In 2011, the ABIM Foundation awarded five Putting the Charter into Practice
grants to projects that advanced the Physician Charter
commitment of just distribution of finite resources
Selected in conjunction with the Council of Medical Specialty Societies and a consumer representative, the grantees and their projects include:
American College of Physicians (ACP) - Stewardship of Resources Case Studies
Per the American College of Physicians Ethics Manual, physicians should practice “parsimonious care” using the best available evidence. To provide concrete guidance in practicing parsimonious care, the American College of Physicians Center for Ethics and Professionalism developed two case studies focusing on physician decisions about resource allocation and stewardship. (subscription required):
As of May 2013, more than 14,000 Medscape visitors had completed the case studies for CME credit.
Additionally, members of ACP’s Ethics, Professionalism and Human Rights Committee presented the case studies in role-playing sessions at the 2013 ACP Annual Meeting. In post-session evaluations, 93 percent of those responding said that the stewardship of resources session “maybe” or “definitely” had increased their skills and 91 percent said that they will do something different following the session. David Fleming, President-Elect of ACP and immediate past Chair of the Ethics, Professionalism and Human Rights Committee created a video reflection on the project.
Costs of Care - Teaching Value
As a medical student, Neel Shah was frustrated by the inability to understand how the costs of medical decisions could impact patients and society. Subsequently, Dr. Shah founded Costs of Care, a Boston-based non-profit whose mission is to “transform American healthcare delivery by empowering patients and their caregivers to deflate medical bills.”
Through its “Teaching Value" project, Costs of Care and educators at Harvard Medical School and the University of Chicago have created interactive, case-based video modules to facilitate reflective learning about stewardship of health care resources among medical students, residents and practicing physicians. The video modules center on the care of a fictional patient admitted to the emergency room.
Each module explores reasons why clinicians commonly overuse medical tests and treatments, such as:
- Physician training;
- Opaque pricing structures;
- Redundant ordering; and
- Patient requests.
Each scenario is coupled with a debriefing video that includes key teaching points, including how to communicate with patients about unnecessary care and reducing overused or misused tests and procedures.
The modules are intended to engage trainees in graduate medical education programs, and will also be used for training both practicing physicians and residents in teaching hospitals, as well as students during third-year internal medicine clerkships. To assess the impact of this program, the project team has created a pre- and post-test of knowledge regarding healthcare costs, as well as follow-up post-tests to assess retention of knowledge and changes in behavior among completers of the modules.
To date, the project has been featured at the 2012 National Physicians Alliance Annual meeting and the AAMC Annual Meeting. Additionally, a “teaser” video for the project, “What if Your Hotel Bill was Like Your Hospital Bill?” was featured in a number of media outlets, including The New York Times.
Johns Hopkins Bayview Medical Center: Aligning Physician Cardiac Enzyme-Ordering Behavior with Established Guidelines
Johns Hopkins Bayview clinicians had a longstanding interest in stewardship of resources, as evidenced by the creation of Physicians for Responsible Ordering (PRO), a Bayview physician group with a mission “to reduce laboratory and radiologic testing with no clinical utility or unfavorable risk/benefit ratio (i.e., waste).” Building on PRO’s efforts, Bayview researchers, in collaboration with practicing physicians, residents and medical students, developed an initiative to reduce the overutilization of cardiac enzyme panels, a commonly ordered diagnostic test. The initiative was comprised of:
- Development and promotion of an evidence-based guideline for ordering of cardiac enzymes for diagnosis of acute coronary syndrome at Bayview;
- Restructuring the hospital’s computer provider order entry (CPOE) system to change provider ordering of cardiac enzyme testing; and,
- Generating cardiac enzyme ordering report cards for house staff and faculty physicians using guideline-based benchmarks. Low performers received coaching to reduce unnecessary ordering, and high performers were interviewed to identify best ordering practices.
In a Bayview grand rounds presentation
, the project team presented preliminary results showing a 66 percent reduction in cardiac-enzyme ordering, with $1.3 million in savings. They also concluded that, “Cost aside [referring to the savings derived], this is the right thing to do for patients
.” The project team will publish further results in a journal article.
National Physicians Alliance (NPA): Putting a “Top Five” List into Practice
In this follow-up effort to its 2009 Putting the Charter into Practice grant project, NPA developed provider and patient versions of videos demonstrating scenarios in which physicians discuss some of the tests and procedures featured in the lists, along with patient education materials.
Currently, residents and faculty at three practices are receiving communication skills training, followed by a six-month period in which the recommendations in their respective specialties will be put into practice. The practices include:
- Long Beach Family Medicine Residency Program
- Yale Primary Care Center
- University of Washington Family Medicine Residency Program
The project team will then use chart audits to compare the pre-intervention and post-intervention rates at which the “"Top 5"” recommendations were followed.
The NPA will also create a virtual practice community committed to the principles of professionalism, good stewardship and patient-centered care. The virtual practice community will use social networking tools to enable providers to:
- share experiences with implementation of the “"Top 5"” lists;
- expand the “"Top 5"” to the “"Top 10;"” and,
- participate in ongoing professionalism educational activities.
As project leader Dr. Marissa Hendrickson noted on The Medical Professionalism Blog, “Particularly in Emergency Medicine practice, it is easy to fall back on getting more information and doing more things for the patient … but especially in our pediatric patients, more isn’t always better.”
Through this project, the University of Minnesota's Division of Pediatric Emergency Medicine developed and implemented evidence-based practice guidelines and electronic clinical decision support tools for common causes of pediatric emergency room visits such as acute gastroenteritis and suspected appendicitis, two childhood conditions for which physicians commonly do not adhere to practice guidelines. This can result in overuse of laboratory testing and, in the case of suspected appendicitis, overuse of CT scans.
The researchers are currently evaluating data on a number of measures, including:
The decision-support tools will remain a part of the hospital’s electronic medical record and the investigators plan to expand the tools to seven other network hospitals.
- The number of children who present to the emergency department (ED) for evaluation of acute abdominal pain or AGE and are evaluated using the guidelines;
- Proportion of providers adopting the guidelines and whether they interpreted them correctly; and,
- Quality of care pre- and one year post-intervention.
The project team has also developed a website with its pediatric emergency medicine decision tools to enable other institutions to learn about the project and access the guidelines. Once the data analysis is complete, the project results will be submitted for inclusion in professional conferences such and for publication in peer-reviewed medical journals.