reprinted from Issue 14, Spring 2012 of Frontiers of Medicine (PDF)
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Getting more tests does not equate to better care,” says Niraj Sehgal, MD, MPH, associate chair for Quality Improvement and Patient Safety.
In addition to being potentially harmful, over-ordering tests contributes to escalating health care costs. “As a lot of the national debate is highlighting, it’s not just about providing safe and high-quality care, but also being cost-effective, so the system can be sustained,” says Krishan Soni, MD, MBA, chief resident in Quality Improvement and Patient Safety.
Yet most physicians don’t know the cost of the tests they order, and may not fully consider the effects of over-testing on both patients and the health care system. To help change this, the Department of Medicine has developed two recent initiatives that foster cost awareness.
Radiology Utilization Awareness Campaign
Sehgal and a project team designed a two-phase intervention focused on providing information about cost and radiation exposure for commonly ordered radiology tests. The goal was to determine whether providing this information would influence ordering practices for hospitalized patients. Faculty were also provided with an educator’s facilitation guide to jump-start conversations with trainees during rounds. Teams were encouraged to discuss and reflect upon whether recently ordered radiology tests were in fact indicated, whether test results changed their clinical management, and how big is the problem of over-ordering radiology tests.
The cost awareness phase of the project led to reduced radiology test ordering in five of six studies evaluated. Residents also reported increased knowledge about the cost of these tests and their likelihood of taking these costs into consideration when ordering.
Cost Awareness Curriculum
Soni and third-year resident Christopher Moriates, MD, developed a yearlong curriculum to increase awareness of the cost and appropriateness of tests, procedures and medications. “As people are learning how to care for their patients, they are also learning to be stewards of effective resource utilization, right from the beginning,” says Soni.
Each month, trainees examine a different condition frequently seen in the hospital, such as chest pain. Moriates and Soni give interns a cost awareness overview, and then share an anonymous, itemized bill from an actual UCSF patient diagnosed with that condition. Half the interns then research evidence-based guidelines to outline which patients should receive which tests and under what circumstances. The other interns research actual practices at UCSF, and the costs of those tests. After discussing their findings with each other, they help Soni and Moriates prepare an hour-long conference to share lessons learned with students, residents and attending physicians.
“We definitely discuss the circumstances in which tests are worth their cost,” says Moriates. “We also find how much we do that costs a lot of money but does not provide any benefit, and the evidence suggests we shouldn’t be doing it…. As a resident, you want to order every single thing that your attending might ask about in the morning. Part of what we need to do is change that culture, so attendings aren’t asking, ‘Why didn’t you order that?’ but rather, ‘Why did you order that test – what is that going to show us?’”
Moriates and Soni have presented their findings from this innovative curriculum at local and national meetings, and the American College of Physicians invited Moriates to join their planning committee to develop a high-value, cost-conscious care curriculum.
For people concerned that cost awareness might lead to rationing of care, Soni has this comparison. “If you went to a mechanic who told you what was wrong with your car, then gave you the necessary services and billed you for them, you wouldn’t call that rationing – you’d call that a trustworthy and effective person who does their job appropriately.”
“In medicine, we’re trying to promote a similar model,” said Soni. “We don’t want to withhold anything you need. It’s all about figuring out what your problems are, and how we can effectively treat them using the least harmful, least invasive and least costly approach.”