Quality

In search of high-value care


 

  • Don’t place, or leave in place, urinary catheters for incontinence or convenience or monitoring of output for non–critically ill patients.
  • Don’t prescribe medications for stress ulcer prophylaxis to medical inpatients unless at high risk for GI complications.
  • Avoid transfusions of red blood cells for arbitrary hemoglobin or hematocrit thresholds and in the absence of symptoms of active coronary disease, heart failure, or stroke.
  • Don’t order continuous telemetry monitoring outside of the ICU without using a protocol that governs continuation.
  • Don’t perform repetitive CBC and chemistry testing in the face of clinical and lab stability.

The ACP launched a high-value care initiative that offers learning resources for clinicians and medical educators, clinical guidelines, and best practice advice. In 2012, a workgroup of internists convened by ACP developed a list of 37 clinical situations in which medical tests are commonly used but do not provide high value.5 Seven of those situations are applicable to adult hospital medicine.

High-value care today: What the experts say

Dr. Amit Pahwa, assistant professor of medicine and pediatrics at Johns Hopkins University, Baltimore

Dr. Amit Pahwa

More than 5 years later, what progress have hospitalists made in adopting high-value care practices? To answer this and other questions, I reached out to three national experts in high-value care in hospital medicine: Amit Pahwa, MD, assistant professor of medicine and pediatrics at Johns Hopkins University, Baltimore, and a course director of “Topics in interdisciplinary medicine: High-value health care”; Christopher Petrilli, MD, clinical assistant professor in the department of medicine at New York University Langone Health and clinical lead, Manhattan campus, value-based management; and Charlie Wray, DO, MS, assistant professor of medicine at the University of California in San Francisco and a coauthor of an article on high-value care in hospital medicine published recently in the Journal of General Internal Medicine6.

Dr. Christopher Petrilli, clinical assistant professor in the department of medicine at NYU Langone Health and clinical lead, Manhattan campus, value-based management

Dr. Christopher Petrilli

The experts agree that awareness of high-value care among practicing physicians and medical trainees has increased in the last few years. Major professional publications have highlighted the topic, including The Journal of Hospital Medicine’s “Things We Do For No Reason” series, JAMA’s “Teachable Moments,” and the American Journal of Medicine’s recurring column dedicated to high-value care practice. Leading teaching institutions have built high-value care curricula as a part of their medical student and resident training. However, widespread adoption has been slow and sometimes difficult.

Dr. Charlie Wray, assistant professor of medicine at University of California, San Francisco

Dr. Charlie Wray

The barriers to adoption of high-value practices among hospitalists are numerous and deep rooted in historical practices and culture. As Dr. Petrilli said, the “culture of overordering [diagnostic tests] is hard to break.” Hospitalists may not have well-developed relationships with patients, or time to explain why some tests or treatments are unnecessary. There is a lack of cost transparency, including the cost of the tests themselves and the downstream costs of additional tests and follow-ups. The best intended interventions fail to produce durable change unless they are seamlessly integrated into a hospitalist’s daily workflow.

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