Costaware Care: A critical core competency

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Cost-aware Care A critical core competency

• Rajiv ChandawarkarMD,
• Shiv Taylor BS,
• Peter Abrams MD,
• Andrew Duffy MD,
• Anthony Voytovich MD,
• Walter Longo MD and
• Robert Kozol MD
• From Division of Plastic Surgery, Departments
  of Surgery Medicine, University of
  Connecticut School of Medicine, Farmington CT and
  Department of Surgery,Yale University School of
  Medicine, New Haven CT

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Background

• FACT
• The healthcare climate is rapidly changing from
  one that used to be a blind-to-cost delivery
  system to one that is under national scrutiny due
  to rising healthcare costs

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Background

• FACT
• 77 million Americans will march towards Medicare
  eligibility by 2011.
• Until then, and thereon, billions of healthcare
  obligations will have to be met.

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Background

• FACT
• Going forward evolving healthcare delivery
  systems will need to sharply focus upon two
  fundamental issues
• cost and quality of care.

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Background

• FACT
• Newer initiatives including the
  Pay-for-Performance program initiated by the CMMS
  and Federation of Hospitals aim at rewarding
  healthcare systems that deliver the best care at
  the lowest cost and seek to disincentivize
  systems that do not.

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Background

• FACT
• In this competitive and charged environment, only
  physicians that are willing to learn about the
  strengths and weaknesses of healthcare systems
  and can deploy them effectively can elicit
  improvements in the patient care.

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Background

• Systems-Based Practice (SBP) is the sixth
  competency defined by the ACGME Outcomes Project.

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Background

• Specifically, SBP requires that "Residents
  demonstrate an awareness of the larger context
  and system of health care and the ability to
  effectively call on system resources to provide
  care that is of optimal value."

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Background

• Rising healthcare costs and new
  pay-for-performance initiatives make it
  imperative that SBP include education on the
  costs of care in general as well as that of
  postoperative complications.

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Study Aim

• Improve resident core-competence in terms of
  their ability to accurately estimate costs of
  postoperative complications.

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Methods

• This prospective, IRB-approved study included 53
  participating general surgery residents from two
  institutions University of Connecticut- and the
  Yale University School of Medicine.

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Methods

• The 3-step educational exercise involved
• Step-1 Residents were provided three clinical
  vignettes detailing common post-surgical
  complications and their specific treatment
  measures, and asked to assign cost-estimates for
  the total treatment for each vignette
• Step-2 Each resident was given a pocket-size
  card listing hospital charges and asked to
  periodically review it during the course of two
  weeks.
• Step-3 They were re-tested (without access to
  the cost-card) for the clinical scenarios as in
  Step1

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Figure 1 Chandawarkar et al
Experimental Design
Step 2 Introduction of Cost Card
D1
D2
Step 1 3 Collection of Data (Observed
Values)
Data Analysis
(Observed
Value - True Value) Percent Error
--------------------------------------------------
x 100
True Value
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Methods

• Estimates for the same clinical vignettes in
  Step-1 recorded.
• Cost-estimates for Step-1 and Step-3 were
  compared using the paired-t test (for the
  entire group) and ANOVA (for differences
  categorized by PGY-level or type of vignette).

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Methods

• Specific questions addressed were
• is there is a difference between the baseline
  cost-estimates and the actual cost
• does introduction of the cost-card improve their
  performance
• do the responses correlate to PGY-level or to the
  clinical vignette.

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Figure 2 Chandawarkar et al
PGY Distribution
PGY
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Figure 3A Chandawarkar et al
Results Percentage Error
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Figure 3B Chandawarkar et al
Results
- 32
- 35
- 38
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Figure 4 Chandawarkar et al
Results
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Chandawarkar et al
Results Distribution of Error vs Case Scenario
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Chandawarkar et al
Results Distribution of Error vs PGY level
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Results

• There was a statistically significant difference
  between the baseline cost-estimates (before
  introduction of the cost-card) and the actual
  cost of the treatment (plt0.05).
• Introduction of the cost-card resulted in a
  statistically significant improvement between the
  cost-estimates before and after the intervention
  (p0.002) with a drop in average percentage error
  by 35 (range 3238).
• Level of PGY-training or type of test-vignette
  (by ANOVA) did not appear to be significant
  factors in the changes in the cost estimates.

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Conclusions

• There is an inherent lack of awareness in the
  resident group about the cost of complications in
  real dollar
• values.
• Introduction of an educational tool such as a
  cost-card measurably improves their overall
  understanding of cost of care.

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Conclusions

• The interventional measures described in this
  study are simple, inexpensive and can be easily
  incorporated into the residency curriculum.
• In the current cost-conscious healthcare
  climate, these educational measures are timely,
  proactive ways to strengthen a core competency
  vital to every resident-training program.