From the Director
Hi everyone, it's been a busy week with Maestro training gearing up - thanks to everyone for working thru the classes added to your schedules. I was excited to hear from
Murat Arcasoy about the 17 abstracts submitted for the Califf Award competition! Looking forward to resiient research night on June 4. This week, don't forget the
Humanities/Voices of Medicine event! This is the first year we are combining the program's event with
Anton Zuiker's Voices of Medicine - please come out and show support for your very talented colleagues.
I heard compliments this week for
John Yeatts, Erin Boehm and Aparna Swaminathan from the cardiology service. Also congratulations to
Matt Summers on his gold star. And a special thanks to
Laura Kujawski who nominated the chiefs for gold stars! Their work on the 2012-13 schedule allowed
Laura and Lauren to get the clinic schedules out in record time, making it easier for patients to get an appointment. And also thanks to
David Ming for working with us on a project to improve timeliness of discharge summaries - Gen Med 3, under the leadership of
Zach Healy and Aimee Chung, had 100% of the DC summaries dictated and singed within 48 hours.
Manesh Patel and Schuyler Jones want to meet up with all residents interested in cardiology! Join them May 16 at 6 pm at Alivia's.
Please don't forget to contact
Ryan Schulties, David Simel or me regarding the applications for the
VA CRQS position! All current JARs (or med peds JAR-2 or med psych SAR-1s) are eligible to apply.
Pubmed for this week goes to
Jenn Rymer! High Economic Burden of Caring for Patients With Suspected Extraesophageal Reflux.
Francis DO,
Rymer JA,
Slaughter JC,
Choksi Y,
Jiramongkolchai P,
Ogbeide E,
Tran C,
Goutte M,
Garrett CG,
Hagaman D,
Vaezi MF. Source:
Am J Gastroenterol. 2013 Apr 2. doi: 10.1038/ajg.2013.69
Have a great week!
Aimee
QI Corner (submitted by Jon Bae, MD)
Medicine Residency Balanced Scorecard
Our medicine residency program balanced scorecard has been posted in sharepoint reflecting performance in FP9 (i.e. March). Check it out now and if interested in learning more, contact your Quality Chiefs or Jon Bae.
Resiliency Alert!
Bryan Sexton from the Duke Patient Safety Center will be at noon conference 5/14 to discuss the results of our Three Good Things exercise from the fall. There will also be an opportunity to do Three Good Things again! Be sure to attend!
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What Did I Read This Week
(submitted by Jon Bae, MD)
Feldman, L., et al. “Impact of Providing Fee Data on Laboratory Test Ordering. A Controlled Clinical Trial.” JAMA Int Med, 2013, online: E1-E6
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For this edition of WIRTW, I thought I would take a break from my usual fare of care transitions and readmissions to read an article related to the most recent Quality Improvement catchphrase. Of course, I am referring to “High Value, Cost Conscious Care”. As health care expenditures continue to grow, it seems the whole world is racing to find ways to reduce waste. For the sake of this article, the waste in question is that of unnecessary
laboratory evaluations. Now without showing my hand too much, the most interesting part of this article for me was the Introduction as it detailed some factoids (clearly much better then full-on facts) about health care expenditures and waste that heretofore were unknown to yours truly. For example, over the last 10 years, the use of imaging and diagnostic tests has increased by 85%. This has contributed to an estimated $1.2 trillion(!) in health care spending waste. Some studies have suggested that 67.9% of inpatient laboratory tests did not contribute to patient care. Ergo, the need for an inspection of how and what we are ordering and more importantly, why we are ordering it. All of these scary stats (or factoids, if you will) has led to an increased push for “high value cost conscious care” including the “Choosing Wisely” campaign (I’m sure you remember my excellent WIRTW on this last year), the new ACP curriculum for Cost Conscious Care (coming soon to a noon conference lecture series near you) as well as what is likely to be an increasing number of publications in the ensuing months similar to this one.
So, that brings me to this piece by Feldman, et al. Herein, the authors describe a simple experiment to consciously, or perhaps subconsciously, influence provider order practices by showing them the “cost” of tests
1. In this case, the cost is the Medicare allowable charge, which is much as it sounds: the maximum dollar amount which Medicare will reimburse a hospital for a particular procedure or test. The investigators first collected a 6-month baseline period of test ordering practices. After this, 60 tests were randomized to an active arm (fee shown) or a control arm (fee not shown). Providers were not educated in any way about the purpose of seeing test fees. And lo and behold, after 6 months, the tests randomized to the active fee arm showed a decrease in ordering of 9% (compared with a 5% increase in the control arm).
Many people have suggested this same type of intervention here at Duke. But before we start dialing up Epic (or MaestroCare if you please) to integrate cost into our test ordering, I think we need to pump the breaks a little first. While I do find it fascinating that behavior changed with such a simple intervention, I still think the verdict on this type of “nudge” is out. First of all, the absolute difference in test ordering was not huge (3.72 tests per patient per day to 3.40). Granted, given the sheer volume of tests ordered, this resulted in decreased charges of around ~$450K in 6 months. Certainly, a decrease in charges of close to a million dollars per year is nothing to sneeze at. However, as I mention in my footnote, the true cost savings of this is harder to figure. I also wonder about the sustainability of the affect on order practices. How long does it take before the information provided becomes nothing more then background noise? For example, can anyone tell me what information is provided on the insulin advisor other then boxes to put in insulin units? Passive reminders such as these quickly become victims to alert fatigue and their effectiveness is limited in the long run. Lastly, and probably more concerning, is that this type of intervention aims to decrease the number of tests ordered across the board rather than decreasing the number of unnecessary tests only. In the spirit of high value cost conscious care, value is the key word. It is not how much you spend, rather the quality of the information received relative to how much it costs. A blunt instrument to reduce all tests may skim some of the waste off the top, but may also subconsciously nudge providers to order less when more is needed. While I agree that we certainly order more than is needed, it is hard to know where the floor is on how much we can decrease lab utilization without affecting patient outcomes. Such is life; the answer to these questions will not be as simple as providing information about cost when ordering labs. It will require a multi-pronged strategy encompassing education, empowerment, and intelligent system design. But at what cost?
I put “cost” in quotations because this grossly oversimplifies the true cost of a test. In this case, the authors are referring to the Medicare allowable charge for an ordered item. This is not to be confused with how much a health care system spends to run a specific test (which takes into account expenses for phlebotomy, materials, equipment) and is influenced by factors like batching, turn-around time, and offset by re-imbursement. We often try to think in simplified terms such as “how much is this test I’m ordering costing this patient” but in truth, this becomes a very tricky question to answer.
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From the Chief Residents
Grand Rounds
Date Speaker Topic
May 17 Aimee Zaas, MD State of IM Residency
Noon Conference
| Date |
Topic |
Lecturer |
Vendor |
| 5/13 |
How Doctors cope with death & dying |
Dr. Galanos |
The Pita Pit |
| 5/14 |
Board Review (45 min), 3 Good Things f/u (15 min) |
ACRs/Brian Sexton |
The Picnic Basket |
| 5/15 |
Prostate Cancer |
Andrew Armstrong |
Saladelia |
| 5/16 |
Oral anticoagulation for atrial fibrillation |
Dr. Granger |
Domino's |
| 5/17 |
Chair's Conference |
Chiefs |
Chick-fil-A |
Free Engraving by Duke Police (submitted by Jason Howard)
In light of the recent thefts (turns out one of our Grad Students had a computer stolen last Friday) I wanted to share the attached flyer from the Duke Police that was posted in the Jones Building. If you are interested make sure you bring your Duke ID or Driver’s License as it mentions on the flyer. If you have questions you can contact the Duke Police at 684-2444.
Duke Police Engraving Service
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From the Residency Office
2013 Learners' Perceptions Survey: Continuity Clinics
Yes, you will see one more email coming your way asking you to take another survey this week.
Why take this survey? First, we value and need your input!
This survey in particular, which focuses on the
continuity clinic experience, is particularly important. The information you provide will help to improve the educational experience for you and your fellow trainees in your residency program. Please take the time to complete this survey.
This is a confidential survey and focuses exclusively on your CONTINUITY CLINIC EXPERIENCE. Because of the importance of this activity in internal medicine training, we would like you to provide input and feedback regarding this experience.
Thank you for your time!
OPPORTUNITY TO TEACH RESIDENTS FELLOWS PATIENT SAFETY AND QUALITY
Duke University Health System is hosting a special edition of the Physician Leadership Course in Patient Safety and Quality on June 14th. The first 50 residents are FREE! ($50 for DUHS physicians, $75 for Affiliates, and $100 for docs external to our health system.)
Course details and registration are available at
http://www.dukepatientsafetycenter.com
- Physician & Affiliate Registration Information; June 14, 2013
- Residents Only Registration Information; June 14, 2013
Quick description:
Our physician leadership course on patient safety and quality is led by internationally recognized leaders in the field. This course is held at the Washington Duke Inn & Golf Club (June 14th), and receives outstanding evaluations for applicability, feasibility, use of evidence, pace and quality of discussions. We cover leading through change, communication and dealing with difficult colleagues, and the science of resilience.
Key Faculty:
Michael Leonard, MD, Co-Chief Medical Officer, Pascal Metrics
http://www.pascalmetrics.com/about/michael-leonard.php
Dr. Bryan Sexton, Ph.D., Director, Duke University Health System Patient Safety Center, View one of Bryan’s recent videos at
http://dukepatientsafetycenter.com/video.asp
Dr. Karen Frush, MD, Chief Patient Safety Officer, Duke University Health System
SAR Board Review Schedule
Board Review Sessions will be held in the MedRes Library, Duke North, 8th Floor. Please contact Megan Diehl or Jeff Clarke if you would like to attend. The schedule is as follows:
| Date |
Topic |
Faculty |
| 14-May |
Endocrine |
Dr. Matt Crowley |
| 22-May |
Renal |
Dr. Butterly |
| 28-May |
Neurology |
Dr. Skeen |
| 5-Jun |
Dermatology/Rheumatology |
Dr. Criscione |
| 11-Jun |
Mixed Bag (Medical ethics, Palliative Medicine, Psych) |
Dr. Zaas, Chiefs |
Employee Health - TB Skin Test
If you are due for a TB Skin test in the next 30 days, you will have a 30 day grace period to complete the test due to a national shortage of the testing supplies. This grace period will end when you receive an official email from either EHOW, OESO or Duke Hospital alerting you that supplies have been received and you should proceed with scheduling your test.
If you have any questions, please contact EOHW (919) 684-3136
Essentials Disability Income Insurance
As a trainee at Duke, you are eligible for concessions on disability insurance that won’t be available once you leave the training program.
The Benefit Planning Group is authorized by AMA Insurance to offer Essentials Disability Income Insurance to eligible finishing residents and fellows. This program offers a simplified application process with no medical exams. Other options exist for trainees not finishing this year. However, you must enroll by 6/30/13 to take advantage of this offer.
This is a once-in-a-career offer; if someone doesn’t sign up this year they won’t be eligible again (for example a finishing resident can’t use this offer when they finish fellowship).
Attached are two fliers that explain some of the benefits and features of the program. If you want to sign up directly and have a PIN please go to
http://mybpginc.com/mflur. If anyone needs information, including a PIN to login, please contact Marc Flur at 919-489-1720 or
mflur@mybpginc.com.
Enrollment Process Resident and Fellow Flyer
Contact Information/Opportunities
Upcoming Dates and Events
- May 14/15: Conflict Management Workshop Register for the morning session, 7-9 am Register for the afternoon session, 4-6 pm
- May 15: Voices of Medicine / Humanities in Medicine
- May 24: Chief Grand Rounds - Jason Webb, MD
- May 31: Chief Grand Rounds - George Cheely, MD
- June 4: Resident Research Conference, Searle Center
- June 7: Chief Grand Rounds - Nicole Greyshock, MD
- June 8: SAR Dinner, Hope Valley Country Club
- June 14: Chief Grand Rounds - Ryan Schulteis, MD
- June 21: Chief Grand Rounds - Jeffrey Clarke, MD
Useful links
