Teaching Cost-Conscious Medicine: Impact of a Simple Educational Intervention on Appropriate Abdominal Imaging at a Community-Based Teaching Hospital

摘要

Introduction “Nobody would quarrel with the proposition that there is a limit to the resources any society can devote to medical care and few would question the suggestion that we are approaching such a limit.”1 This statement from an editorial written in 1975 reminds us that reducing health-care expenditures in the United States has been a long-lasting struggle. The United States has the most expensive health care system in the world.2 The relentless increase in the cost of health care has been identified as the single largest threat to the future of health care in our nation.3,4 Optimizing the practice of cost-conscious medicine is essential. Nevertheless, US medical education has yet to seriously teach cost-conscious medical decision making to future physicians.5,6 Only 25% of residency programs have formal methods to teach about the costs of diagnostic tests, treatments, and medications to residents.6 Surveys of residents across multiple specialties suggest that current efforts to teach cost-conscious test ordering in undergraduate medical education are inadequate.7 It is therefore not surprising that most physicians do not appear to know the costs of the laboratory tests, imaging studies, or medications they order for their patients.3,8–18 The call has been made for residency programs to include teaching cost-consciousness in providing care as part of their educational curriculum.6,7,16,17,19. Adoption of cost-consciousness and stewardship of resources has been proposed as a new seventh competency.3 Medical imaging has been identified as an attractive target for resident education because data suggest that many imaging examinations are ordered inappropriately, and that there are acceptable, less expensive diagnostic alternatives.20–22 An educational intervention on cost-conscious and appropriate abdominal imaging was launched at Scripps Mercy Hospital in September 2010. This intervention incorporated the American College of Radiology (ACR) appropriateness criteria for abdominal imaging,23,24 along with lectures on cost-conscious medical decision making and discussion of the actual hospital charges for commonly ordered abdominal studies. We hypothesized that the intervention would reduce resident ordering of abdominal computed tomography (CT) scans and result in demonstrable overall cost reductions.;Methods Study Site Scripps Mercy Hospital is a community-based teaching hospital and level-one trauma center in San Diego, CA. Scripps Mercy has an Accreditation Council for Graduate Medical Education (ACGME)-accredited internal medicine program with 33 residents, a family medicine program with 24 residents, and a transitional year program with 18 residents.;Results Following the educational intervention mean abdominal CT scans per patient were significantly reduced from 1.7 to 1.4 studies (P < .001). Total abdominal imaging studies per patient (all imaging modalities) also were significantly reduced from 3.1 to 2.7 studies (P ?=? .02). Combined MRI and ultrasound studies per patient (radiation-free modalities) showed no significant difference (0.60–0.57 studies, respectively, P ?=? .45). The mean number of abdominal CT scans per patient per hospital day decreased significantly from 0.50 studies to 0.43 studies (P ?=? .02). Combined MRI and ultrasound studies per patient per hospital day was unchanged at 0.18 studies (P ?=? .97). The total radiology studies per patient per hospital day (all modalities) and the average patient length of stay demonstrated no significant difference (0.80–0.75 studies per patient per day, P ?=? .17 and 5.4–4.8?days, P ?=? .42, respectively). There was no difference for in-hospital mortality pre- and postintervention (2.17% and 1.70%, respectively, P ?=? .48). The average patient radiation dose from medical imaging decreased significantly from 16.7?mSv to 14.0?mSv (P < .001). There was no significant difference in the average number of patients per inpatient team (12.53 for pre- and 13.53 for postin