce adverse events in acute care settings: a systematic review. BMJ Qual Saf. 2014;23(7):548-555. PubMed
47. Dykes PC, Stade D, Chang F, et al. Participatory design and development of a patient-centered toolkit to engage hospitalized patients and care partners in their plan of care. AMIA Annu Symp Proc. 2014;2014:486-495. PubMed
48. Coxeter P, Del Mar CB, McGregor L, Beller EM, Hoffmann TC. Interventions to facilitate shared decision making to address antibiotic use for acute respiratory infections in primary care. Cochrane Database Syst Rev. 2015;(11):CD010907. PubMed
49. Stacey D, Legare F, Col NF, et al. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev. 2014;(1):CD001431. PubMed
50. Bank AJ, Gage RM. Annual impact of scribes on physician productivity and revenue in a cardiology clinic. Clinicoecon Outcomes Res. 2015;7:489-495. PubMed
51. Lyles CR, Sarkar U, Schillinger D, et al. Refilling medications through an online patient portal: consistent improvements in adherence across racial/ethnic groups. J Am Med Inform Assoc. 2016;23(e1):e28-e33. PubMed
52. Kruse CS, Bolton K, Freriks G. The effect of patient portals on quality outcomes and its implications to meaningful use: a systematic review. J Med Internet Res. 2015;17(2):e44. PubMed
53. Smith CD. Teaching high-value, cost-conscious care to residents: the Alliance for Academic Internal Medicine-American College of Physicians curriculum. Ann Intern Med. 2012;157(4):284-286. PubMed
54. Redberg RF. Less is more. Arch Intern Med. 2010;170(7):584. PubMed
65. Birkmeyer JD, Reames BN, McCulloch P, Carr AJ, Campbell WB, Wennberg JE. Understanding of regional variation in the use of surgery. Lancet. 2013;382(9898):1121-1129. PubMed
66. Pearson SD, Goldman L, Orav EJ, et al. Triage decisions for emergency department patients with chest pain: do physicians’ risk attitudes make the difference? J Gen Intern Med. 1995;10(10):557-564. PubMed
67. Tubbs EP, Elrod JA, Flum DR. Risk taking and tolerance of uncertainty: implications for surgeons. J Surg Res. 2006;131(1):1-6. PubMed
68. Zaat JO, van Eijk JT. General practitioners’ uncertainty, risk preference, and use of laboratory tests. Med Care. 1992;30(9):846-854. PubMed
69. Barnato AE, Tate JA, Rodriguez KL, Zickmund SL, Arnold RM. Norms of decision making in the ICU: a case study of two academic medical centers at the extremes of end-of-life treatment intensity. Intensive Care Med. 2012;38(11):1886-1896. PubMed
70. Fisher ES, Wennberg JE, Stukel TA, et al. Associations among hospital capacity, utilization, and mortality of US Medicare beneficiaries, controlling for sociodemographic factors. Health Serv Res. 2000;34(6):1351-1362. PubMed
71. Yasaitis LC, Bynum JP, Skinner JS. Association between physician supply, local practice norms, and outpatient visit rates. Med Care. 2013;51(6):524-531. PubMed
72. Chen C, Petterson S, Phillips R, Bazemore A, Mullan F. Spending patterns in region of residency training and subsequent expenditures for care provided by practicing physicians for Medicare beneficiaries. JAMA. 2014;312(22):2385-2393. PubMed
73. Ryskina KL, Smith CD, Weissman A, et al. U.S. internal medicine residents’ knowledge and practice of high-value care: a national survey. Acad Med. 2015;90(10):1373-1379. PubMed
74. Khullar D, Chokshi DA, Kocher R, et al. Behavioral economics and physician compensation—promise and challenges. N Engl J Med. 2015;372(24):2281-2283. PubMed
75. Landon BE, Reschovsky J, Reed M, Blumenthal D. Personal, organizational, and market level influences on physicians’ practice patterns: results of a national survey of primary care physicians. Med Care. 2001;39(8):889-905. PubMed
76. Fanari Z, Abraham N, Kolm P, et al. Aggressive measures to decrease “door to balloon” time and incidence of unnecessary cardiac catheterization: potential risks and role of quality improvement. Mayo Clin Proc. 2015;90(12):1614-1622. PubMed
77. Kerr EA, Lucatorto MA, Holleman R, Hogan MM, Klamerus ML, Hofer TP. Monitoring performance for blood pressure management among patients with diabetes mellitus: too much of a good thing? Arch Intern Med. 2012;172(12):938-945. PubMed
78. Verhofstede R, Smets T, Cohen J, Costantini M, Van Den Noortgate N, Deliens L. Implementing the care programme for the last days of life in an acute geriatric hospital ward: a phase 2 mixed method study. BMC Palliat Care. 2016;15:27. PubMed
© 2017 Society of Hospital Medicine
SOAP‐V Method for Bending the Cost Curve
Today's medical students will enter practice over the next decade and inherit the escalating costs of the US healthcare system. Approximately 30% of healthcare costs, or $750 billion dollars annually, are spent on unnecessary tests or procedures.[1] High healthcare costs combined with calls to eliminate waste, improve patient safety, and increase quality[2] are driving our healthcare system to evolve from a fee‐based system to a value‐based system. Additionally, many patients are being harmed by overtesting and the stress associated with rising healthcare bills. Financial risk has increasingly shifted to patients in the form of higher deductibles and reduced caps, and medical indebtedness is the number 1 risk for bankruptcy.[3, 4] False positive results of low‐yield diagnostic tests lead to additional testing, anxiety, excess radiation exposure, and unnecessary invasive procedures.[5] To minimize harm to patients, evidence must guide physicians in their ordering behavior. In addition, any care plan a physician develops should be individualized to incorporate patients' values and preferences. Unfortunately, medical students, who are at an impressionable stage in their careers, frequently observe overtesting and unnecessary treatment behaviors in their clinical encounters.[6] Instead, our medical students and trainees must be prepared to deliver patient care that is evidence based, patient centered, and cost conscious. They must become effective stewards of limited healthcare resources.
To help prepare our students for this evolving healthcare paradigm, we created a new tool called SOAP‐V (Subjective‐Objective‐Assessment‐PlanValue), designed to embed discussion of healthcare value into medical student oral presentations and note writing. Students are encouraged to use this tool at the point of care to bring up value concepts with physicians and residents as part of medical decision making. In so doing, we propose that medical students can serve as change agents to shift physician practice at our academic medical centers to focus on healthcare value. This article describes the SOAP‐V tool, contains links to educational materials to help hospitalists and other clinician educators to implement this tool, and provides preliminary findings and reflections.
INNOVATION
SOAP‐V was conceived at the Millennium Conference on Teaching High‐Value Care, which was sponsored by the Beth Israel Deaconess Medical Center Shapiro Institute for Education and Research, the Association of American Medical Colleges, and the American College of Physicians. Educators from several medical schools decided to form a group to specifically consider ways to train medical students and residents in the concept of high‐value care (HVC), which is framed as improving patient outcomes while decreasing patient cost and harm.[7] Our group recognized several challenges in teaching HVC. First, physician practice habits are influenced by the way they are trained,[8] yet faculty who teach those future physicians frequently have not themselves been taught, nor do they consistently practice HVC.[9] Second, we needed to teach students the requisite HVC knowledge, attitudes, and skills, and therefore wanted to provide opportunities to not only learn, but practice, HVC, preferably in authentic patient experiences to optimize their learning.[10, 11] Third, we recognized that adding another teaching task to the already oversubscribed day of an attending might understandably be met with resistance. We envisioned a tool that could be used with minimal or no faculty training, could be attached to authentic patient experiences, and based on LEAN‐Six Sigma principles,[12] would be embedded in the normal workflow. Furthermore, we considered social networking principles, such as those described by Christakis and Fowler that describe how an individual's behavior impacts behaviors of those surrounding them,[13] and hoped to empower medical students to serve as change agents. Medical students could initiate discussions of value concepts at the point of care in a way that challenges a heavily entrenched test‐ordering culture and encourages other members of the team to balance potential benefit with harms and cost. Following the conference, the group held bimonthly phone conferences and subsequently developed the SOAP‐V tool, created teaching materials, and planned a research project on SOAP‐V.
SOAP‐V modifies the traditional SOAP (Subjective‐Objective‐Assessment‐Plan) oral presentation or medical note, to include value (V). It serves as a cognitive forcing function designed to create a pause and promote discussions of HVC during patient delivery. It prompts the student to ask 3 value questions: (1) Before choosing an intervention, have I considered whether the result would change management? (2) Have I incorporated the patient's goals and values, and considered the potential harm of the intervention compared to alternatives? (3) What is the known and potential cost of the intervention, both immediate and downstream? The student gathers information during the patient interview and brings back the information to the team during rounds where management decisions are made.
In the summer of 2014, we launched an institutional review boardapproved, multi‐institutional study to implement SOAP‐V at Penn State College of Medicine, Harvard Medical School, and Case Western Reserve University School of Medicine for third‐year medical students during their internal medicine clerkships. Students in the intervention arm participated in an interactive workshop on SOAP‐V. Authors S.F., S.G., and C.D.P., who serve as clerkship directors in internal medicine, provided student training for each cohort of intervention students at the beginning of each rotation on general medicine inpatient wards. The workshop began with trigger videos that demonstrate pressures encountered by a student on rounds that might lead to overuse.[14] Following a discussion on overuse and methods to avoid overuse, the students were introduced to the SOAP‐V framework, watched a video of a student modeling a SOAP‐V presentation on rounds,[15] and engaged in a SOAP‐V role play. They received a SOAP‐V pocket card as well as a Web link to Healthcare Bluebook[16] to research costs. An outline of the session and associated materials can be found in an online attachment.[17] The students then used the SOAP‐V tool during inpatient rounds. We advised supervising faculty that students might present using a SOAP‐V format, and provided them with a SOAP‐V card, but we did not provide faculty development on SOAP‐V. Students participating in the control arm did not receive training specific to SOAP‐V.
Students in intervention and control arms at each school were surveyed on their attitudes toward HVC at the beginning of the clerkship year and then again at the completion of the medicine clerkship via a 19‐item questionnaire soliciting perceptions and self‐reported practices in HVC. Intervention arm students received biweekly e‐mail links that allowed them to anonymously document their use of SOAP‐V, as well as an end‐of‐clerkship open‐ended question about the usefulness of SOAP‐V. We analyzed questionnaire results using McNemar's test for paired data.
PRELIMINARY FINDINGS
The preintervention attitudinal survey (n = 226) demonstrated that although 90% of medical students agreed on the importance of considering costs of treatments, only 50% felt comfortable bringing up cost considerations with their team, and 50% considered costs to the healthcare system in clinical decisions. An interim analysis of the available data at 6 months (response rate approximately 50% across sites) showed that students in the intervention arm reported increased agreement with the phrases, I have the power to address the economic healthcare crisis (pre‐37%, post‐65%, P = 0.046); I would be comfortable initiating a discussion about unnecessary tests or treatments with my team, (pre‐46%, post‐85%, P = 0.027); and In my clinical decisions, I consider the potential costs to the healthcare system (pre‐41%, post‐60%, P = 0.023) compared to control arm students, who showed no significant differences pre‐ versus postrotation in these 3 domains (Figure 1).
To date, biweekly surveys and direct observation of rounds have verified student use of SOAP‐V. Student comments have included: Allowed me the ability to raise important issues with the team while feeling like I was helping my patients and the healthcare system. A great principle that I used almost daily. Great to implement this at such a young stage in my med career. Broadened my perspective on the role of a physician.
SOAP‐V has inspired some of our medical students to consider value in healthcare more closely. In a notable example, a SOAP‐Vtrained student admitted a young man with lymphadenopathy, pulmonary infiltrates, and weight loss who underwent an extensive and costly workup including liver biopsy, bronchoscopy, and multiple computed tomography and positron emission tomography scans and was eventually diagnosed with sarcoidosis. The SOAP‐Vtrained student reviewed the patient's workup, estimated that the team spent more than $6000 to make the diagnosis, and recommended a more cost‐effective approach.
Common barriers experienced by the pilot sites included time constraints limiting discussion of value, variability in perceived receptivity depending on team leadership, and student confidence in initiating this dialogue. Solutions included underscoring the notion that value discussions can be brief, may be appropriately initiated by any member of the team, and may have an effect on choice of management and/or patient preference issues that can make medical care more efficient and effective. Resident and faculty physicians were made aware of the intervention, and encouraged to support students in using the SOAP‐V tool.
CONCLUSION
SOAP‐V was successfully implemented within the inpatient internal medicine clerkship at 3 academic institutions. Our preliminary results demonstrate that students can use this framework to apply considerations of high‐value, cost‐conscious care in their medical decision making and to promote discussion of these concepts during rounds with their inpatient teams. Students in the intervention arm report greater comfort discussing unnecessary tests and treatments with their team and a greater likelihood to consider potential costs to the healthcare system. Additionally, these students commented that the SOAP‐V framework broadened their perspective on their role as a physician in curbing costs, and that they felt more empowered to address the economic healthcare crisis. The next phase of our project will involve conducting end‐of‐year surveys to evaluate whether SOAP‐V has a persistent impact on the frequency and quality of value discussions on rounds, as well as students' attitudes about cost consciousness. We will also gauge whether resident and faculty attitudes about HVC have changed as a result of the intervention.
Our SOAP‐V student training was provided in a 1‐hour session. We believe that the ease of training and the simplicity of the SOAP‐V framework permit SOAP‐V to be easily transferred for use by residents, medical students in other clerkships, and other healthcare learners. Additional research is needed to demonstrate this expanded use and prove sustainability. An additional important question is whether use of SOAP‐V by students and residents results in reductions in unnecessary costs. Future educational efforts will include embedding the SOAP‐V tool in other clerkships and promoting the SOAP‐V tool within corresponding residencies in both hospital and outpatient clinic settings and analyzing potential reductions in wasteful spending.
It is generally conceived that medical students learn the information they are taught, and are impacted by the culture in which they reside; multiple studies bear this out.[18, 19] However, students may also be change agents. Our students will inherit the healthcare systems of the future. We must empower them to change the status quo. There can be tremendous utility in employing such a bottom up approach to process improvement. What a student discusses today may spark the resident (or faculty) to consider in their own workflow tomorrow. In this way, we envision that the SOAP‐V is a tool by which ideas concerning HVC can be generated and shared at the point of care. It is our hope that this straightforward intervention is one that may slowly change the culture and perhaps eventually the practice patterns of our academic medical centers.
Disclosure
Nothing to report.
- Institute of Medicine. The Healthcare Imperative: Lowering Costs and Improving Outcomes. Washington, DC: The National Academies Press; 2010.
- Institute for Healthcare Improvement. IHI triple aim initiative. Available at: http://www.ihi.org/Engage/Initiatives/TripleAim/pages/default.aspx. Accessed August 7, 2015.
- , , , . Medical bankruptcy in the United States, 2007. Am J Med. 2009;122(8):741–746.
- . Kaiser Family Foundation. Health care costs: a primer. Key information on health care costs and their impact. May 2012. Available at: https://kaiserfamilyfoundation.files.wordpress.com/2013/01/7670–03.pdf. Accessed August 7, 2015.
- , . Over‐testing: why more is not better. Am J Med. 2014;127:362–363.
- , , . Medical student perceptions of cost‐conscious care in an internal medicine clerkship: a thematic analysis [published online May 1, 2015]. J Gen Intern Med. doi: 10.1007/s11606‐015‐3324‐4.
- , , , . High‐value, cost‐conscious health care: concepts for clinicians to evaluate the benefits, harms, and costs of medical interventions. Ann Intern Med. 2011;154:174–180.
- . Providing high‐value, cost‐conscious care: a critical seventh general competency for physicians. Ann Intern Med. 2011;155:386–388.
- , , . Teaching value in academic environments: shifting the ivory tower. JAMA. 2013;310(16):1671–1672.
- , , . Theories of teaching. In: The Adult Learner. New York, NY: Routledge; 2012:72–114.
- . Medical education and the maintenance of incompetence. Med Teach. 2006;28:690–696.
- , , , , . Lean Six Sigma in healthcare. J Healthcare Qual. 2006;2:4–11
- , . Connected. New York, NY: Little, Brown 2009.
- Teaching Value Project. Costs of care. Available at: teachingvalue.org Available at: https://www.dropbox.com/s/tb8ysfjtzklwd8g/OverrunPart1.webm; https://www.dropbox.com/s/cxt9mvabj4re4g9/OverrunPart2.webm. Accessed August 7, 2015.
- , , . SOAP‐V [online video]. Available at: https://www.youtube.com/watch?v=goUgAzLuTzY47(2):134–143.
- , , , , , . How medical students learn from residents in the workplace: a qualitative study. Acad Med. 2014:89(3):490–496.
Today's medical students will enter practice over the next decade and inherit the escalating costs of the US healthcare system. Approximately 30% of healthcare costs, or $750 billion dollars annually, are spent on unnecessary tests or procedures.[1] High healthcare costs combined with calls to eliminate waste, improve patient safety, and increase quality[2] are driving our healthcare system to evolve from a fee‐based system to a value‐based system. Additionally, many patients are being harmed by overtesting and the stress associated with rising healthcare bills. Financial risk has increasingly shifted to patients in the form of higher deductibles and reduced caps, and medical indebtedness is the number 1 risk for bankruptcy.[3, 4] False positive results of low‐yield diagnostic tests lead to additional testing, anxiety, excess radiation exposure, and unnecessary invasive procedures.[5] To minimize harm to patients, evidence must guide physicians in their ordering behavior. In addition, any care plan a physician develops should be individualized to incorporate patients' values and preferences. Unfortunately, medical students, who are at an impressionable stage in their careers, frequently observe overtesting and unnecessary treatment behaviors in their clinical encounters.[6] Instead, our medical students and trainees must be prepared to deliver patient care that is evidence based, patient centered, and cost conscious. They must become effective stewards of limited healthcare resources.
To help prepare our students for this evolving healthcare paradigm, we created a new tool called SOAP‐V (Subjective‐Objective‐Assessment‐PlanValue), designed to embed discussion of healthcare value into medical student oral presentations and note writing. Students are encouraged to use this tool at the point of care to bring up value concepts with physicians and residents as part of medical decision making. In so doing, we propose that medical students can serve as change agents to shift physician practice at our academic medical centers to focus on healthcare value. This article describes the SOAP‐V tool, contains links to educational materials to help hospitalists and other clinician educators to implement this tool, and provides preliminary findings and reflections.
INNOVATION
SOAP‐V was conceived at the Millennium Conference on Teaching High‐Value Care, which was sponsored by the Beth Israel Deaconess Medical Center Shapiro Institute for Education and Research, the Association of American Medical Colleges, and the American College of Physicians. Educators from several medical schools decided to form a group to specifically consider ways to train medical students and residents in the concept of high‐value care (HVC), which is framed as improving patient outcomes while decreasing patient cost and harm.[7] Our group recognized several challenges in teaching HVC. First, physician practice habits are influenced by the way they are trained,[8] yet faculty who teach those future physicians frequently have not themselves been taught, nor do they consistently practice HVC.[9] Second, we needed to teach students the requisite HVC knowledge, attitudes, and skills, and therefore wanted to provide opportunities to not only learn, but practice, HVC, preferably in authentic patient experiences to optimize their learning.[10, 11] Third, we recognized that adding another teaching task to the already oversubscribed day of an attending might understandably be met with resistance. We envisioned a tool that could be used with minimal or no faculty training, could be attached to authentic patient experiences, and based on LEAN‐Six Sigma principles,[12] would be embedded in the normal workflow. Furthermore, we considered social networking principles, such as those described by Christakis and Fowler that describe how an individual's behavior impacts behaviors of those surrounding them,[13] and hoped to empower medical students to serve as change agents. Medical students could initiate discussions of value concepts at the point of care in a way that challenges a heavily entrenched test‐ordering culture and encourages other members of the team to balance potential benefit with harms and cost. Following the conference, the group held bimonthly phone conferences and subsequently developed the SOAP‐V tool, created teaching materials, and planned a research project on SOAP‐V.
SOAP‐V modifies the traditional SOAP (Subjective‐Objective‐Assessment‐Plan) oral presentation or medical note, to include value (V). It serves as a cognitive forcing function designed to create a pause and promote discussions of HVC during patient delivery. It prompts the student to ask 3 value questions: (1) Before choosing an intervention, have I considered whether the result would change management? (2) Have I incorporated the patient's goals and values, and considered the potential harm of the intervention compared to alternatives? (3) What is the known and potential cost of the intervention, both immediate and downstream? The student gathers information during the patient interview and brings back the information to the team during rounds where management decisions are made.
In the summer of 2014, we launched an institutional review boardapproved, multi‐institutional study to implement SOAP‐V at Penn State College of Medicine, Harvard Medical School, and Case Western Reserve University School of Medicine for third‐year medical students during their internal medicine clerkships. Students in the intervention arm participated in an interactive workshop on SOAP‐V. Authors S.F., S.G., and C.D.P., who serve as clerkship directors in internal medicine, provided student training for each cohort of intervention students at the beginning of each rotation on general medicine inpatient wards. The workshop began with trigger videos that demonstrate pressures encountered by a student on rounds that might lead to overuse.[14] Following a discussion on overuse and methods to avoid overuse, the students were introduced to the SOAP‐V framework, watched a video of a student modeling a SOAP‐V presentation on rounds,[15] and engaged in a SOAP‐V role play. They received a SOAP‐V pocket card as well as a Web link to Healthcare Bluebook[16] to research costs. An outline of the session and associated materials can be found in an online attachment.[17] The students then used the SOAP‐V tool during inpatient rounds. We advised supervising faculty that students might present using a SOAP‐V format, and provided them with a SOAP‐V card, but we did not provide faculty development on SOAP‐V. Students participating in the control arm did not receive training specific to SOAP‐V.
Students in intervention and control arms at each school were surveyed on their attitudes toward HVC at the beginning of the clerkship year and then again at the completion of the medicine clerkship via a 19‐item questionnaire soliciting perceptions and self‐reported practices in HVC. Intervention arm students received biweekly e‐mail links that allowed them to anonymously document their use of SOAP‐V, as well as an end‐of‐clerkship open‐ended question about the usefulness of SOAP‐V. We analyzed questionnaire results using McNemar's test for paired data.
PRELIMINARY FINDINGS
The preintervention attitudinal survey (n = 226) demonstrated that although 90% of medical students agreed on the importance of considering costs of treatments, only 50% felt comfortable bringing up cost considerations with their team, and 50% considered costs to the healthcare system in clinical decisions. An interim analysis of the available data at 6 months (response rate approximately 50% across sites) showed that students in the intervention arm reported increased agreement with the phrases, I have the power to address the economic healthcare crisis (pre‐37%, post‐65%, P = 0.046); I would be comfortable initiating a discussion about unnecessary tests or treatments with my team, (pre‐46%, post‐85%, P = 0.027); and In my clinical decisions, I consider the potential costs to the healthcare system (pre‐41%, post‐60%, P = 0.023) compared to control arm students, who showed no significant differences pre‐ versus postrotation in these 3 domains (Figure 1).
To date, biweekly surveys and direct observation of rounds have verified student use of SOAP‐V. Student comments have included: Allowed me the ability to raise important issues with the team while feeling like I was helping my patients and the healthcare system. A great principle that I used almost daily. Great to implement this at such a young stage in my med career. Broadened my perspective on the role of a physician.
SOAP‐V has inspired some of our medical students to consider value in healthcare more closely. In a notable example, a SOAP‐Vtrained student admitted a young man with lymphadenopathy, pulmonary infiltrates, and weight loss who underwent an extensive and costly workup including liver biopsy, bronchoscopy, and multiple computed tomography and positron emission tomography scans and was eventually diagnosed with sarcoidosis. The SOAP‐Vtrained student reviewed the patient's workup, estimated that the team spent more than $6000 to make the diagnosis, and recommended a more cost‐effective approach.
Common barriers experienced by the pilot sites included time constraints limiting discussion of value, variability in perceived receptivity depending on team leadership, and student confidence in initiating this dialogue. Solutions included underscoring the notion that value discussions can be brief, may be appropriately initiated by any member of the team, and may have an effect on choice of management and/or patient preference issues that can make medical care more efficient and effective. Resident and faculty physicians were made aware of the intervention, and encouraged to support students in using the SOAP‐V tool.
CONCLUSION
SOAP‐V was successfully implemented within the inpatient internal medicine clerkship at 3 academic institutions. Our preliminary results demonstrate that students can use this framework to apply considerations of high‐value, cost‐conscious care in their medical decision making and to promote discussion of these concepts during rounds with their inpatient teams. Students in the intervention arm report greater comfort discussing unnecessary tests and treatments with their team and a greater likelihood to consider potential costs to the healthcare system. Additionally, these students commented that the SOAP‐V framework broadened their perspective on their role as a physician in curbing costs, and that they felt more empowered to address the economic healthcare crisis. The next phase of our project will involve conducting end‐of‐year surveys to evaluate whether SOAP‐V has a persistent impact on the frequency and quality of value discussions on rounds, as well as students' attitudes about cost consciousness. We will also gauge whether resident and faculty attitudes about HVC have changed as a result of the intervention.
Our SOAP‐V student training was provided in a 1‐hour session. We believe that the ease of training and the simplicity of the SOAP‐V framework permit SOAP‐V to be easily transferred for use by residents, medical students in other clerkships, and other healthcare learners. Additional research is needed to demonstrate this expanded use and prove sustainability. An additional important question is whether use of SOAP‐V by students and residents results in reductions in unnecessary costs. Future educational efforts will include embedding the SOAP‐V tool in other clerkships and promoting the SOAP‐V tool within corresponding residencies in both hospital and outpatient clinic settings and analyzing potential reductions in wasteful spending.
It is generally conceived that medical students learn the information they are taught, and are impacted by the culture in which they reside; multiple studies bear this out.[18, 19] However, students may also be change agents. Our students will inherit the healthcare systems of the future. We must empower them to change the status quo. There can be tremendous utility in employing such a bottom up approach to process improvement. What a student discusses today may spark the resident (or faculty) to consider in their own workflow tomorrow. In this way, we envision that the SOAP‐V is a tool by which ideas concerning HVC can be generated and shared at the point of care. It is our hope that this straightforward intervention is one that may slowly change the culture and perhaps eventually the practice patterns of our academic medical centers.
Disclosure
Nothing to report.
Today's medical students will enter practice over the next decade and inherit the escalating costs of the US healthcare system. Approximately 30% of healthcare costs, or $750 billion dollars annually, are spent on unnecessary tests or procedures.[1] High healthcare costs combined with calls to eliminate waste, improve patient safety, and increase quality[2] are driving our healthcare system to evolve from a fee‐based system to a value‐based system. Additionally, many patients are being harmed by overtesting and the stress associated with rising healthcare bills. Financial risk has increasingly shifted to patients in the form of higher deductibles and reduced caps, and medical indebtedness is the number 1 risk for bankruptcy.[3, 4] False positive results of low‐yield diagnostic tests lead to additional testing, anxiety, excess radiation exposure, and unnecessary invasive procedures.[5] To minimize harm to patients, evidence must guide physicians in their ordering behavior. In addition, any care plan a physician develops should be individualized to incorporate patients' values and preferences. Unfortunately, medical students, who are at an impressionable stage in their careers, frequently observe overtesting and unnecessary treatment behaviors in their clinical encounters.[6] Instead, our medical students and trainees must be prepared to deliver patient care that is evidence based, patient centered, and cost conscious. They must become effective stewards of limited healthcare resources.
To help prepare our students for this evolving healthcare paradigm, we created a new tool called SOAP‐V (Subjective‐Objective‐Assessment‐PlanValue), designed to embed discussion of healthcare value into medical student oral presentations and note writing. Students are encouraged to use this tool at the point of care to bring up value concepts with physicians and residents as part of medical decision making. In so doing, we propose that medical students can serve as change agents to shift physician practice at our academic medical centers to focus on healthcare value. This article describes the SOAP‐V tool, contains links to educational materials to help hospitalists and other clinician educators to implement this tool, and provides preliminary findings and reflections.
INNOVATION
SOAP‐V was conceived at the Millennium Conference on Teaching High‐Value Care, which was sponsored by the Beth Israel Deaconess Medical Center Shapiro Institute for Education and Research, the Association of American Medical Colleges, and the American College of Physicians. Educators from several medical schools decided to form a group to specifically consider ways to train medical students and residents in the concept of high‐value care (HVC), which is framed as improving patient outcomes while decreasing patient cost and harm.[7] Our group recognized several challenges in teaching HVC. First, physician practice habits are influenced by the way they are trained,[8] yet faculty who teach those future physicians frequently have not themselves been taught, nor do they consistently practice HVC.[9] Second, we needed to teach students the requisite HVC knowledge, attitudes, and skills, and therefore wanted to provide opportunities to not only learn, but practice, HVC, preferably in authentic patient experiences to optimize their learning.[10, 11] Third, we recognized that adding another teaching task to the already oversubscribed day of an attending might understandably be met with resistance. We envisioned a tool that could be used with minimal or no faculty training, could be attached to authentic patient experiences, and based on LEAN‐Six Sigma principles,[12] would be embedded in the normal workflow. Furthermore, we considered social networking principles, such as those described by Christakis and Fowler that describe how an individual's behavior impacts behaviors of those surrounding them,[13] and hoped to empower medical students to serve as change agents. Medical students could initiate discussions of value concepts at the point of care in a way that challenges a heavily entrenched test‐ordering culture and encourages other members of the team to balance potential benefit with harms and cost. Following the conference, the group held bimonthly phone conferences and subsequently developed the SOAP‐V tool, created teaching materials, and planned a research project on SOAP‐V.
SOAP‐V modifies the traditional SOAP (Subjective‐Objective‐Assessment‐Plan) oral presentation or medical note, to include value (V). It serves as a cognitive forcing function designed to create a pause and promote discussions of HVC during patient delivery. It prompts the student to ask 3 value questions: (1) Before choosing an intervention, have I considered whether the result would change management? (2) Have I incorporated the patient's goals and values, and considered the potential harm of the intervention compared to alternatives? (3) What is the known and potential cost of the intervention, both immediate and downstream? The student gathers information during the patient interview and brings back the information to the team during rounds where management decisions are made.
In the summer of 2014, we launched an institutional review boardapproved, multi‐institutional study to implement SOAP‐V at Penn State College of Medicine, Harvard Medical School, and Case Western Reserve University School of Medicine for third‐year medical students during their internal medicine clerkships. Students in the intervention arm participated in an interactive workshop on SOAP‐V. Authors S.F., S.G., and C.D.P., who serve as clerkship directors in internal medicine, provided student training for each cohort of intervention students at the beginning of each rotation on general medicine inpatient wards. The workshop began with trigger videos that demonstrate pressures encountered by a student on rounds that might lead to overuse.[14] Following a discussion on overuse and methods to avoid overuse, the students were introduced to the SOAP‐V framework, watched a video of a student modeling a SOAP‐V presentation on rounds,[15] and engaged in a SOAP‐V role play. They received a SOAP‐V pocket card as well as a Web link to Healthcare Bluebook[16] to research costs. An outline of the session and associated materials can be found in an online attachment.[17] The students then used the SOAP‐V tool during inpatient rounds. We advised supervising faculty that students might present using a SOAP‐V format, and provided them with a SOAP‐V card, but we did not provide faculty development on SOAP‐V. Students participating in the control arm did not receive training specific to SOAP‐V.
Students in intervention and control arms at each school were surveyed on their attitudes toward HVC at the beginning of the clerkship year and then again at the completion of the medicine clerkship via a 19‐item questionnaire soliciting perceptions and self‐reported practices in HVC. Intervention arm students received biweekly e‐mail links that allowed them to anonymously document their use of SOAP‐V, as well as an end‐of‐clerkship open‐ended question about the usefulness of SOAP‐V. We analyzed questionnaire results using McNemar's test for paired data.
PRELIMINARY FINDINGS
The preintervention attitudinal survey (n = 226) demonstrated that although 90% of medical students agreed on the importance of considering costs of treatments, only 50% felt comfortable bringing up cost considerations with their team, and 50% considered costs to the healthcare system in clinical decisions. An interim analysis of the available data at 6 months (response rate approximately 50% across sites) showed that students in the intervention arm reported increased agreement with the phrases, I have the power to address the economic healthcare crisis (pre‐37%, post‐65%, P = 0.046); I would be comfortable initiating a discussion about unnecessary tests or treatments with my team, (pre‐46%, post‐85%, P = 0.027); and In my clinical decisions, I consider the potential costs to the healthcare system (pre‐41%, post‐60%, P = 0.023) compared to control arm students, who showed no significant differences pre‐ versus postrotation in these 3 domains (Figure 1).
To date, biweekly surveys and direct observation of rounds have verified student use of SOAP‐V. Student comments have included: Allowed me the ability to raise important issues with the team while feeling like I was helping my patients and the healthcare system. A great principle that I used almost daily. Great to implement this at such a young stage in my med career. Broadened my perspective on the role of a physician.
SOAP‐V has inspired some of our medical students to consider value in healthcare more closely. In a notable example, a SOAP‐Vtrained student admitted a young man with lymphadenopathy, pulmonary infiltrates, and weight loss who underwent an extensive and costly workup including liver biopsy, bronchoscopy, and multiple computed tomography and positron emission tomography scans and was eventually diagnosed with sarcoidosis. The SOAP‐Vtrained student reviewed the patient's workup, estimated that the team spent more than $6000 to make the diagnosis, and recommended a more cost‐effective approach.
Common barriers experienced by the pilot sites included time constraints limiting discussion of value, variability in perceived receptivity depending on team leadership, and student confidence in initiating this dialogue. Solutions included underscoring the notion that value discussions can be brief, may be appropriately initiated by any member of the team, and may have an effect on choice of management and/or patient preference issues that can make medical care more efficient and effective. Resident and faculty physicians were made aware of the intervention, and encouraged to support students in using the SOAP‐V tool.
CONCLUSION
SOAP‐V was successfully implemented within the inpatient internal medicine clerkship at 3 academic institutions. Our preliminary results demonstrate that students can use this framework to apply considerations of high‐value, cost‐conscious care in their medical decision making and to promote discussion of these concepts during rounds with their inpatient teams. Students in the intervention arm report greater comfort discussing unnecessary tests and treatments with their team and a greater likelihood to consider potential costs to the healthcare system. Additionally, these students commented that the SOAP‐V framework broadened their perspective on their role as a physician in curbing costs, and that they felt more empowered to address the economic healthcare crisis. The next phase of our project will involve conducting end‐of‐year surveys to evaluate whether SOAP‐V has a persistent impact on the frequency and quality of value discussions on rounds, as well as students' attitudes about cost consciousness. We will also gauge whether resident and faculty attitudes about HVC have changed as a result of the intervention.
Our SOAP‐V student training was provided in a 1‐hour session. We believe that the ease of training and the simplicity of the SOAP‐V framework permit SOAP‐V to be easily transferred for use by residents, medical students in other clerkships, and other healthcare learners. Additional research is needed to demonstrate this expanded use and prove sustainability. An additional important question is whether use of SOAP‐V by students and residents results in reductions in unnecessary costs. Future educational efforts will include embedding the SOAP‐V tool in other clerkships and promoting the SOAP‐V tool within corresponding residencies in both hospital and outpatient clinic settings and analyzing potential reductions in wasteful spending.
It is generally conceived that medical students learn the information they are taught, and are impacted by the culture in which they reside; multiple studies bear this out.[18, 19] However, students may also be change agents. Our students will inherit the healthcare systems of the future. We must empower them to change the status quo. There can be tremendous utility in employing such a bottom up approach to process improvement. What a student discusses today may spark the resident (or faculty) to consider in their own workflow tomorrow. In this way, we envision that the SOAP‐V is a tool by which ideas concerning HVC can be generated and shared at the point of care. It is our hope that this straightforward intervention is one that may slowly change the culture and perhaps eventually the practice patterns of our academic medical centers.
Disclosure
Nothing to report.
- Institute of Medicine. The Healthcare Imperative: Lowering Costs and Improving Outcomes. Washington, DC: The National Academies Press; 2010.
- Institute for Healthcare Improvement. IHI triple aim initiative. Available at: http://www.ihi.org/Engage/Initiatives/TripleAim/pages/default.aspx. Accessed August 7, 2015.
- , , , . Medical bankruptcy in the United States, 2007. Am J Med. 2009;122(8):741–746.
- . Kaiser Family Foundation. Health care costs: a primer. Key information on health care costs and their impact. May 2012. Available at: https://kaiserfamilyfoundation.files.wordpress.com/2013/01/7670–03.pdf. Accessed August 7, 2015.
- , . Over‐testing: why more is not better. Am J Med. 2014;127:362–363.
- , , . Medical student perceptions of cost‐conscious care in an internal medicine clerkship: a thematic analysis [published online May 1, 2015]. J Gen Intern Med. doi: 10.1007/s11606‐015‐3324‐4.
- , , , . High‐value, cost‐conscious health care: concepts for clinicians to evaluate the benefits, harms, and costs of medical interventions. Ann Intern Med. 2011;154:174–180.
- . Providing high‐value, cost‐conscious care: a critical seventh general competency for physicians. Ann Intern Med. 2011;155:386–388.
- , , . Teaching value in academic environments: shifting the ivory tower. JAMA. 2013;310(16):1671–1672.
- , , . Theories of teaching. In: The Adult Learner. New York, NY: Routledge; 2012:72–114.
- . Medical education and the maintenance of incompetence. Med Teach. 2006;28:690–696.
- , , , , . Lean Six Sigma in healthcare. J Healthcare Qual. 2006;2:4–11
- , . Connected. New York, NY: Little, Brown 2009.
- Teaching Value Project. Costs of care. Available at: teachingvalue.org Available at: https://www.dropbox.com/s/tb8ysfjtzklwd8g/OverrunPart1.webm; https://www.dropbox.com/s/cxt9mvabj4re4g9/OverrunPart2.webm. Accessed August 7, 2015.
- , , . SOAP‐V [online video]. Available at: https://www.youtube.com/watch?v=goUgAzLuTzY47(2):134–143.
- , , , , , . How medical students learn from residents in the workplace: a qualitative study. Acad Med. 2014:89(3):490–496.
- Institute of Medicine. The Healthcare Imperative: Lowering Costs and Improving Outcomes. Washington, DC: The National Academies Press; 2010.
- Institute for Healthcare Improvement. IHI triple aim initiative. Available at: http://www.ihi.org/Engage/Initiatives/TripleAim/pages/default.aspx. Accessed August 7, 2015.
- , , , . Medical bankruptcy in the United States, 2007. Am J Med. 2009;122(8):741–746.
- . Kaiser Family Foundation. Health care costs: a primer. Key information on health care costs and their impact. May 2012. Available at: https://kaiserfamilyfoundation.files.wordpress.com/2013/01/7670–03.pdf. Accessed August 7, 2015.
- , . Over‐testing: why more is not better. Am J Med. 2014;127:362–363.
- , , . Medical student perceptions of cost‐conscious care in an internal medicine clerkship: a thematic analysis [published online May 1, 2015]. J Gen Intern Med. doi: 10.1007/s11606‐015‐3324‐4.
- , , , . High‐value, cost‐conscious health care: concepts for clinicians to evaluate the benefits, harms, and costs of medical interventions. Ann Intern Med. 2011;154:174–180.
- . Providing high‐value, cost‐conscious care: a critical seventh general competency for physicians. Ann Intern Med. 2011;155:386–388.
- , , . Teaching value in academic environments: shifting the ivory tower. JAMA. 2013;310(16):1671–1672.
- , , . Theories of teaching. In: The Adult Learner. New York, NY: Routledge; 2012:72–114.
- . Medical education and the maintenance of incompetence. Med Teach. 2006;28:690–696.
- , , , , . Lean Six Sigma in healthcare. J Healthcare Qual. 2006;2:4–11
- , . Connected. New York, NY: Little, Brown 2009.
- Teaching Value Project. Costs of care. Available at: teachingvalue.org Available at: https://www.dropbox.com/s/tb8ysfjtzklwd8g/OverrunPart1.webm; https://www.dropbox.com/s/cxt9mvabj4re4g9/OverrunPart2.webm. Accessed August 7, 2015.
- , , . SOAP‐V [online video]. Available at: https://www.youtube.com/watch?v=goUgAzLuTzY47(2):134–143.
- , , , , , . How medical students learn from residents in the workplace: a qualitative study. Acad Med. 2014:89(3):490–496.
