Christopher Moriates, MD

Avoiding Low‐Value Services at the Point of Care

The largest contributor to the approximately $750 billion in annual healthcare waste is unnecessary services, which includes overuse, discretionary use beyond benchmarks, and unnecessary choice of higher‐cost services.[19] Drivers of overuse include medical culture, fee‐for‐service payments, patient expectations, and fear of malpractice litigation.[20] For practicing hospitalists, the most substantial motivation for overuse may be a desire to reassure patients and themselves.[21] Unfortunately, patients commonly overestimate the benefits and underestimate the potential harms of testing and treatments.[22] However, clear communication with patients can reduce overuse, underuse, and misuse.[23]

Specific targets for improving appropriate resource utilization may be identified from resources such as Choosing Wisely lists, guidelines, and appropriateness criteria. The Choosing Wisely campaign has brought together an unprecedented number of medical specialty societies to issue top five lists of things that physicians and patients should question (www.choosingwisely.org). In February 2013, the Society of Hospital Medicine released their Choosing Wisely lists for both adult and pediatric hospital medicine (Table 1).[6, 24] Hospitalists report printing out these lists, posting them in offices and clinical areas, and handing them out to trainees and colleagues.[25] Likewise, the American College of Radiology (ACR) and the American College of Cardiology provide appropriateness criteria that are designed to help clinicians determine the most appropriate test for specific clinical scenarios.[26, 27] Hospitalists can integrate these decisions into their progress notes to prompt them to think about potential overuse, as well as communicate their clinical reasoning to other providers.

As an example of this strategy, 1 multi‐institutional group has started training medical students to augment the traditional subjective‐objective‐assessment‐plan (SOAP) daily template with a value section (SOAP‐V), creating a cognitive forcing function to promote discussion of high‐value care delivery.[28] Physicians could include brief thoughts in this section about why they chose a specific intervention, their consideration of the potential benefits and harms compared to alternatives, how it may incorporate the patient's goals and values, and the known and potential costs of the intervention. Similarly, Flanders and Saint recommend that daily progress notes and sign‐outs include the indication, day of administration, and expected duration of therapy for all antimicrobial treatments, as a mechanism for curbing antimicrobial overuse in hospitalized patients.[29] Likewise, hospitalists can also document whether or not a patient needs routine labs, telemetry, continuous pulse oximetry, or other interventions or monitoring. It is not yet clear how effective this type of strategy will be, and drawbacks include creating longer progress notes and requiring more time for documentation. Another approach would be to work with the electronic health record to flag patients who are scheduled for telemetry or other potentially wasteful practices to inspire a daily practice audit to question whether the patient still meets criteria for such care. This approach acknowledges that patient's clinical status changes, and overcomes the inertia that results in so many therapies being continued despite a need or indication.

Communicating With Patients Who Want Everything

Some patients may be more worried about not getting every possible test, rather than concerns regarding associated costs. This may oftentimes be related to patients routinely overestimating the benefits of testing and treatments while not realizing the many potential downstream harms.[22] The perception is that patient demands frequently drive overtesting, but studies suggest the demanding patient is actually much less common than most physicians think.[30]

The Choosing Wisely campaign features video modules that provide a framework and specific examples for physician‐patient communication around some of the Choosing Wisely recommendations (available at: http://www.choosingwisely.org/resources/modules). These modules highlight key skills for communication, including: (1) providing clear recommendations, (2) eliciting patient beliefs and questions, (3) providing empathy, partnership, and legitimation, and (4) confirming agreement and overcoming barriers.

Clinicians can explain why they do not believe that a test will help a patient and can share their concerns about the potential harms and downstream consequences of a given test. In addition, Consumer Reports and other groups have created trusted resources for patients that provide clear information for the public about unnecessary testing and services.

Learn and Teach Value

Traditionally, healthcare costs have largely remained hidden from both the public and medical professionals.[31, 32] As a result, hospitalists are generally not aware of the costs associated with their care.[33, 34] Although medical education has historically avoided the topic of healthcare costs,[35] recent calls to teach healthcare value have led to new educational efforts.[35, 36, 37] Future generations of medical professionals will be trained in these skills, but current hospitalists should seek opportunities to improve their knowledge of healthcare value and costs.

Fortunately, several resources can fill this gap. In addition to Choosing Wisely and ACR appropriateness criteria discussed above, newer tools focus on how to operationalize these recommendations with patients. The American College of Physicians (ACP) has launched a high‐value care educational platform that includes clinical recommendations, physician resources, curricula and public policy recommendations, and patient resources to help them understand the benefits, harms, and costs of tests and treatments for common clinical issues (https://hvc.acponline.org). The ACP's high‐value care educational modules are free, and the website also includes case‐based modules that provide free continuing medical education credit for practicing physicians. The Institute for Healthcare Improvement (IHI) provides courses covering quality improvement, patient safety, and value through their IHI Open School platform (www.ihi.org/education/emhiopenschool).

In an effort to provide frontline clinicians with the knowledge and tools necessary to address healthcare value, we have authored a textbook, Understanding Value‐Based Healthcare.[38] To identify the most promising ways of teaching these concepts, we also host the annual Teaching Value & Choosing Wisely Challenge and convene the Teaching Value in Healthcare Learning Network (bit.ly/teachingvaluenetwork) through our nonprofit, Costs of Care.[39]

In addition, hospitalists can also advocate for greater price transparency to help improve cost awareness and drive more appropriate care. The evidence on the effect of transparent costs in the electronic ordering system is evolving. Historically, efforts to provide diagnostic test prices at time of order led to mixed results,[40] but recent studies show clear benefits in resource utilization related to some form of cost display.[41, 42] This may be because physicians care more about healthcare costs and resource utilization than before. Feldman and colleagues found in a controlled clinical trial at Johns Hopkins that providing the costs of lab tests resulted in substantial decreases of certain lab tests and yielded a net cost reduction (based on 2011 Medicare Allowable Rate) of more than $400,000 at the hospital level during the 6‐month intervention period.[41] A recent systematic review concluded that charge information changed ordering and prescribing behavior in the majority of studies.[42] Some hospitalist programs are developing dashboards for various quality and utilization metrics. Sharing ratings or metrics internally or publically is a powerful way to motivate behavior change.[43]

Conduct Value‐Improvement Projects

Hospitalists across the country have largely taken the lead on designing value‐improvement pilots, programs, and groups within hospitals. Although value‐improvement projects may be built upon the established structures and techniques for quality improvement, importantly these programs should also include expertise in cost analyses.[8] Furthermore, some traditional quality‐improvement programs have failed to result in actual cost savings[44]; thus, it is not enough to simply rebrand quality improvement with a banner of value. Value‐improvement efforts must overcome the cultural hurdle of more care as better care, as well as pay careful attention to the diplomacy required with value improvement, because reducing costs may result in decreased revenue for certain departments or even decreases in individuals' wages.

One framework that we have used to guide value‐improvement project design is COST: culture, oversight accountability, system support, and training.[45] This approach leverages principles from implementation science to ensure that value‐improvement projects successfully provide multipronged tactics for overcoming the many barriers to high‐value care delivery. Figure 1 includes a worksheet for individual clinicians or teams to use when initially planning value‐improvement project interventions.[46] The examples in this worksheet come from a successful project at the University of California, San Francisco aimed at improving blood utilization stewardship by supporting adherence to a restrictive transfusion strategy. To address culture, a hospital‐wide campaign was led by physician peer champions to raise awareness about appropriate transfusion practices. This included posters that featured prominent local physician leaders displaying their support for the program. Oversight was provided through regular audit and feedback. Each month the number of patients on the medicine service who received transfusion with a pretransfusion hemoglobin above 8 grams per deciliter was shared at a faculty lunch meeting and shown on a graph included in the quality newsletter that was widely distributed in the hospital. The ordering system in the electronic medical record was eventually modified to include the patient's pretransfusion hemoglobin level at time of transfusion order and to provide default options and advice based on whether or not guidelines would generally recommend transfusion. Hospitalists and resident physicians were trained through multiple lectures and informal teaching settings about the rationale behind the changes and the evidence that supported a restrictive transfusion strategy.

Figure 1

Launch High‐Value Care Programs

As value‐improvement projects grow, some institutions have created high‐value care programs and infrastructure. In March 2012, the University of California, San Francisco Division of Hospital Medicine launched a high‐value care program to promote healthcare value and clinician engagement.[8] The program was led by clinical hospitalists alongside a financial administrator, and aimed to use financial data to identify areas with clear evidence of waste, create evidence‐based interventions that would simultaneously improve quality while cutting costs, and pair interventions with cost awareness education and culture change efforts. In the first year of this program, 6 projects were launched targeting: (1) nebulizer to inhaler transitions,[47] (2) overuse of proton pump inhibitor stress ulcer prophlaxis,[48] (3) transfusions, (4) telemetry, (5) ionized calcium lab ordering, and (6) repeat inpatient echocardiograms.[8]

Similar hospitalist‐led groups have now formed across the country including the Johns Hopkins High‐Value Care Committee, Johns Hopkins Bayview Physicians for Responsible Ordering, and High‐Value Carolina. These groups are relatively new, and best practices and early lessons are still emerging, but all focus on engaging frontline clinicians in choosing targets and leading multipronged intervention efforts.

What About Financial Incentives?

Hospitalist high‐value care groups thus far have mostly focused on intrinsic motivations for decreasing waste by appealing to hospitalists' sense of professionalism and their commitment to improve patient affordability. When financial incentives are used, it is important that they are well aligned with internal motivations for clinicians to provide the best possible care to their patients. The Institute of Medicine recommends that payments are structured in a way to reward continuous learning and improvement in the provision of best care at lower cost.[19] In the Geisinger Health System in Pennsylvania, physician incentives are designed to reward teamwork and collaboration. For example, endocrinologists' goals are based on good control of glucose levels for all diabetes patients in the system, not just those they see.[49] Moreover, a collaborative approach is encouraged by bringing clinicians together across disciplinary service lines to plan, budget, and evaluate one another's performance. These efforts are partly credited with a 43% reduction in hospitalized days and $100 per member per month in savings among diabetic patients.[50]

Healthcare leaders, Drs. Tom Lee and Toby Cosgrove, have made a number of recommendations for creating incentives that lead to sustainable changes in care delivery[49]: avoid attaching large sums to any single target, watch for conflicts of interest, reward collaboration, and communicate the incentive program and goals clearly to clinicians.

In general, when appropriate extrinsic motivators align or interact synergistically with intrinsic motivation, it can promote high levels of performance and satisfaction.[51]

Avoiding Low‐Value Services at the Point of Care

The largest contributor to the approximately $750 billion in annual healthcare waste is unnecessary services, which includes overuse, discretionary use beyond benchmarks, and unnecessary choice of higher‐cost services.[19] Drivers of overuse include medical culture, fee‐for‐service payments, patient expectations, and fear of malpractice litigation.[20] For practicing hospitalists, the most substantial motivation for overuse may be a desire to reassure patients and themselves.[21] Unfortunately, patients commonly overestimate the benefits and underestimate the potential harms of testing and treatments.[22] However, clear communication with patients can reduce overuse, underuse, and misuse.[23]

Specific targets for improving appropriate resource utilization may be identified from resources such as Choosing Wisely lists, guidelines, and appropriateness criteria. The Choosing Wisely campaign has brought together an unprecedented number of medical specialty societies to issue top five lists of things that physicians and patients should question (www.choosingwisely.org). In February 2013, the Society of Hospital Medicine released their Choosing Wisely lists for both adult and pediatric hospital medicine (Table 1).[6, 24] Hospitalists report printing out these lists, posting them in offices and clinical areas, and handing them out to trainees and colleagues.[25] Likewise, the American College of Radiology (ACR) and the American College of Cardiology provide appropriateness criteria that are designed to help clinicians determine the most appropriate test for specific clinical scenarios.[26, 27] Hospitalists can integrate these decisions into their progress notes to prompt them to think about potential overuse, as well as communicate their clinical reasoning to other providers.

As an example of this strategy, 1 multi‐institutional group has started training medical students to augment the traditional subjective‐objective‐assessment‐plan (SOAP) daily template with a value section (SOAP‐V), creating a cognitive forcing function to promote discussion of high‐value care delivery.[28] Physicians could include brief thoughts in this section about why they chose a specific intervention, their consideration of the potential benefits and harms compared to alternatives, how it may incorporate the patient's goals and values, and the known and potential costs of the intervention. Similarly, Flanders and Saint recommend that daily progress notes and sign‐outs include the indication, day of administration, and expected duration of therapy for all antimicrobial treatments, as a mechanism for curbing antimicrobial overuse in hospitalized patients.[29] Likewise, hospitalists can also document whether or not a patient needs routine labs, telemetry, continuous pulse oximetry, or other interventions or monitoring. It is not yet clear how effective this type of strategy will be, and drawbacks include creating longer progress notes and requiring more time for documentation. Another approach would be to work with the electronic health record to flag patients who are scheduled for telemetry or other potentially wasteful practices to inspire a daily practice audit to question whether the patient still meets criteria for such care. This approach acknowledges that patient's clinical status changes, and overcomes the inertia that results in so many therapies being continued despite a need or indication.

Communicating With Patients Who Want Everything

Some patients may be more worried about not getting every possible test, rather than concerns regarding associated costs. This may oftentimes be related to patients routinely overestimating the benefits of testing and treatments while not realizing the many potential downstream harms.[22] The perception is that patient demands frequently drive overtesting, but studies suggest the demanding patient is actually much less common than most physicians think.[30]

The Choosing Wisely campaign features video modules that provide a framework and specific examples for physician‐patient communication around some of the Choosing Wisely recommendations (available at: http://www.choosingwisely.org/resources/modules). These modules highlight key skills for communication, including: (1) providing clear recommendations, (2) eliciting patient beliefs and questions, (3) providing empathy, partnership, and legitimation, and (4) confirming agreement and overcoming barriers.

Clinicians can explain why they do not believe that a test will help a patient and can share their concerns about the potential harms and downstream consequences of a given test. In addition, Consumer Reports and other groups have created trusted resources for patients that provide clear information for the public about unnecessary testing and services.

Learn and Teach Value

Traditionally, healthcare costs have largely remained hidden from both the public and medical professionals.[31, 32] As a result, hospitalists are generally not aware of the costs associated with their care.[33, 34] Although medical education has historically avoided the topic of healthcare costs,[35] recent calls to teach healthcare value have led to new educational efforts.[35, 36, 37] Future generations of medical professionals will be trained in these skills, but current hospitalists should seek opportunities to improve their knowledge of healthcare value and costs.

Fortunately, several resources can fill this gap. In addition to Choosing Wisely and ACR appropriateness criteria discussed above, newer tools focus on how to operationalize these recommendations with patients. The American College of Physicians (ACP) has launched a high‐value care educational platform that includes clinical recommendations, physician resources, curricula and public policy recommendations, and patient resources to help them understand the benefits, harms, and costs of tests and treatments for common clinical issues (https://hvc.acponline.org). The ACP's high‐value care educational modules are free, and the website also includes case‐based modules that provide free continuing medical education credit for practicing physicians. The Institute for Healthcare Improvement (IHI) provides courses covering quality improvement, patient safety, and value through their IHI Open School platform (www.ihi.org/education/emhiopenschool).

In an effort to provide frontline clinicians with the knowledge and tools necessary to address healthcare value, we have authored a textbook, Understanding Value‐Based Healthcare.[38] To identify the most promising ways of teaching these concepts, we also host the annual Teaching Value & Choosing Wisely Challenge and convene the Teaching Value in Healthcare Learning Network (bit.ly/teachingvaluenetwork) through our nonprofit, Costs of Care.[39]

In addition, hospitalists can also advocate for greater price transparency to help improve cost awareness and drive more appropriate care. The evidence on the effect of transparent costs in the electronic ordering system is evolving. Historically, efforts to provide diagnostic test prices at time of order led to mixed results,[40] but recent studies show clear benefits in resource utilization related to some form of cost display.[41, 42] This may be because physicians care more about healthcare costs and resource utilization than before. Feldman and colleagues found in a controlled clinical trial at Johns Hopkins that providing the costs of lab tests resulted in substantial decreases of certain lab tests and yielded a net cost reduction (based on 2011 Medicare Allowable Rate) of more than $400,000 at the hospital level during the 6‐month intervention period.[41] A recent systematic review concluded that charge information changed ordering and prescribing behavior in the majority of studies.[42] Some hospitalist programs are developing dashboards for various quality and utilization metrics. Sharing ratings or metrics internally or publically is a powerful way to motivate behavior change.[43]

Conduct Value‐Improvement Projects

Hospitalists across the country have largely taken the lead on designing value‐improvement pilots, programs, and groups within hospitals. Although value‐improvement projects may be built upon the established structures and techniques for quality improvement, importantly these programs should also include expertise in cost analyses.[8] Furthermore, some traditional quality‐improvement programs have failed to result in actual cost savings[44]; thus, it is not enough to simply rebrand quality improvement with a banner of value. Value‐improvement efforts must overcome the cultural hurdle of more care as better care, as well as pay careful attention to the diplomacy required with value improvement, because reducing costs may result in decreased revenue for certain departments or even decreases in individuals' wages.

One framework that we have used to guide value‐improvement project design is COST: culture, oversight accountability, system support, and training.[45] This approach leverages principles from implementation science to ensure that value‐improvement projects successfully provide multipronged tactics for overcoming the many barriers to high‐value care delivery. Figure 1 includes a worksheet for individual clinicians or teams to use when initially planning value‐improvement project interventions.[46] The examples in this worksheet come from a successful project at the University of California, San Francisco aimed at improving blood utilization stewardship by supporting adherence to a restrictive transfusion strategy. To address culture, a hospital‐wide campaign was led by physician peer champions to raise awareness about appropriate transfusion practices. This included posters that featured prominent local physician leaders displaying their support for the program. Oversight was provided through regular audit and feedback. Each month the number of patients on the medicine service who received transfusion with a pretransfusion hemoglobin above 8 grams per deciliter was shared at a faculty lunch meeting and shown on a graph included in the quality newsletter that was widely distributed in the hospital. The ordering system in the electronic medical record was eventually modified to include the patient's pretransfusion hemoglobin level at time of transfusion order and to provide default options and advice based on whether or not guidelines would generally recommend transfusion. Hospitalists and resident physicians were trained through multiple lectures and informal teaching settings about the rationale behind the changes and the evidence that supported a restrictive transfusion strategy.

Figure 1

Launch High‐Value Care Programs

As value‐improvement projects grow, some institutions have created high‐value care programs and infrastructure. In March 2012, the University of California, San Francisco Division of Hospital Medicine launched a high‐value care program to promote healthcare value and clinician engagement.[8] The program was led by clinical hospitalists alongside a financial administrator, and aimed to use financial data to identify areas with clear evidence of waste, create evidence‐based interventions that would simultaneously improve quality while cutting costs, and pair interventions with cost awareness education and culture change efforts. In the first year of this program, 6 projects were launched targeting: (1) nebulizer to inhaler transitions,[47] (2) overuse of proton pump inhibitor stress ulcer prophlaxis,[48] (3) transfusions, (4) telemetry, (5) ionized calcium lab ordering, and (6) repeat inpatient echocardiograms.[8]

Similar hospitalist‐led groups have now formed across the country including the Johns Hopkins High‐Value Care Committee, Johns Hopkins Bayview Physicians for Responsible Ordering, and High‐Value Carolina. These groups are relatively new, and best practices and early lessons are still emerging, but all focus on engaging frontline clinicians in choosing targets and leading multipronged intervention efforts.

What About Financial Incentives?

Hospitalist high‐value care groups thus far have mostly focused on intrinsic motivations for decreasing waste by appealing to hospitalists' sense of professionalism and their commitment to improve patient affordability. When financial incentives are used, it is important that they are well aligned with internal motivations for clinicians to provide the best possible care to their patients. The Institute of Medicine recommends that payments are structured in a way to reward continuous learning and improvement in the provision of best care at lower cost.[19] In the Geisinger Health System in Pennsylvania, physician incentives are designed to reward teamwork and collaboration. For example, endocrinologists' goals are based on good control of glucose levels for all diabetes patients in the system, not just those they see.[49] Moreover, a collaborative approach is encouraged by bringing clinicians together across disciplinary service lines to plan, budget, and evaluate one another's performance. These efforts are partly credited with a 43% reduction in hospitalized days and $100 per member per month in savings among diabetic patients.[50]

Healthcare leaders, Drs. Tom Lee and Toby Cosgrove, have made a number of recommendations for creating incentives that lead to sustainable changes in care delivery[49]: avoid attaching large sums to any single target, watch for conflicts of interest, reward collaboration, and communicate the incentive program and goals clearly to clinicians.

In general, when appropriate extrinsic motivators align or interact synergistically with intrinsic motivation, it can promote high levels of performance and satisfaction.[51]

Avoiding Low‐Value Services at the Point of Care

The largest contributor to the approximately $750 billion in annual healthcare waste is unnecessary services, which includes overuse, discretionary use beyond benchmarks, and unnecessary choice of higher‐cost services.[19] Drivers of overuse include medical culture, fee‐for‐service payments, patient expectations, and fear of malpractice litigation.[20] For practicing hospitalists, the most substantial motivation for overuse may be a desire to reassure patients and themselves.[21] Unfortunately, patients commonly overestimate the benefits and underestimate the potential harms of testing and treatments.[22] However, clear communication with patients can reduce overuse, underuse, and misuse.[23]

Specific targets for improving appropriate resource utilization may be identified from resources such as Choosing Wisely lists, guidelines, and appropriateness criteria. The Choosing Wisely campaign has brought together an unprecedented number of medical specialty societies to issue top five lists of things that physicians and patients should question (www.choosingwisely.org). In February 2013, the Society of Hospital Medicine released their Choosing Wisely lists for both adult and pediatric hospital medicine (Table 1).[6, 24] Hospitalists report printing out these lists, posting them in offices and clinical areas, and handing them out to trainees and colleagues.[25] Likewise, the American College of Radiology (ACR) and the American College of Cardiology provide appropriateness criteria that are designed to help clinicians determine the most appropriate test for specific clinical scenarios.[26, 27] Hospitalists can integrate these decisions into their progress notes to prompt them to think about potential overuse, as well as communicate their clinical reasoning to other providers.

As an example of this strategy, 1 multi‐institutional group has started training medical students to augment the traditional subjective‐objective‐assessment‐plan (SOAP) daily template with a value section (SOAP‐V), creating a cognitive forcing function to promote discussion of high‐value care delivery.[28] Physicians could include brief thoughts in this section about why they chose a specific intervention, their consideration of the potential benefits and harms compared to alternatives, how it may incorporate the patient's goals and values, and the known and potential costs of the intervention. Similarly, Flanders and Saint recommend that daily progress notes and sign‐outs include the indication, day of administration, and expected duration of therapy for all antimicrobial treatments, as a mechanism for curbing antimicrobial overuse in hospitalized patients.[29] Likewise, hospitalists can also document whether or not a patient needs routine labs, telemetry, continuous pulse oximetry, or other interventions or monitoring. It is not yet clear how effective this type of strategy will be, and drawbacks include creating longer progress notes and requiring more time for documentation. Another approach would be to work with the electronic health record to flag patients who are scheduled for telemetry or other potentially wasteful practices to inspire a daily practice audit to question whether the patient still meets criteria for such care. This approach acknowledges that patient's clinical status changes, and overcomes the inertia that results in so many therapies being continued despite a need or indication.

Communicating With Patients Who Want Everything

Some patients may be more worried about not getting every possible test, rather than concerns regarding associated costs. This may oftentimes be related to patients routinely overestimating the benefits of testing and treatments while not realizing the many potential downstream harms.[22] The perception is that patient demands frequently drive overtesting, but studies suggest the demanding patient is actually much less common than most physicians think.[30]

The Choosing Wisely campaign features video modules that provide a framework and specific examples for physician‐patient communication around some of the Choosing Wisely recommendations (available at: http://www.choosingwisely.org/resources/modules). These modules highlight key skills for communication, including: (1) providing clear recommendations, (2) eliciting patient beliefs and questions, (3) providing empathy, partnership, and legitimation, and (4) confirming agreement and overcoming barriers.

Clinicians can explain why they do not believe that a test will help a patient and can share their concerns about the potential harms and downstream consequences of a given test. In addition, Consumer Reports and other groups have created trusted resources for patients that provide clear information for the public about unnecessary testing and services.

Learn and Teach Value

Traditionally, healthcare costs have largely remained hidden from both the public and medical professionals.[31, 32] As a result, hospitalists are generally not aware of the costs associated with their care.[33, 34] Although medical education has historically avoided the topic of healthcare costs,[35] recent calls to teach healthcare value have led to new educational efforts.[35, 36, 37] Future generations of medical professionals will be trained in these skills, but current hospitalists should seek opportunities to improve their knowledge of healthcare value and costs.

Fortunately, several resources can fill this gap. In addition to Choosing Wisely and ACR appropriateness criteria discussed above, newer tools focus on how to operationalize these recommendations with patients. The American College of Physicians (ACP) has launched a high‐value care educational platform that includes clinical recommendations, physician resources, curricula and public policy recommendations, and patient resources to help them understand the benefits, harms, and costs of tests and treatments for common clinical issues (https://hvc.acponline.org). The ACP's high‐value care educational modules are free, and the website also includes case‐based modules that provide free continuing medical education credit for practicing physicians. The Institute for Healthcare Improvement (IHI) provides courses covering quality improvement, patient safety, and value through their IHI Open School platform (www.ihi.org/education/emhiopenschool).

In an effort to provide frontline clinicians with the knowledge and tools necessary to address healthcare value, we have authored a textbook, Understanding Value‐Based Healthcare.[38] To identify the most promising ways of teaching these concepts, we also host the annual Teaching Value & Choosing Wisely Challenge and convene the Teaching Value in Healthcare Learning Network (bit.ly/teachingvaluenetwork) through our nonprofit, Costs of Care.[39]

In addition, hospitalists can also advocate for greater price transparency to help improve cost awareness and drive more appropriate care. The evidence on the effect of transparent costs in the electronic ordering system is evolving. Historically, efforts to provide diagnostic test prices at time of order led to mixed results,[40] but recent studies show clear benefits in resource utilization related to some form of cost display.[41, 42] This may be because physicians care more about healthcare costs and resource utilization than before. Feldman and colleagues found in a controlled clinical trial at Johns Hopkins that providing the costs of lab tests resulted in substantial decreases of certain lab tests and yielded a net cost reduction (based on 2011 Medicare Allowable Rate) of more than $400,000 at the hospital level during the 6‐month intervention period.[41] A recent systematic review concluded that charge information changed ordering and prescribing behavior in the majority of studies.[42] Some hospitalist programs are developing dashboards for various quality and utilization metrics. Sharing ratings or metrics internally or publically is a powerful way to motivate behavior change.[43]

Conduct Value‐Improvement Projects

Hospitalists across the country have largely taken the lead on designing value‐improvement pilots, programs, and groups within hospitals. Although value‐improvement projects may be built upon the established structures and techniques for quality improvement, importantly these programs should also include expertise in cost analyses.[8] Furthermore, some traditional quality‐improvement programs have failed to result in actual cost savings[44]; thus, it is not enough to simply rebrand quality improvement with a banner of value. Value‐improvement efforts must overcome the cultural hurdle of more care as better care, as well as pay careful attention to the diplomacy required with value improvement, because reducing costs may result in decreased revenue for certain departments or even decreases in individuals' wages.

One framework that we have used to guide value‐improvement project design is COST: culture, oversight accountability, system support, and training.[45] This approach leverages principles from implementation science to ensure that value‐improvement projects successfully provide multipronged tactics for overcoming the many barriers to high‐value care delivery. Figure 1 includes a worksheet for individual clinicians or teams to use when initially planning value‐improvement project interventions.[46] The examples in this worksheet come from a successful project at the University of California, San Francisco aimed at improving blood utilization stewardship by supporting adherence to a restrictive transfusion strategy. To address culture, a hospital‐wide campaign was led by physician peer champions to raise awareness about appropriate transfusion practices. This included posters that featured prominent local physician leaders displaying their support for the program. Oversight was provided through regular audit and feedback. Each month the number of patients on the medicine service who received transfusion with a pretransfusion hemoglobin above 8 grams per deciliter was shared at a faculty lunch meeting and shown on a graph included in the quality newsletter that was widely distributed in the hospital. The ordering system in the electronic medical record was eventually modified to include the patient's pretransfusion hemoglobin level at time of transfusion order and to provide default options and advice based on whether or not guidelines would generally recommend transfusion. Hospitalists and resident physicians were trained through multiple lectures and informal teaching settings about the rationale behind the changes and the evidence that supported a restrictive transfusion strategy.

Figure 1

Launch High‐Value Care Programs

As value‐improvement projects grow, some institutions have created high‐value care programs and infrastructure. In March 2012, the University of California, San Francisco Division of Hospital Medicine launched a high‐value care program to promote healthcare value and clinician engagement.[8] The program was led by clinical hospitalists alongside a financial administrator, and aimed to use financial data to identify areas with clear evidence of waste, create evidence‐based interventions that would simultaneously improve quality while cutting costs, and pair interventions with cost awareness education and culture change efforts. In the first year of this program, 6 projects were launched targeting: (1) nebulizer to inhaler transitions,[47] (2) overuse of proton pump inhibitor stress ulcer prophlaxis,[48] (3) transfusions, (4) telemetry, (5) ionized calcium lab ordering, and (6) repeat inpatient echocardiograms.[8]

Similar hospitalist‐led groups have now formed across the country including the Johns Hopkins High‐Value Care Committee, Johns Hopkins Bayview Physicians for Responsible Ordering, and High‐Value Carolina. These groups are relatively new, and best practices and early lessons are still emerging, but all focus on engaging frontline clinicians in choosing targets and leading multipronged intervention efforts.

What About Financial Incentives?

Hospitalist high‐value care groups thus far have mostly focused on intrinsic motivations for decreasing waste by appealing to hospitalists' sense of professionalism and their commitment to improve patient affordability. When financial incentives are used, it is important that they are well aligned with internal motivations for clinicians to provide the best possible care to their patients. The Institute of Medicine recommends that payments are structured in a way to reward continuous learning and improvement in the provision of best care at lower cost.[19] In the Geisinger Health System in Pennsylvania, physician incentives are designed to reward teamwork and collaboration. For example, endocrinologists' goals are based on good control of glucose levels for all diabetes patients in the system, not just those they see.[49] Moreover, a collaborative approach is encouraged by bringing clinicians together across disciplinary service lines to plan, budget, and evaluate one another's performance. These efforts are partly credited with a 43% reduction in hospitalized days and $100 per member per month in savings among diabetic patients.[50]

Healthcare leaders, Drs. Tom Lee and Toby Cosgrove, have made a number of recommendations for creating incentives that lead to sustainable changes in care delivery[49]: avoid attaching large sums to any single target, watch for conflicts of interest, reward collaboration, and communicate the incentive program and goals clearly to clinicians.

In general, when appropriate extrinsic motivators align or interact synergistically with intrinsic motivation, it can promote high levels of performance and satisfaction.[51]

Background

With recent changes in resident duty hours and staffing models, the number of clinical handoffs during a patient's hospital stay has been increasing.[5] The omission of critical information and the transfer of erroneous information during handoffs is common, which contributes to preventable medical errors.[6]

Findings

This prospective intervention study of a resident handoff program in 9 hospitals sought to improve communication between healthcare providers and to decrease medical errors. The I‐PASS mnemonic, which stands for illness severity, patient summary, action list, situation awareness, and synthesis by receiver, was introduced to standardize oral and written handoffs. The program also included a 2‐hour workshop, a 1‐hour role‐playing and simulation session, a computer module, a faculty development program, direct observation tools, and a culture change campaign. Medical errors decreased by 23% following the intervention, compared to the preintervention baseline (24.5 vs 18.8 per 100 admissions, P < 0.001), and the rate of preventable adverse events dropped by 30% (4.7 vs 3.3 events per 100 admissions, P < 0.001), whereas nonpreventable adverse events did not change. Process measures of handoff quality uniformly improved with the intervention. The duration of oral handoffs was approximately 2.5 minutes per patient both before and during the intervention period.

Cautions

Not all of the sites in the study saw significant reductions in medical errors; 3 of the programs did not have significantly improved medical error rates following implementation of the I‐PASS handoff bundle. The study design was not a randomized controlled trial, and thus the pre‐ versus postimplementation analyses cannot draw definitive causal links between the intervention and the observed improvements in safety outcomes. Furthermore, this study was done with pediatric residents, and one cannot assume that the results will translate to practicing hospitalists, who may not benefit as much from a scripted sign‐out.

Implications

A comprehensive handoff program that included the I‐PASS mnemonic along with extensive training, faculty development, and a culture‐change campaign was associated with impressive improvements in patient safety outcomes, without negatively effecting workflow.

Background

Hospital readmissions are common, costly, and potentially represent a failure to adequately prepare patients for hospital discharge, but efforts to prevent 30‐day readmissions have been mixed.[7] The investigators in this study offer a novel framework, the cumulative complexity model, as a way to conceptualize postdischarge outcomes such as readmission. The model depicts the balance between the patient's workload of managing their illness, including the demands of monitoring treatment and self‐care, and the patient's capacity to handle that workfunctionality, financial/social resources, literacy, and empowerment. Workload‐capacity imbalances (when workload outstrips capacity) may lead to progressively increasing illness and increasing complexity, which contribute to poor patient outcomes like readmissions. Decreasing a patient's workload or increasing their capacity may be effective in reducing readmissions.

Findings

Investigators sought to identify factors associated with successful interventions to reduce 30‐day readmissions, including how the interventions fit into the cumulative complexity model. After performing a comprehensive search of randomized trials of interventions to reduce readmissions, the investigators identified 42 randomized trials with the primary outcome of 30‐day readmission rates. In addition to reviewing intervention characteristics, blinded raters scored interventions based on their effects on reducing or increasing patient workload and reducing or increasing patient capacity for self‐care. Interventions that had several components (eg, pharmacy education, postdischarge phone calls, visiting nurses, health coaches, close primary care follow‐up) were more likely to be successful (1.4 times as likely; P = 0.001), as were interventions that involved 2 or more individuals (1.3 times as likely; P = 0.05). Interventions that were published prior to 2002 were 1.6 times more likely to have reduced readmissions (P = 0.01). When applied to the cumulative complexity model, interventions that sought to augment patient capacity for self‐care were 1.3 times as likely to be successful (P = 0.04), whereas no relationship was found between an intervention's effect on patient workload and readmission.

Cautions

The authors evaluated each intervention based on the degree to which it was likely to affect patient workload and patient capacity. Because a multifaceted intervention may have had components that increased patient workload (eg, more self‐monitoring, appointments) and decreased patient workload (home visits, visiting nurses), the true effect of patient workload on readmissions may not have been optimally analyzed in this study. Additionally, this element of the study relied on a value judgment original to this work. Interventions that are burdensome to some, may be beneficial to those with the capacity and resources to access the care.

Implications

The body of studies reviewed suggests that interventions to reduce 30‐day readmissions are on the whole successful. Their findings are in keeping with past studies demonstrating more successful interventions that are resource‐intensive and multifaceted. Finding successful interventions that are also cost‐effective may be challenging. This article adds the cumulative complexity framework to what we already know about readmissions, highlighting patient capacity to manage the burden of their Illness as a new factor for success. Efforts to deliver patient‐centered education, explore barriers to adherence, and provide health coaching may be more successful than interventions that unwittingly add to the burden of disease treatment (multiple follow‐up appointments, complex medication schedules, and posthospital surveys and patient self‐assessments).

Background

Patient activation is widely recognized as the knowledge, skills, and confidence a person has in managing their own health or healthcare. Higher patient activation has been associated with improved health outcomes, but the relationship between patient activation and readmission to the hospital within 30 days is unknown.[8]

Findings

Using data from Project RED‐LIT (Re‐Engineered Discharge for patients with low health literacy), a randomized controlled trial conducted at an urban safety‐net hospital, investigators examined the relationship between all unplanned utilization events of hospital services within 30 days of discharge and patient activation, as measured by an abbreviated 8‐item version of the validated Patient Activation Measure (PAM). The PAM uses agreement with statements about a patient's sense of responsibility for his or her own health, confidence in seeking care and following through with medical treatments, and confidence in managing new problems to measure activation. The 695 participants were divided into quartiles based on their PAM score, and the investigators looked at the rates of unplanned utilization events in each group. After adjusting for potential confounders such as gender, age, Charlson Comorbidity Index, insurance, marital status, and education, there remained a significant effect between PAM and 30‐day hospital reutilization. Compared with those who scored in the highest quartile of activation, those in the lowest quartile had 1.75 times the rate of 30‐day reutilization (P < 0.001). Those in the second highest and third highest quartile had 1.3 (P = 0.03) and 1.5 times (P < 0.001) the rate of reutilization demonstrating a dose‐response relationship between activation and low reutilization.

Cautions

It is as yet unclear how best to apply these results and whether activation is a modifiable risk factor. Can a patient become more activated by providing more education and coaching during their hospital stay? Can providing close follow‐up and home services make a person more confident to manage their own illness? Although early identification of patients with low activation using PAM is being done at many hospitals, there is no study to suggest that targeting these patients can reduce readmission.

Implications

A low level of patient activation appears to be a risk factor for unplanned hospital utilization within 30 days of discharge. Given the increasing financial penalties, many hospitals across the country are using the PAM to determine how much support and which services they provide after discharge. Identifying these patients early in their hospitalization could allow providers to spend more time and attention on preparing them for managing their own illness after discharge. As above, the effects of this intervention on readmissions is as yet unclear.

Background

Effective patient‐physician communication is associated with improved patient satisfaction, care quality, and clinical outcomes.[9] Whether a shared understanding of the plan of care between patients and clinicians affects satisfaction is unknown.

Findings

One hundred seventy‐seven patients who had 2 or more medical conditions, 2 or more medical procedures, and 2 or more days in the hospital were interviewed on the day of discharge. Patients were questioned about their overall understanding of their hospitalization and about specific aspects of their care. They were also asked to provide objective data to measure their understanding of their hospital course by (1) listing their medical diagnoses, (2) identifying indications for medication on discharge paperwork, and (3) listing tests or procedures they underwent from a standard list. Patients were then asked to rate their satisfaction with their hospitalization. Patients' self‐reported understanding was an average of 4.0 (very good) on a 5‐point scale. Their measured understanding scores for medical diagnoses, indications for medications and tests and procedures were 48.9%, 56.2%, and 59.4%, respectively. Factors associated with poor understanding of their hospital course were increasing age, less education, lower household income, black race, and longer length of stay. Patients reported a mean satisfaction of 4.0 (very satisfied). Higher self‐reported understanding was associated with higher patient satisfaction, irrespective of actual understanding.

Cautions

Despite their suboptimal measured understanding of their hospital course, the average patient rated their understanding as very good. This suggests that patients are either poor judges of effective communication or have low expectations for understanding. It also calls into question the relationship between quality of communication and patient satisfaction, because despite their satisfaction, patients' actual understanding was low. There was, however, a clear and positive relationship between patients' perceived understanding and their satisfaction, suggesting that shared understanding remains integral to patient satisfaction.

Implications

Patient satisfaction appears to be tied to patients' perceived understanding of their care, but when tested actual understanding was suboptimal. Further efforts in patient satisfaction should not only focus on the quality of our communication, but on the resulting understanding of our patients.

Background

Although high readmission rates are a national problem, a minority of patients treated for common conditions like pneumonia, heart failure, and chronic obstructive pulmonary disease are readmitted for the same problem.[10] This suggests that readmissions may stem not from poor disease management, but from patient vulnerability to illness in the period following hospitalization.

Findings

In this viewpoint opinion article, the authors suggest that the depersonalizing and stressful hospital atmosphere contributes to a transient vulnerability in the period following hospitalization that makes it challenging for patients to care for themselves and their illness. They offer specific strategies for changing the nature of our hospital care to promote healing and to decrease patient stress. The authors suggest promoting personalization through accommodation of family members, and allowing personal clothing and personal dcor in their rooms. Physicians and consultants should make appointments so that patients and families can know when to expect important visits. The authors also focus on the provision of rest and nourishment by reducing nighttime disruption and the elimination on unnecessary restrictive diets. They argue that the hospital is a place of stressful disruptions and surprises, which could all be ameliorated by providing patients with a way to understand the members of their team and their roles as well as through providing a clear schedule for the day. Healthcare providers should not enter a room unannounced, and patients should be given private rooms as much as possible. Last, the authors focus on the elimination of unnecessary tests and procedures such as blood draws, telemetry, and urine cultures and the encouragement of activity by providing activities where patients can gather together outside their rooms.

Cautions

If these changes seem simple, they may not be. Many involve a significant shift in our thinking on how we provide carefrom a focus on disease and provider convenience to a true consideration for the health and peace of mind of our patients. Starting with small steps, such as reductions in phlebotomy and nighttime vital signs checks for the most stable patients and ensuring accommodations for families, may make this long list seem less daunting.

Implications

By promoting factors that affect a patient's well beingrest, nutrition, peace of mindwe may be discharging patients who are better equipped to manage their illness after their hospitalization.

Background

National efforts, such as the Choosing Wisely campaign, seek to decrease overuse of low‐value services.[11] The extent of the problem of overtesting among hospitalists and the underlying drivers for unnecessary testing in this group have not been clearly defined.

Findings

Practicing adult medicine hospitalists across the country were given a questionnaire that included clinical vignettes for common inpatient scenarios: a preoperative evaluation and a syncope workup. Respondents were randomly provided 1 of 4 versions of each vignette, which contained the same clinical information but varied by a family member's request for further testing and by disclosure of the occupation of the family member. For example, in the preoperative evaluation, the vignettes either: (1) provided no details about the patient's son; (2) identified the son as a physician; (3) mentioned the son's request for testing, but did not identify the son as a physician; or (4) identified the son as a physician who requested testing. The syncope vignette versions were structured similarly, except the family member was the patient's wife and she was an attorney. The authors collected 1020 responses from an initial pool of 1500, for a decent 68% response rate. Hospitalists commonly reported overuse of testing, with 52% to 65% of respondents requesting unnecessary testing in the preoperative evaluation scenario, and 82% to 85% in the syncope scenario. The majority of physicians reported that they knew the testing was not clinically indicated based on evidence or guidelines, but were ordering the test due to a desire to reassure the patients or themselves.

Cautions

Responses to clinical vignettes in a survey may not represent actually practices. In addition, all hospitalists surveyed in this study were members of the Society of Hospital Medicine, so may not accurately exemplify all practicing hospitalists.

Implications

Overuse of testing is very common among hospitalists. Although roughly one‐third of respondents incorrectly thought that testing in the given scenarios was supported by the evidence or guidelines, the majority knew that testing was not clinically indicated and reported ordering tests to help reassure their patients or themselves. This suggests evidence‐based medicine approaches to overuse, such as the Choosing Wisely campaign and the emergence of appropriateness criteria, are likely necessary but insufficient to change physician practice patterns. Efforts to decrease overuse will need to engage clinicians and patients in ways that help overcome the attitude that more testing is required to provide reassurance.

Background

Patient expectations have been implicated as a contributor to overuse of medical interventions. Studies that have measured patients' understanding of the potential benefits and harms of medical treatments and tests have been scattered across the literature.

Findings

This systematic review aggregated all studies that have quantitatively assessed patients' expectations of the benefits and/or harms of any treatment or test. Of more than 15,000 records screened, only 36 articles met the inclusion criteria of describing a study in which participants were asked to provide a quantitative estimate of the expected benefits and/or harms of a treatment, test, or screen. Fourteen of the studies (40%) focused on screening, 15 (43%) on treatment, 3 (9%) on a test, and 3 (9%) on both treatment and screening. Topics included cancer, medications, surgery, cardiovascular disease, and fetal‐maternal medicine. The majority of patients overestimated intervention benefit and underestimated harm, regardless of whether the intervention was a test or a treatment. For example, more than half of participants overestimated benefit for 22 of the 34 outcomes (65%) for which overestimation data were provided, and a majority of participants underestimated harm for 10 of the 15 outcomes (67%) with underestimation data available.

Cautions

This systematic review included a limited number of studies, with varying levels of quality and a lot of heterogeneity, making it difficult to reach clear aggregate conclusions.

Implications

Patients are often overly optimistic about medical interventions and they downplay potential risks, making it more difficult to effectively discourage overuse. Clinicians should clearly understand and communicate realistic expectations for the potential benefits and risks of screening, testing, and medical treatments with patients and the public at large.

Background

Antibiotics are life‐saving therapies, but when used in inappropriate scenarios they can pose many risks.

Findings

This large national database study used the MarketScan Hospital Drug Database and the Centers for Disease Control and Prevention's (CDC) Emerging Infections Program data to explore antibiotic prescribing in hospital patients. More than half of all hospitalized patients (55.7%) received antibiotics during their stay. Half of all treatment antibiotics were prescribed for the treatment of either lower respiratory infections, urinary tract infections, or presumed gram‐positive infections. There was wide variation seen in antibiotic usage across hospital wards. Objective criteria for potential improvement in antimicrobial use were developed and applied at a subset of 36 hospitals. Antibiotic prescribing could be improved in 37.2% of the most common prescription scenarios reviewed, including patients receiving vancomycin or those being treated for a urinary tract infection. The impact of reducing inpatient antibiotic exposure on the incidence of Clostridium difficile colitis was modeled using data from 2 hospitals, revealing that decreasing hospitalized patients' exposure to broad‐spectrum antibiotics by 30% would lead to a 26% reduction in C difficile infections (interquartile range = 15%38%).

Cautions

Some of the estimates in this study are based on a convenience sample of claims and hospital‐based data, thus may not be an accurate representation, particularly when extrapolating to all US hospitals.

Implications

Antibiotic overuse is a rampant problem in hospitals, with many severe downstream effects such as C difficile infections and antimicrobial resistance. All hospital units should have an antibiotic stewardship program and should monitor antibiotic usage.

Lee TC, Frenette C, Jayaraman D, Green L, Pilote L. Antibiotic self‐stewardship: trainee‐led structured antibiotic time‐outs to improve antimicrobial use. Ann Intern Med. 2014;161(10 suppl):S53S58.

Background

The CDC and other groups have called for stewardship programs to address antibiotic overuse.[12] Few interventions have been shown to successfully engage medical trainees in efforts to improve their own antibiotic prescribing practices.

Findings

An antibiotic self‐stewardship program was developed and led by internal medicine residents at Montreal General Hospital. The intervention included a monthly resident education lecture on antimicrobial stewardship and twice‐weekly time‐out audits using a structured electronic checklist. Adherence with auditing was 80%. Total costs for antibiotics decreased from $149,743 CAD to $80,319 CAD, mostly due to an observed reduction in carbapenems. Moxifloxicin use decreased by 1.9 defined daily doses per 1000 patient‐days per month (P = 0.048). Rates of clostridium difficile colitis declined from 24.2 to 19.6 per 10,000 patient‐days, although this trend did not meet statistical significance (incidence rate ratio, 0.8 [confidence interval, 0.5‐1.3]).

Cautions

Although the use of some broader spectrum antibiotics decreased, there was no measurable change in overall antibiotic use, suggesting that physicians may have narrowed antibiotics but did not often completely discontinue them. The time‐series analyses in this study cannot provide causal conclusions between the intervention and outcomes. In fact, carbapenem usage appears to have significantly decreased prior to the implementation of the program, for unclear reasons. The feasibility of this educational intervention outside of a residency program is unclear.

Implications

A combination of education, oversight and frontline clinician engagement in structured time‐outs may be effective, at least in narrowing antibiotic usage. The structured audit checklist developed by these authors is available for free in the supplementary materials of the Annals of Internal Medicine article.

Disclosures: Dr. Moriates has received grant funding from the ABIM Foundation, and royalties from McGraw‐Hill for the textbook Understanding Value‐Based Healthcare. The authors report no conflicts of interest.

Background

With recent changes in resident duty hours and staffing models, the number of clinical handoffs during a patient's hospital stay has been increasing.[5] The omission of critical information and the transfer of erroneous information during handoffs is common, which contributes to preventable medical errors.[6]

Findings

This prospective intervention study of a resident handoff program in 9 hospitals sought to improve communication between healthcare providers and to decrease medical errors. The I‐PASS mnemonic, which stands for illness severity, patient summary, action list, situation awareness, and synthesis by receiver, was introduced to standardize oral and written handoffs. The program also included a 2‐hour workshop, a 1‐hour role‐playing and simulation session, a computer module, a faculty development program, direct observation tools, and a culture change campaign. Medical errors decreased by 23% following the intervention, compared to the preintervention baseline (24.5 vs 18.8 per 100 admissions, P < 0.001), and the rate of preventable adverse events dropped by 30% (4.7 vs 3.3 events per 100 admissions, P < 0.001), whereas nonpreventable adverse events did not change. Process measures of handoff quality uniformly improved with the intervention. The duration of oral handoffs was approximately 2.5 minutes per patient both before and during the intervention period.

Cautions

Not all of the sites in the study saw significant reductions in medical errors; 3 of the programs did not have significantly improved medical error rates following implementation of the I‐PASS handoff bundle. The study design was not a randomized controlled trial, and thus the pre‐ versus postimplementation analyses cannot draw definitive causal links between the intervention and the observed improvements in safety outcomes. Furthermore, this study was done with pediatric residents, and one cannot assume that the results will translate to practicing hospitalists, who may not benefit as much from a scripted sign‐out.

Implications

A comprehensive handoff program that included the I‐PASS mnemonic along with extensive training, faculty development, and a culture‐change campaign was associated with impressive improvements in patient safety outcomes, without negatively effecting workflow.

Background

Hospital readmissions are common, costly, and potentially represent a failure to adequately prepare patients for hospital discharge, but efforts to prevent 30‐day readmissions have been mixed.[7] The investigators in this study offer a novel framework, the cumulative complexity model, as a way to conceptualize postdischarge outcomes such as readmission. The model depicts the balance between the patient's workload of managing their illness, including the demands of monitoring treatment and self‐care, and the patient's capacity to handle that workfunctionality, financial/social resources, literacy, and empowerment. Workload‐capacity imbalances (when workload outstrips capacity) may lead to progressively increasing illness and increasing complexity, which contribute to poor patient outcomes like readmissions. Decreasing a patient's workload or increasing their capacity may be effective in reducing readmissions.

Findings

Investigators sought to identify factors associated with successful interventions to reduce 30‐day readmissions, including how the interventions fit into the cumulative complexity model. After performing a comprehensive search of randomized trials of interventions to reduce readmissions, the investigators identified 42 randomized trials with the primary outcome of 30‐day readmission rates. In addition to reviewing intervention characteristics, blinded raters scored interventions based on their effects on reducing or increasing patient workload and reducing or increasing patient capacity for self‐care. Interventions that had several components (eg, pharmacy education, postdischarge phone calls, visiting nurses, health coaches, close primary care follow‐up) were more likely to be successful (1.4 times as likely; P = 0.001), as were interventions that involved 2 or more individuals (1.3 times as likely; P = 0.05). Interventions that were published prior to 2002 were 1.6 times more likely to have reduced readmissions (P = 0.01). When applied to the cumulative complexity model, interventions that sought to augment patient capacity for self‐care were 1.3 times as likely to be successful (P = 0.04), whereas no relationship was found between an intervention's effect on patient workload and readmission.

Cautions

The authors evaluated each intervention based on the degree to which it was likely to affect patient workload and patient capacity. Because a multifaceted intervention may have had components that increased patient workload (eg, more self‐monitoring, appointments) and decreased patient workload (home visits, visiting nurses), the true effect of patient workload on readmissions may not have been optimally analyzed in this study. Additionally, this element of the study relied on a value judgment original to this work. Interventions that are burdensome to some, may be beneficial to those with the capacity and resources to access the care.

Implications

The body of studies reviewed suggests that interventions to reduce 30‐day readmissions are on the whole successful. Their findings are in keeping with past studies demonstrating more successful interventions that are resource‐intensive and multifaceted. Finding successful interventions that are also cost‐effective may be challenging. This article adds the cumulative complexity framework to what we already know about readmissions, highlighting patient capacity to manage the burden of their Illness as a new factor for success. Efforts to deliver patient‐centered education, explore barriers to adherence, and provide health coaching may be more successful than interventions that unwittingly add to the burden of disease treatment (multiple follow‐up appointments, complex medication schedules, and posthospital surveys and patient self‐assessments).

Background

Patient activation is widely recognized as the knowledge, skills, and confidence a person has in managing their own health or healthcare. Higher patient activation has been associated with improved health outcomes, but the relationship between patient activation and readmission to the hospital within 30 days is unknown.[8]

Findings

Using data from Project RED‐LIT (Re‐Engineered Discharge for patients with low health literacy), a randomized controlled trial conducted at an urban safety‐net hospital, investigators examined the relationship between all unplanned utilization events of hospital services within 30 days of discharge and patient activation, as measured by an abbreviated 8‐item version of the validated Patient Activation Measure (PAM). The PAM uses agreement with statements about a patient's sense of responsibility for his or her own health, confidence in seeking care and following through with medical treatments, and confidence in managing new problems to measure activation. The 695 participants were divided into quartiles based on their PAM score, and the investigators looked at the rates of unplanned utilization events in each group. After adjusting for potential confounders such as gender, age, Charlson Comorbidity Index, insurance, marital status, and education, there remained a significant effect between PAM and 30‐day hospital reutilization. Compared with those who scored in the highest quartile of activation, those in the lowest quartile had 1.75 times the rate of 30‐day reutilization (P < 0.001). Those in the second highest and third highest quartile had 1.3 (P = 0.03) and 1.5 times (P < 0.001) the rate of reutilization demonstrating a dose‐response relationship between activation and low reutilization.

Cautions

It is as yet unclear how best to apply these results and whether activation is a modifiable risk factor. Can a patient become more activated by providing more education and coaching during their hospital stay? Can providing close follow‐up and home services make a person more confident to manage their own illness? Although early identification of patients with low activation using PAM is being done at many hospitals, there is no study to suggest that targeting these patients can reduce readmission.

Implications

A low level of patient activation appears to be a risk factor for unplanned hospital utilization within 30 days of discharge. Given the increasing financial penalties, many hospitals across the country are using the PAM to determine how much support and which services they provide after discharge. Identifying these patients early in their hospitalization could allow providers to spend more time and attention on preparing them for managing their own illness after discharge. As above, the effects of this intervention on readmissions is as yet unclear.

Background

Effective patient‐physician communication is associated with improved patient satisfaction, care quality, and clinical outcomes.[9] Whether a shared understanding of the plan of care between patients and clinicians affects satisfaction is unknown.

Findings

One hundred seventy‐seven patients who had 2 or more medical conditions, 2 or more medical procedures, and 2 or more days in the hospital were interviewed on the day of discharge. Patients were questioned about their overall understanding of their hospitalization and about specific aspects of their care. They were also asked to provide objective data to measure their understanding of their hospital course by (1) listing their medical diagnoses, (2) identifying indications for medication on discharge paperwork, and (3) listing tests or procedures they underwent from a standard list. Patients were then asked to rate their satisfaction with their hospitalization. Patients' self‐reported understanding was an average of 4.0 (very good) on a 5‐point scale. Their measured understanding scores for medical diagnoses, indications for medications and tests and procedures were 48.9%, 56.2%, and 59.4%, respectively. Factors associated with poor understanding of their hospital course were increasing age, less education, lower household income, black race, and longer length of stay. Patients reported a mean satisfaction of 4.0 (very satisfied). Higher self‐reported understanding was associated with higher patient satisfaction, irrespective of actual understanding.

Cautions

Despite their suboptimal measured understanding of their hospital course, the average patient rated their understanding as very good. This suggests that patients are either poor judges of effective communication or have low expectations for understanding. It also calls into question the relationship between quality of communication and patient satisfaction, because despite their satisfaction, patients' actual understanding was low. There was, however, a clear and positive relationship between patients' perceived understanding and their satisfaction, suggesting that shared understanding remains integral to patient satisfaction.

Implications

Patient satisfaction appears to be tied to patients' perceived understanding of their care, but when tested actual understanding was suboptimal. Further efforts in patient satisfaction should not only focus on the quality of our communication, but on the resulting understanding of our patients.

Background

Although high readmission rates are a national problem, a minority of patients treated for common conditions like pneumonia, heart failure, and chronic obstructive pulmonary disease are readmitted for the same problem.[10] This suggests that readmissions may stem not from poor disease management, but from patient vulnerability to illness in the period following hospitalization.

Findings

In this viewpoint opinion article, the authors suggest that the depersonalizing and stressful hospital atmosphere contributes to a transient vulnerability in the period following hospitalization that makes it challenging for patients to care for themselves and their illness. They offer specific strategies for changing the nature of our hospital care to promote healing and to decrease patient stress. The authors suggest promoting personalization through accommodation of family members, and allowing personal clothing and personal dcor in their rooms. Physicians and consultants should make appointments so that patients and families can know when to expect important visits. The authors also focus on the provision of rest and nourishment by reducing nighttime disruption and the elimination on unnecessary restrictive diets. They argue that the hospital is a place of stressful disruptions and surprises, which could all be ameliorated by providing patients with a way to understand the members of their team and their roles as well as through providing a clear schedule for the day. Healthcare providers should not enter a room unannounced, and patients should be given private rooms as much as possible. Last, the authors focus on the elimination of unnecessary tests and procedures such as blood draws, telemetry, and urine cultures and the encouragement of activity by providing activities where patients can gather together outside their rooms.

Cautions

If these changes seem simple, they may not be. Many involve a significant shift in our thinking on how we provide carefrom a focus on disease and provider convenience to a true consideration for the health and peace of mind of our patients. Starting with small steps, such as reductions in phlebotomy and nighttime vital signs checks for the most stable patients and ensuring accommodations for families, may make this long list seem less daunting.

Implications

By promoting factors that affect a patient's well beingrest, nutrition, peace of mindwe may be discharging patients who are better equipped to manage their illness after their hospitalization.

Background

National efforts, such as the Choosing Wisely campaign, seek to decrease overuse of low‐value services.[11] The extent of the problem of overtesting among hospitalists and the underlying drivers for unnecessary testing in this group have not been clearly defined.

Findings

Practicing adult medicine hospitalists across the country were given a questionnaire that included clinical vignettes for common inpatient scenarios: a preoperative evaluation and a syncope workup. Respondents were randomly provided 1 of 4 versions of each vignette, which contained the same clinical information but varied by a family member's request for further testing and by disclosure of the occupation of the family member. For example, in the preoperative evaluation, the vignettes either: (1) provided no details about the patient's son; (2) identified the son as a physician; (3) mentioned the son's request for testing, but did not identify the son as a physician; or (4) identified the son as a physician who requested testing. The syncope vignette versions were structured similarly, except the family member was the patient's wife and she was an attorney. The authors collected 1020 responses from an initial pool of 1500, for a decent 68% response rate. Hospitalists commonly reported overuse of testing, with 52% to 65% of respondents requesting unnecessary testing in the preoperative evaluation scenario, and 82% to 85% in the syncope scenario. The majority of physicians reported that they knew the testing was not clinically indicated based on evidence or guidelines, but were ordering the test due to a desire to reassure the patients or themselves.

Cautions

Responses to clinical vignettes in a survey may not represent actually practices. In addition, all hospitalists surveyed in this study were members of the Society of Hospital Medicine, so may not accurately exemplify all practicing hospitalists.

Implications

Overuse of testing is very common among hospitalists. Although roughly one‐third of respondents incorrectly thought that testing in the given scenarios was supported by the evidence or guidelines, the majority knew that testing was not clinically indicated and reported ordering tests to help reassure their patients or themselves. This suggests evidence‐based medicine approaches to overuse, such as the Choosing Wisely campaign and the emergence of appropriateness criteria, are likely necessary but insufficient to change physician practice patterns. Efforts to decrease overuse will need to engage clinicians and patients in ways that help overcome the attitude that more testing is required to provide reassurance.

Background

Patient expectations have been implicated as a contributor to overuse of medical interventions. Studies that have measured patients' understanding of the potential benefits and harms of medical treatments and tests have been scattered across the literature.

Findings

This systematic review aggregated all studies that have quantitatively assessed patients' expectations of the benefits and/or harms of any treatment or test. Of more than 15,000 records screened, only 36 articles met the inclusion criteria of describing a study in which participants were asked to provide a quantitative estimate of the expected benefits and/or harms of a treatment, test, or screen. Fourteen of the studies (40%) focused on screening, 15 (43%) on treatment, 3 (9%) on a test, and 3 (9%) on both treatment and screening. Topics included cancer, medications, surgery, cardiovascular disease, and fetal‐maternal medicine. The majority of patients overestimated intervention benefit and underestimated harm, regardless of whether the intervention was a test or a treatment. For example, more than half of participants overestimated benefit for 22 of the 34 outcomes (65%) for which overestimation data were provided, and a majority of participants underestimated harm for 10 of the 15 outcomes (67%) with underestimation data available.

Cautions

This systematic review included a limited number of studies, with varying levels of quality and a lot of heterogeneity, making it difficult to reach clear aggregate conclusions.

Implications

Patients are often overly optimistic about medical interventions and they downplay potential risks, making it more difficult to effectively discourage overuse. Clinicians should clearly understand and communicate realistic expectations for the potential benefits and risks of screening, testing, and medical treatments with patients and the public at large.

Background

Antibiotics are life‐saving therapies, but when used in inappropriate scenarios they can pose many risks.

Findings

This large national database study used the MarketScan Hospital Drug Database and the Centers for Disease Control and Prevention's (CDC) Emerging Infections Program data to explore antibiotic prescribing in hospital patients. More than half of all hospitalized patients (55.7%) received antibiotics during their stay. Half of all treatment antibiotics were prescribed for the treatment of either lower respiratory infections, urinary tract infections, or presumed gram‐positive infections. There was wide variation seen in antibiotic usage across hospital wards. Objective criteria for potential improvement in antimicrobial use were developed and applied at a subset of 36 hospitals. Antibiotic prescribing could be improved in 37.2% of the most common prescription scenarios reviewed, including patients receiving vancomycin or those being treated for a urinary tract infection. The impact of reducing inpatient antibiotic exposure on the incidence of Clostridium difficile colitis was modeled using data from 2 hospitals, revealing that decreasing hospitalized patients' exposure to broad‐spectrum antibiotics by 30% would lead to a 26% reduction in C difficile infections (interquartile range = 15%38%).

Cautions

Some of the estimates in this study are based on a convenience sample of claims and hospital‐based data, thus may not be an accurate representation, particularly when extrapolating to all US hospitals.

Implications

Antibiotic overuse is a rampant problem in hospitals, with many severe downstream effects such as C difficile infections and antimicrobial resistance. All hospital units should have an antibiotic stewardship program and should monitor antibiotic usage.

Lee TC, Frenette C, Jayaraman D, Green L, Pilote L. Antibiotic self‐stewardship: trainee‐led structured antibiotic time‐outs to improve antimicrobial use. Ann Intern Med. 2014;161(10 suppl):S53S58.

Background

The CDC and other groups have called for stewardship programs to address antibiotic overuse.[12] Few interventions have been shown to successfully engage medical trainees in efforts to improve their own antibiotic prescribing practices.

Findings

An antibiotic self‐stewardship program was developed and led by internal medicine residents at Montreal General Hospital. The intervention included a monthly resident education lecture on antimicrobial stewardship and twice‐weekly time‐out audits using a structured electronic checklist. Adherence with auditing was 80%. Total costs for antibiotics decreased from $149,743 CAD to $80,319 CAD, mostly due to an observed reduction in carbapenems. Moxifloxicin use decreased by 1.9 defined daily doses per 1000 patient‐days per month (P = 0.048). Rates of clostridium difficile colitis declined from 24.2 to 19.6 per 10,000 patient‐days, although this trend did not meet statistical significance (incidence rate ratio, 0.8 [confidence interval, 0.5‐1.3]).

Cautions

Although the use of some broader spectrum antibiotics decreased, there was no measurable change in overall antibiotic use, suggesting that physicians may have narrowed antibiotics but did not often completely discontinue them. The time‐series analyses in this study cannot provide causal conclusions between the intervention and outcomes. In fact, carbapenem usage appears to have significantly decreased prior to the implementation of the program, for unclear reasons. The feasibility of this educational intervention outside of a residency program is unclear.

Implications

A combination of education, oversight and frontline clinician engagement in structured time‐outs may be effective, at least in narrowing antibiotic usage. The structured audit checklist developed by these authors is available for free in the supplementary materials of the Annals of Internal Medicine article.

Disclosures: Dr. Moriates has received grant funding from the ABIM Foundation, and royalties from McGraw‐Hill for the textbook Understanding Value‐Based Healthcare. The authors report no conflicts of interest.

Background

With recent changes in resident duty hours and staffing models, the number of clinical handoffs during a patient's hospital stay has been increasing.[5] The omission of critical information and the transfer of erroneous information during handoffs is common, which contributes to preventable medical errors.[6]

Findings

This prospective intervention study of a resident handoff program in 9 hospitals sought to improve communication between healthcare providers and to decrease medical errors. The I‐PASS mnemonic, which stands for illness severity, patient summary, action list, situation awareness, and synthesis by receiver, was introduced to standardize oral and written handoffs. The program also included a 2‐hour workshop, a 1‐hour role‐playing and simulation session, a computer module, a faculty development program, direct observation tools, and a culture change campaign. Medical errors decreased by 23% following the intervention, compared to the preintervention baseline (24.5 vs 18.8 per 100 admissions, P < 0.001), and the rate of preventable adverse events dropped by 30% (4.7 vs 3.3 events per 100 admissions, P < 0.001), whereas nonpreventable adverse events did not change. Process measures of handoff quality uniformly improved with the intervention. The duration of oral handoffs was approximately 2.5 minutes per patient both before and during the intervention period.

Cautions

Not all of the sites in the study saw significant reductions in medical errors; 3 of the programs did not have significantly improved medical error rates following implementation of the I‐PASS handoff bundle. The study design was not a randomized controlled trial, and thus the pre‐ versus postimplementation analyses cannot draw definitive causal links between the intervention and the observed improvements in safety outcomes. Furthermore, this study was done with pediatric residents, and one cannot assume that the results will translate to practicing hospitalists, who may not benefit as much from a scripted sign‐out.

Implications

A comprehensive handoff program that included the I‐PASS mnemonic along with extensive training, faculty development, and a culture‐change campaign was associated with impressive improvements in patient safety outcomes, without negatively effecting workflow.

Background

Hospital readmissions are common, costly, and potentially represent a failure to adequately prepare patients for hospital discharge, but efforts to prevent 30‐day readmissions have been mixed.[7] The investigators in this study offer a novel framework, the cumulative complexity model, as a way to conceptualize postdischarge outcomes such as readmission. The model depicts the balance between the patient's workload of managing their illness, including the demands of monitoring treatment and self‐care, and the patient's capacity to handle that workfunctionality, financial/social resources, literacy, and empowerment. Workload‐capacity imbalances (when workload outstrips capacity) may lead to progressively increasing illness and increasing complexity, which contribute to poor patient outcomes like readmissions. Decreasing a patient's workload or increasing their capacity may be effective in reducing readmissions.

Findings

Investigators sought to identify factors associated with successful interventions to reduce 30‐day readmissions, including how the interventions fit into the cumulative complexity model. After performing a comprehensive search of randomized trials of interventions to reduce readmissions, the investigators identified 42 randomized trials with the primary outcome of 30‐day readmission rates. In addition to reviewing intervention characteristics, blinded raters scored interventions based on their effects on reducing or increasing patient workload and reducing or increasing patient capacity for self‐care. Interventions that had several components (eg, pharmacy education, postdischarge phone calls, visiting nurses, health coaches, close primary care follow‐up) were more likely to be successful (1.4 times as likely; P = 0.001), as were interventions that involved 2 or more individuals (1.3 times as likely; P = 0.05). Interventions that were published prior to 2002 were 1.6 times more likely to have reduced readmissions (P = 0.01). When applied to the cumulative complexity model, interventions that sought to augment patient capacity for self‐care were 1.3 times as likely to be successful (P = 0.04), whereas no relationship was found between an intervention's effect on patient workload and readmission.

Cautions

The authors evaluated each intervention based on the degree to which it was likely to affect patient workload and patient capacity. Because a multifaceted intervention may have had components that increased patient workload (eg, more self‐monitoring, appointments) and decreased patient workload (home visits, visiting nurses), the true effect of patient workload on readmissions may not have been optimally analyzed in this study. Additionally, this element of the study relied on a value judgment original to this work. Interventions that are burdensome to some, may be beneficial to those with the capacity and resources to access the care.

Implications

The body of studies reviewed suggests that interventions to reduce 30‐day readmissions are on the whole successful. Their findings are in keeping with past studies demonstrating more successful interventions that are resource‐intensive and multifaceted. Finding successful interventions that are also cost‐effective may be challenging. This article adds the cumulative complexity framework to what we already know about readmissions, highlighting patient capacity to manage the burden of their Illness as a new factor for success. Efforts to deliver patient‐centered education, explore barriers to adherence, and provide health coaching may be more successful than interventions that unwittingly add to the burden of disease treatment (multiple follow‐up appointments, complex medication schedules, and posthospital surveys and patient self‐assessments).

Background

Patient activation is widely recognized as the knowledge, skills, and confidence a person has in managing their own health or healthcare. Higher patient activation has been associated with improved health outcomes, but the relationship between patient activation and readmission to the hospital within 30 days is unknown.[8]

Findings

Using data from Project RED‐LIT (Re‐Engineered Discharge for patients with low health literacy), a randomized controlled trial conducted at an urban safety‐net hospital, investigators examined the relationship between all unplanned utilization events of hospital services within 30 days of discharge and patient activation, as measured by an abbreviated 8‐item version of the validated Patient Activation Measure (PAM). The PAM uses agreement with statements about a patient's sense of responsibility for his or her own health, confidence in seeking care and following through with medical treatments, and confidence in managing new problems to measure activation. The 695 participants were divided into quartiles based on their PAM score, and the investigators looked at the rates of unplanned utilization events in each group. After adjusting for potential confounders such as gender, age, Charlson Comorbidity Index, insurance, marital status, and education, there remained a significant effect between PAM and 30‐day hospital reutilization. Compared with those who scored in the highest quartile of activation, those in the lowest quartile had 1.75 times the rate of 30‐day reutilization (P < 0.001). Those in the second highest and third highest quartile had 1.3 (P = 0.03) and 1.5 times (P < 0.001) the rate of reutilization demonstrating a dose‐response relationship between activation and low reutilization.

Cautions

It is as yet unclear how best to apply these results and whether activation is a modifiable risk factor. Can a patient become more activated by providing more education and coaching during their hospital stay? Can providing close follow‐up and home services make a person more confident to manage their own illness? Although early identification of patients with low activation using PAM is being done at many hospitals, there is no study to suggest that targeting these patients can reduce readmission.

Implications

A low level of patient activation appears to be a risk factor for unplanned hospital utilization within 30 days of discharge. Given the increasing financial penalties, many hospitals across the country are using the PAM to determine how much support and which services they provide after discharge. Identifying these patients early in their hospitalization could allow providers to spend more time and attention on preparing them for managing their own illness after discharge. As above, the effects of this intervention on readmissions is as yet unclear.

Background

Effective patient‐physician communication is associated with improved patient satisfaction, care quality, and clinical outcomes.[9] Whether a shared understanding of the plan of care between patients and clinicians affects satisfaction is unknown.

Findings

One hundred seventy‐seven patients who had 2 or more medical conditions, 2 or more medical procedures, and 2 or more days in the hospital were interviewed on the day of discharge. Patients were questioned about their overall understanding of their hospitalization and about specific aspects of their care. They were also asked to provide objective data to measure their understanding of their hospital course by (1) listing their medical diagnoses, (2) identifying indications for medication on discharge paperwork, and (3) listing tests or procedures they underwent from a standard list. Patients were then asked to rate their satisfaction with their hospitalization. Patients' self‐reported understanding was an average of 4.0 (very good) on a 5‐point scale. Their measured understanding scores for medical diagnoses, indications for medications and tests and procedures were 48.9%, 56.2%, and 59.4%, respectively. Factors associated with poor understanding of their hospital course were increasing age, less education, lower household income, black race, and longer length of stay. Patients reported a mean satisfaction of 4.0 (very satisfied). Higher self‐reported understanding was associated with higher patient satisfaction, irrespective of actual understanding.

Cautions

Despite their suboptimal measured understanding of their hospital course, the average patient rated their understanding as very good. This suggests that patients are either poor judges of effective communication or have low expectations for understanding. It also calls into question the relationship between quality of communication and patient satisfaction, because despite their satisfaction, patients' actual understanding was low. There was, however, a clear and positive relationship between patients' perceived understanding and their satisfaction, suggesting that shared understanding remains integral to patient satisfaction.

Implications

Patient satisfaction appears to be tied to patients' perceived understanding of their care, but when tested actual understanding was suboptimal. Further efforts in patient satisfaction should not only focus on the quality of our communication, but on the resulting understanding of our patients.

Background

Although high readmission rates are a national problem, a minority of patients treated for common conditions like pneumonia, heart failure, and chronic obstructive pulmonary disease are readmitted for the same problem.[10] This suggests that readmissions may stem not from poor disease management, but from patient vulnerability to illness in the period following hospitalization.

Findings

In this viewpoint opinion article, the authors suggest that the depersonalizing and stressful hospital atmosphere contributes to a transient vulnerability in the period following hospitalization that makes it challenging for patients to care for themselves and their illness. They offer specific strategies for changing the nature of our hospital care to promote healing and to decrease patient stress. The authors suggest promoting personalization through accommodation of family members, and allowing personal clothing and personal dcor in their rooms. Physicians and consultants should make appointments so that patients and families can know when to expect important visits. The authors also focus on the provision of rest and nourishment by reducing nighttime disruption and the elimination on unnecessary restrictive diets. They argue that the hospital is a place of stressful disruptions and surprises, which could all be ameliorated by providing patients with a way to understand the members of their team and their roles as well as through providing a clear schedule for the day. Healthcare providers should not enter a room unannounced, and patients should be given private rooms as much as possible. Last, the authors focus on the elimination of unnecessary tests and procedures such as blood draws, telemetry, and urine cultures and the encouragement of activity by providing activities where patients can gather together outside their rooms.

Cautions

If these changes seem simple, they may not be. Many involve a significant shift in our thinking on how we provide carefrom a focus on disease and provider convenience to a true consideration for the health and peace of mind of our patients. Starting with small steps, such as reductions in phlebotomy and nighttime vital signs checks for the most stable patients and ensuring accommodations for families, may make this long list seem less daunting.

Implications

By promoting factors that affect a patient's well beingrest, nutrition, peace of mindwe may be discharging patients who are better equipped to manage their illness after their hospitalization.

Background

National efforts, such as the Choosing Wisely campaign, seek to decrease overuse of low‐value services.[11] The extent of the problem of overtesting among hospitalists and the underlying drivers for unnecessary testing in this group have not been clearly defined.

Findings

Practicing adult medicine hospitalists across the country were given a questionnaire that included clinical vignettes for common inpatient scenarios: a preoperative evaluation and a syncope workup. Respondents were randomly provided 1 of 4 versions of each vignette, which contained the same clinical information but varied by a family member's request for further testing and by disclosure of the occupation of the family member. For example, in the preoperative evaluation, the vignettes either: (1) provided no details about the patient's son; (2) identified the son as a physician; (3) mentioned the son's request for testing, but did not identify the son as a physician; or (4) identified the son as a physician who requested testing. The syncope vignette versions were structured similarly, except the family member was the patient's wife and she was an attorney. The authors collected 1020 responses from an initial pool of 1500, for a decent 68% response rate. Hospitalists commonly reported overuse of testing, with 52% to 65% of respondents requesting unnecessary testing in the preoperative evaluation scenario, and 82% to 85% in the syncope scenario. The majority of physicians reported that they knew the testing was not clinically indicated based on evidence or guidelines, but were ordering the test due to a desire to reassure the patients or themselves.

Cautions

Responses to clinical vignettes in a survey may not represent actually practices. In addition, all hospitalists surveyed in this study were members of the Society of Hospital Medicine, so may not accurately exemplify all practicing hospitalists.

Implications

Overuse of testing is very common among hospitalists. Although roughly one‐third of respondents incorrectly thought that testing in the given scenarios was supported by the evidence or guidelines, the majority knew that testing was not clinically indicated and reported ordering tests to help reassure their patients or themselves. This suggests evidence‐based medicine approaches to overuse, such as the Choosing Wisely campaign and the emergence of appropriateness criteria, are likely necessary but insufficient to change physician practice patterns. Efforts to decrease overuse will need to engage clinicians and patients in ways that help overcome the attitude that more testing is required to provide reassurance.

Background

Patient expectations have been implicated as a contributor to overuse of medical interventions. Studies that have measured patients' understanding of the potential benefits and harms of medical treatments and tests have been scattered across the literature.

Findings

This systematic review aggregated all studies that have quantitatively assessed patients' expectations of the benefits and/or harms of any treatment or test. Of more than 15,000 records screened, only 36 articles met the inclusion criteria of describing a study in which participants were asked to provide a quantitative estimate of the expected benefits and/or harms of a treatment, test, or screen. Fourteen of the studies (40%) focused on screening, 15 (43%) on treatment, 3 (9%) on a test, and 3 (9%) on both treatment and screening. Topics included cancer, medications, surgery, cardiovascular disease, and fetal‐maternal medicine. The majority of patients overestimated intervention benefit and underestimated harm, regardless of whether the intervention was a test or a treatment. For example, more than half of participants overestimated benefit for 22 of the 34 outcomes (65%) for which overestimation data were provided, and a majority of participants underestimated harm for 10 of the 15 outcomes (67%) with underestimation data available.

Cautions

This systematic review included a limited number of studies, with varying levels of quality and a lot of heterogeneity, making it difficult to reach clear aggregate conclusions.

Implications

Patients are often overly optimistic about medical interventions and they downplay potential risks, making it more difficult to effectively discourage overuse. Clinicians should clearly understand and communicate realistic expectations for the potential benefits and risks of screening, testing, and medical treatments with patients and the public at large.

Background

Antibiotics are life‐saving therapies, but when used in inappropriate scenarios they can pose many risks.

Findings

This large national database study used the MarketScan Hospital Drug Database and the Centers for Disease Control and Prevention's (CDC) Emerging Infections Program data to explore antibiotic prescribing in hospital patients. More than half of all hospitalized patients (55.7%) received antibiotics during their stay. Half of all treatment antibiotics were prescribed for the treatment of either lower respiratory infections, urinary tract infections, or presumed gram‐positive infections. There was wide variation seen in antibiotic usage across hospital wards. Objective criteria for potential improvement in antimicrobial use were developed and applied at a subset of 36 hospitals. Antibiotic prescribing could be improved in 37.2% of the most common prescription scenarios reviewed, including patients receiving vancomycin or those being treated for a urinary tract infection. The impact of reducing inpatient antibiotic exposure on the incidence of Clostridium difficile colitis was modeled using data from 2 hospitals, revealing that decreasing hospitalized patients' exposure to broad‐spectrum antibiotics by 30% would lead to a 26% reduction in C difficile infections (interquartile range = 15%38%).

Cautions

Some of the estimates in this study are based on a convenience sample of claims and hospital‐based data, thus may not be an accurate representation, particularly when extrapolating to all US hospitals.

Implications

Antibiotic overuse is a rampant problem in hospitals, with many severe downstream effects such as C difficile infections and antimicrobial resistance. All hospital units should have an antibiotic stewardship program and should monitor antibiotic usage.

Lee TC, Frenette C, Jayaraman D, Green L, Pilote L. Antibiotic self‐stewardship: trainee‐led structured antibiotic time‐outs to improve antimicrobial use. Ann Intern Med. 2014;161(10 suppl):S53S58.

Background

The CDC and other groups have called for stewardship programs to address antibiotic overuse.[12] Few interventions have been shown to successfully engage medical trainees in efforts to improve their own antibiotic prescribing practices.

Findings

An antibiotic self‐stewardship program was developed and led by internal medicine residents at Montreal General Hospital. The intervention included a monthly resident education lecture on antimicrobial stewardship and twice‐weekly time‐out audits using a structured electronic checklist. Adherence with auditing was 80%. Total costs for antibiotics decreased from $149,743 CAD to $80,319 CAD, mostly due to an observed reduction in carbapenems. Moxifloxicin use decreased by 1.9 defined daily doses per 1000 patient‐days per month (P = 0.048). Rates of clostridium difficile colitis declined from 24.2 to 19.6 per 10,000 patient‐days, although this trend did not meet statistical significance (incidence rate ratio, 0.8 [confidence interval, 0.5‐1.3]).

Cautions

Although the use of some broader spectrum antibiotics decreased, there was no measurable change in overall antibiotic use, suggesting that physicians may have narrowed antibiotics but did not often completely discontinue them. The time‐series analyses in this study cannot provide causal conclusions between the intervention and outcomes. In fact, carbapenem usage appears to have significantly decreased prior to the implementation of the program, for unclear reasons. The feasibility of this educational intervention outside of a residency program is unclear.

Implications

A combination of education, oversight and frontline clinician engagement in structured time‐outs may be effective, at least in narrowing antibiotic usage. The structured audit checklist developed by these authors is available for free in the supplementary materials of the Annals of Internal Medicine article.

Disclosures: Dr. Moriates has received grant funding from the ABIM Foundation, and royalties from McGraw‐Hill for the textbook Understanding Value‐Based Healthcare. The authors report no conflicts of interest.

Organizational Framework

The HVC program is co‐led by a UCSF hospitalist (C.M.) and the administrator of the Division of Hospital Medicine (M.N.). Team members include hospitalists, hospital medicine fellows, resident physicians, pharmacists, project coordinators, and other administrators. The team meets in person for 1 hour every month. Project teams and ad hoc subcommittee groups often convene between meetings.

Our HVC program was placed within the infrastructure, and under the leadership, of our already established quality improvement (QI) program at UCSF. Our Division of Hospital Medicine Director of Quality and Safety (M.M.) thus oversees the QI, patient safety, patient experience, and high‐value care efforts.

The HVC program funding is largely in personnel costs. The physician leader (15% effort) is funded by the Division of Hospital Medicine, whereas the administrator is cofunded by both the division and by the medical center (largely through her roles as both division administrator and service line director). An administrative assistant within the division is also assigned to help with administrative tasks. Some additional data gathering and project support comes from existing medical center QI infrastructure, the decision support services unit, and through UCSF's new Center for Healthcare Value. Other ancillary costs for our projects have included publicity, data analytics, and information technology infrastructure. We estimate that the costs of this program are approximately $50,000 to $75,000 annually.

Framework for Identifying Target Projects

Robust Analysis of Costs

We created a framework for identifying, designing, and promoting projects specifically aimed at improving healthcare value (Figure 1). Financial data were used to identify areas with clear evidence of waste in the hospital, areas of high cost with no benefit in health outcomes. We focused particularly on obtaining cost and billing data for our medical service, which provided important insight into potential targets for improvements in value. For example, in 2011, the Division of Hospital Medicine spent more than $1 million annually in direct costs for the administration of nebulized bronchodilator therapies (nebs) to nonintensive care unit patients on the medical service.[13] These high costs, exposed by billing data, were believed to represent potential unnecessary testing and/or procedures. Not every area of high cost was deemed a target for intervention. For example, the use of recombinant factor VIII appeared a necessary expenditure (over $1 million per year) for our patients with hemophilia. Although our efforts focused on reducing waste, it is worth noting that healthcare value can also be increased by improving the delivery of high‐value services.

Figure 1

Intervention Strategy

Our general approach has been to design and implement multifaceted interventions, adapted from previous QI literature (Figure 1).[17] Given the importance of frontline clinician engagement to successful project implementation,[18, 19, 20] our interventions are physician‐driven and are vetted by a large group of clinicians prior to launch. The HVC program also explicitly seeks stakeholder input, perspective, and buy‐in prior to implementation. For example, we involved respiratory therapists (RTs) in the design of the Nebs No More After 24 project, thus ensuring that the interventions fit within their workflow and align with their care‐delivery goals.

Local publicity campaigns provide education and reminders for clinicians. Posters, such as the Nebs No More After 24 poster (Figure 2), were hung in physician, nursing, and RT work areas. Pens featuring the catchphrase Nebs No More After 24 were distributed to clinicians.

Figure 2

In addition to presentations to residents through the UCSF cost awareness curriculum, educational presentations were also delivered to attending physicians and to other allied members of the healthcare team (eg, nurses, RTs) during regularly scheduled staff meetings.

The metrics for each of the projects were regularly monitored, and targeted feedback was provided to clinicians. For the Nebs No More After 24 campaign, data for the number of nebs delivered on the target floor were provided to resident physicians during the cost awareness conference each month, and the data were presented to attending hospitalists in the monthly QI newsletter. This academic year, transfusion and telemetry data are presented via the same strategy.

Stakeholder recruitment, education, and promotional campaigns are important to program launches, but to sustain projects over the long‐term, system changes may be necessary. We have pursued changes in the computerized provider order entry (CPOE) system, such as removing nebs from the admission order set or putting a default duration for certain telemetry orders. Systems‐level interventions, although more difficult to achieve, play an important role in creating enduring changes when paired with educational interventions.

Challenges and Lessons Learned

Limitations and Next Steps

Our goal is to provide guidance on exporting the approach of our HVC program to other institutions, but there may be several limitations. First, our strategy relied on several contributing factors that may be unique to our institution. We had engaged frontline physician champions, who may not be available or have the necessary support at other academic or community organizations. Our UCSF cost awareness curriculum provided an educational foundation and framework for our projects. We also had institutional commitment in the form of our medical center division administrator.

Second, there are up‐front costs to running our committee, which are primarily related to personnel funding as described in the Methods. Over the next year we aim to calculate cost‐effectiveness ratios for our projects and overall return on investment for each of our projects, as we have done for the Nebs No More After 24 project (see Supporting Information, Table 1, in the online version of this article). Based on this analysis, the modest upfront costs appear to be easily recouped over the course of the year.

We have anecdotally noted a culture change in the way that our physicians discuss and consider testing. For example, it is common now to hear ward teams on morning rounds consider the costs of testing or discuss the need for prophylactic proton pump inhibitors. An important next step for our HVC program is the building of better data infrastructures for our own electronic health record system to allow us to more quickly, accurately, and comprehensively identify new targets and monitor the progress and sustainability of our projects. The Institute of Medicine has noted that the adoption of technology is a key strategy to creating a continuously learning healthcare system.[1] It is our hope that through consistent audit and feedback of resource utilization we can translate our early gains into sustainable changes in practice.

Furthermore, we hope to target and enact additional organizational changes, including creating CPOE‐linked interventions to help reinforce and further our objectives. We believe that creating systems that make it easier to do the right thing will help the cause of embedding HVC practices throughout our medical center. We have begun to scale some of our projects, such as the Nebs No More After 24 campaign, medical center wide, and ultimately we hope to disseminate successful projects and models beyond our medical center to contribute to the national movement to provide the best care at lower costs.

As discussed above, our interventions are targeted at simultaneous improvements in quality with decreased costs. However, the goal is not to hide our cost interventions behind the banner of quality. We believe that there is a shifting culture that is increasingly ready to accept cost alone as a meaningful patient harm, worthy of interventions on its own merits, assuming that quality and safety remain stable.[26, 27]

Organizational Framework

The HVC program is co‐led by a UCSF hospitalist (C.M.) and the administrator of the Division of Hospital Medicine (M.N.). Team members include hospitalists, hospital medicine fellows, resident physicians, pharmacists, project coordinators, and other administrators. The team meets in person for 1 hour every month. Project teams and ad hoc subcommittee groups often convene between meetings.

Our HVC program was placed within the infrastructure, and under the leadership, of our already established quality improvement (QI) program at UCSF. Our Division of Hospital Medicine Director of Quality and Safety (M.M.) thus oversees the QI, patient safety, patient experience, and high‐value care efforts.

The HVC program funding is largely in personnel costs. The physician leader (15% effort) is funded by the Division of Hospital Medicine, whereas the administrator is cofunded by both the division and by the medical center (largely through her roles as both division administrator and service line director). An administrative assistant within the division is also assigned to help with administrative tasks. Some additional data gathering and project support comes from existing medical center QI infrastructure, the decision support services unit, and through UCSF's new Center for Healthcare Value. Other ancillary costs for our projects have included publicity, data analytics, and information technology infrastructure. We estimate that the costs of this program are approximately $50,000 to $75,000 annually.

Framework for Identifying Target Projects

Robust Analysis of Costs

We created a framework for identifying, designing, and promoting projects specifically aimed at improving healthcare value (Figure 1). Financial data were used to identify areas with clear evidence of waste in the hospital, areas of high cost with no benefit in health outcomes. We focused particularly on obtaining cost and billing data for our medical service, which provided important insight into potential targets for improvements in value. For example, in 2011, the Division of Hospital Medicine spent more than $1 million annually in direct costs for the administration of nebulized bronchodilator therapies (nebs) to nonintensive care unit patients on the medical service.[13] These high costs, exposed by billing data, were believed to represent potential unnecessary testing and/or procedures. Not every area of high cost was deemed a target for intervention. For example, the use of recombinant factor VIII appeared a necessary expenditure (over $1 million per year) for our patients with hemophilia. Although our efforts focused on reducing waste, it is worth noting that healthcare value can also be increased by improving the delivery of high‐value services.

Figure 1

Intervention Strategy

Our general approach has been to design and implement multifaceted interventions, adapted from previous QI literature (Figure 1).[17] Given the importance of frontline clinician engagement to successful project implementation,[18, 19, 20] our interventions are physician‐driven and are vetted by a large group of clinicians prior to launch. The HVC program also explicitly seeks stakeholder input, perspective, and buy‐in prior to implementation. For example, we involved respiratory therapists (RTs) in the design of the Nebs No More After 24 project, thus ensuring that the interventions fit within their workflow and align with their care‐delivery goals.

Local publicity campaigns provide education and reminders for clinicians. Posters, such as the Nebs No More After 24 poster (Figure 2), were hung in physician, nursing, and RT work areas. Pens featuring the catchphrase Nebs No More After 24 were distributed to clinicians.

Figure 2

In addition to presentations to residents through the UCSF cost awareness curriculum, educational presentations were also delivered to attending physicians and to other allied members of the healthcare team (eg, nurses, RTs) during regularly scheduled staff meetings.

The metrics for each of the projects were regularly monitored, and targeted feedback was provided to clinicians. For the Nebs No More After 24 campaign, data for the number of nebs delivered on the target floor were provided to resident physicians during the cost awareness conference each month, and the data were presented to attending hospitalists in the monthly QI newsletter. This academic year, transfusion and telemetry data are presented via the same strategy.

Stakeholder recruitment, education, and promotional campaigns are important to program launches, but to sustain projects over the long‐term, system changes may be necessary. We have pursued changes in the computerized provider order entry (CPOE) system, such as removing nebs from the admission order set or putting a default duration for certain telemetry orders. Systems‐level interventions, although more difficult to achieve, play an important role in creating enduring changes when paired with educational interventions.

Challenges and Lessons Learned

Limitations and Next Steps

Our goal is to provide guidance on exporting the approach of our HVC program to other institutions, but there may be several limitations. First, our strategy relied on several contributing factors that may be unique to our institution. We had engaged frontline physician champions, who may not be available or have the necessary support at other academic or community organizations. Our UCSF cost awareness curriculum provided an educational foundation and framework for our projects. We also had institutional commitment in the form of our medical center division administrator.

Second, there are up‐front costs to running our committee, which are primarily related to personnel funding as described in the Methods. Over the next year we aim to calculate cost‐effectiveness ratios for our projects and overall return on investment for each of our projects, as we have done for the Nebs No More After 24 project (see Supporting Information, Table 1, in the online version of this article). Based on this analysis, the modest upfront costs appear to be easily recouped over the course of the year.

We have anecdotally noted a culture change in the way that our physicians discuss and consider testing. For example, it is common now to hear ward teams on morning rounds consider the costs of testing or discuss the need for prophylactic proton pump inhibitors. An important next step for our HVC program is the building of better data infrastructures for our own electronic health record system to allow us to more quickly, accurately, and comprehensively identify new targets and monitor the progress and sustainability of our projects. The Institute of Medicine has noted that the adoption of technology is a key strategy to creating a continuously learning healthcare system.[1] It is our hope that through consistent audit and feedback of resource utilization we can translate our early gains into sustainable changes in practice.

Furthermore, we hope to target and enact additional organizational changes, including creating CPOE‐linked interventions to help reinforce and further our objectives. We believe that creating systems that make it easier to do the right thing will help the cause of embedding HVC practices throughout our medical center. We have begun to scale some of our projects, such as the Nebs No More After 24 campaign, medical center wide, and ultimately we hope to disseminate successful projects and models beyond our medical center to contribute to the national movement to provide the best care at lower costs.

As discussed above, our interventions are targeted at simultaneous improvements in quality with decreased costs. However, the goal is not to hide our cost interventions behind the banner of quality. We believe that there is a shifting culture that is increasingly ready to accept cost alone as a meaningful patient harm, worthy of interventions on its own merits, assuming that quality and safety remain stable.[26, 27]

Organizational Framework

The HVC program is co‐led by a UCSF hospitalist (C.M.) and the administrator of the Division of Hospital Medicine (M.N.). Team members include hospitalists, hospital medicine fellows, resident physicians, pharmacists, project coordinators, and other administrators. The team meets in person for 1 hour every month. Project teams and ad hoc subcommittee groups often convene between meetings.

Our HVC program was placed within the infrastructure, and under the leadership, of our already established quality improvement (QI) program at UCSF. Our Division of Hospital Medicine Director of Quality and Safety (M.M.) thus oversees the QI, patient safety, patient experience, and high‐value care efforts.

The HVC program funding is largely in personnel costs. The physician leader (15% effort) is funded by the Division of Hospital Medicine, whereas the administrator is cofunded by both the division and by the medical center (largely through her roles as both division administrator and service line director). An administrative assistant within the division is also assigned to help with administrative tasks. Some additional data gathering and project support comes from existing medical center QI infrastructure, the decision support services unit, and through UCSF's new Center for Healthcare Value. Other ancillary costs for our projects have included publicity, data analytics, and information technology infrastructure. We estimate that the costs of this program are approximately $50,000 to $75,000 annually.

Framework for Identifying Target Projects

Robust Analysis of Costs

We created a framework for identifying, designing, and promoting projects specifically aimed at improving healthcare value (Figure 1). Financial data were used to identify areas with clear evidence of waste in the hospital, areas of high cost with no benefit in health outcomes. We focused particularly on obtaining cost and billing data for our medical service, which provided important insight into potential targets for improvements in value. For example, in 2011, the Division of Hospital Medicine spent more than $1 million annually in direct costs for the administration of nebulized bronchodilator therapies (nebs) to nonintensive care unit patients on the medical service.[13] These high costs, exposed by billing data, were believed to represent potential unnecessary testing and/or procedures. Not every area of high cost was deemed a target for intervention. For example, the use of recombinant factor VIII appeared a necessary expenditure (over $1 million per year) for our patients with hemophilia. Although our efforts focused on reducing waste, it is worth noting that healthcare value can also be increased by improving the delivery of high‐value services.

Figure 1

Intervention Strategy

Our general approach has been to design and implement multifaceted interventions, adapted from previous QI literature (Figure 1).[17] Given the importance of frontline clinician engagement to successful project implementation,[18, 19, 20] our interventions are physician‐driven and are vetted by a large group of clinicians prior to launch. The HVC program also explicitly seeks stakeholder input, perspective, and buy‐in prior to implementation. For example, we involved respiratory therapists (RTs) in the design of the Nebs No More After 24 project, thus ensuring that the interventions fit within their workflow and align with their care‐delivery goals.

Local publicity campaigns provide education and reminders for clinicians. Posters, such as the Nebs No More After 24 poster (Figure 2), were hung in physician, nursing, and RT work areas. Pens featuring the catchphrase Nebs No More After 24 were distributed to clinicians.

Figure 2

In addition to presentations to residents through the UCSF cost awareness curriculum, educational presentations were also delivered to attending physicians and to other allied members of the healthcare team (eg, nurses, RTs) during regularly scheduled staff meetings.

The metrics for each of the projects were regularly monitored, and targeted feedback was provided to clinicians. For the Nebs No More After 24 campaign, data for the number of nebs delivered on the target floor were provided to resident physicians during the cost awareness conference each month, and the data were presented to attending hospitalists in the monthly QI newsletter. This academic year, transfusion and telemetry data are presented via the same strategy.

Stakeholder recruitment, education, and promotional campaigns are important to program launches, but to sustain projects over the long‐term, system changes may be necessary. We have pursued changes in the computerized provider order entry (CPOE) system, such as removing nebs from the admission order set or putting a default duration for certain telemetry orders. Systems‐level interventions, although more difficult to achieve, play an important role in creating enduring changes when paired with educational interventions.

Challenges and Lessons Learned

Limitations and Next Steps

Our goal is to provide guidance on exporting the approach of our HVC program to other institutions, but there may be several limitations. First, our strategy relied on several contributing factors that may be unique to our institution. We had engaged frontline physician champions, who may not be available or have the necessary support at other academic or community organizations. Our UCSF cost awareness curriculum provided an educational foundation and framework for our projects. We also had institutional commitment in the form of our medical center division administrator.

Second, there are up‐front costs to running our committee, which are primarily related to personnel funding as described in the Methods. Over the next year we aim to calculate cost‐effectiveness ratios for our projects and overall return on investment for each of our projects, as we have done for the Nebs No More After 24 project (see Supporting Information, Table 1, in the online version of this article). Based on this analysis, the modest upfront costs appear to be easily recouped over the course of the year.

We have anecdotally noted a culture change in the way that our physicians discuss and consider testing. For example, it is common now to hear ward teams on morning rounds consider the costs of testing or discuss the need for prophylactic proton pump inhibitors. An important next step for our HVC program is the building of better data infrastructures for our own electronic health record system to allow us to more quickly, accurately, and comprehensively identify new targets and monitor the progress and sustainability of our projects. The Institute of Medicine has noted that the adoption of technology is a key strategy to creating a continuously learning healthcare system.[1] It is our hope that through consistent audit and feedback of resource utilization we can translate our early gains into sustainable changes in practice.

Furthermore, we hope to target and enact additional organizational changes, including creating CPOE‐linked interventions to help reinforce and further our objectives. We believe that creating systems that make it easier to do the right thing will help the cause of embedding HVC practices throughout our medical center. We have begun to scale some of our projects, such as the Nebs No More After 24 campaign, medical center wide, and ultimately we hope to disseminate successful projects and models beyond our medical center to contribute to the national movement to provide the best care at lower costs.

As discussed above, our interventions are targeted at simultaneous improvements in quality with decreased costs. However, the goal is not to hide our cost interventions behind the banner of quality. We believe that there is a shifting culture that is increasingly ready to accept cost alone as a meaningful patient harm, worthy of interventions on its own merits, assuming that quality and safety remain stable.[26, 27]