A 10-step program to successfully reduce low-value care.

The cost of health care in the United States is approaching 18% of the gross national product, an expenditure that is competing with dollars being used for other purposes. One way to reduce the cost of care is by identifying and reducing low-value care (LVC): patient care that offers little to no benefit in specific clinical scenarios, adds cost, and may, through adverse effects or adverse outcomes, actually harm patients. The authors have been involved in identifying and reducing LVC for more than 15 years and have created a practical, 10-step approach to effectively integrate LVC reduction programs into medical systems. The approach has been tested, with results reported in peer-reviewed journals. Key steps include assembling accurate, meaningful data; creating simple yet dramatic practitioner reports; learning to identify and manage the stages of change; and developing an outreach strategy anchored in nonjudgmental communication, explicit core values, and a well-articulated reason to focus on reducing LVC.

Physicians' perceptions of autonomy support during transition to value-based reimbursement: A multi-center psychometric evaluation of six-item and three-item measures.

BACKGROUND: Successive health system reforms have steadily eroded physician autonomy. Escalating accountability demands placed on physicians concurrent with diminishing autonomy plus widespread "cost cutting" endanger clinical work-life quality and, in turn, threaten patient-care quality, safety, and continuity. This has engendered a renewed emphasis on bettering physician work-life to safeguard patient care. Research indicates that autonomy support could be an effective intervention point in this dynamic, and that improving healthcare practitioners' experience of autonomy can promote better patient outcomes. New measures of autonomy support towards physicians during systemic/organizational transformation are thus needed. OBJECTIVE: We investigated the validity and reliability of two versions of a brief measure of physicians' perceptions of autonomy support. DESIGN: Psychometric evaluation of practitioners' responses to a theory-based, pilot-tested, multi-center, cross-sectional survey-questionnaire. PARTICIPANTS: Physicians serving in California, Massachusetts, or upstate New York clinical practices implementing pay-for-performance incentives were eligible. We obtained responses from 1,534 (35.14%) of 4,365 physicians surveyed. ANALYSIS: We randomly partitioned the study sample equitably into derivation and validation subsamples. We conducted parallel analysis, inter-item/point-biserial correlations, and item-response-theory-based graded response modeling on six autonomy support items. Three items with the highest (a) point-biserial correlations, (b) item-level discrimination and (c) information capture were used to construct a short-form (3-item) version of the full (6-item) autonomy scale. We utilized exploratory structural equation modeling and confirmatory factor analysis to establish the factor structure and construct validity of the full-length and short-form scales before comparing their factor invariance, reliability and interrater agreement across physician subgroups. FINDINGS: All six autonomy support items loaded highly onto one factor accounting for the majority of variance and demonstrating good data fit. The three most discriminating and informative items loaded equally well onto a single factor with similar goodness-of-fit to the data. The three-item scale correlated highly with its six-item parent, showing equally high sensitivity and specificity in discriminating high autonomy support. Variability in scores nested predominantly at within- rather than between-subgroup levels. CONCLUSIONS AND IMPLICATIONS: Our data supported the factor structure, construct validity, internal consistency, and reliability of six- and three-item autonomy support scales. These brief tools are easily incorporated into multi-dimensional questionnaires at relatively low cost.

"Won't You Be My Doctor?": Four Keys to a Satisfying Relationship in an Increasingly Virtual World.

Despite rapid technological advances in healthcare, medicine is still largely practiced in a doctor's office one conversation at a time. This reality is changing rapidly during the COVID-19 pandemic as face-to-face conversations with primary care practitioners are being replaced by virtual visits conducted by phone or video conferencing. Communication challenges in patient-practitioner relationships exist in face-to-face visits and they are accentuated in virtual ones. Absent a physical examination and other sensory data, conversation is the primary means by which safe, satisfying care depends. We present 4 steps to help patients and practitioners work together to obtain optimal results from virtual or face-to-face visits, summarized by the acronym PREP: Prepare, Rehearse, Engage, and Persist. Based on 80 years of combined clinical practice and research, we recommend strategies to help bridge the gap between what patients want and deserve in their medical visits and practitioners' understanding of their patients' concerns.

Job satisfaction and guideline adherence among physicians: Moderating effects of perceived autonomy support and job control.

Value-based purchasing of physician services aims to incentivize greater adherence to clinical practice guidelines. By increasing job demands, new reimbursement models could adversely affect job satisfaction and, indirectly, clinical performance. Studies of satisfaction-performance associations among healthcare practitioners have yielded inconsistent findings. We investigated whether physicians' perceptions of autonomy support and job control significantly moderate the relationship between practice satisfaction and guideline adherence in a pay-for-performance context. We performed secondary analysis of a study dataset created by merging prospective information on clinical services provided by Rochester (NY)-based primary physicians (N = 156) during the years 2001-2004 with census data on specific characteristics of their ambulatory-care populations, claims-sourced information on attributes of their primary care practices, and survey data on their work-related attitudes. Greater job satisfaction had a significant multivariate association with lower adherence (ß = -0.139; p=<.0001) among physicians that perceived low autonomy support from the market-dominant payer organization. For physicians experiencing high autonomy support, a positive satisfaction-adherence association existed (ß = 0.105; p=<.0001). Low job control was a negative moderator (ß = -0.103; p=<.0001), and high control a positive moderator (ß = 0.071; p=<.0001), of the influence of job satisfaction on guideline adherence. Given the limitations of this study, such as the cross-sectional survey data and potential for unmeasured confounding variables, the validity of our findings should be tested by future research. We conclude that payers attempting to over-direct partner physicians can demotivate the satisfied physicians from achieving top-level guideline adherence, thereby squandering opportunities for intrinsic satisfaction to improve guideline adherence. To optimize the potential for job satisfaction to motivate greater guideline adherence, it may be important for payers to be perceptibly more supportive of physicians' autonomy and sense of job control.

A community-wide quality improvement initiative to improve hypertension control and reduce disparities.

Initiatives to improve hypertension control within academic medical centers and closed health systems have been extensively studied, but large community-wide quality improvement (QI) initiatives have been both less common and less successful in the United States. The authors examined a community-wide QI initiative across 226 843 patients from 198 practices in nine counties across upstate New York to improve hypertension control and reduce disparities. The QI initiative focused on (a) providing population and practice-level comparative data, (b) community engagement, especially in underserved communities, and (c) practice-level quality improvement assistance, but was not designed to examine causality of specific components. Across the nine counties, hypertension control rates improved from 61.9% in 2011 to 69.5% in 2016. Improvements were greatest among whites (73.7%-81.5%) and more modest among black patients (58.8%-64.7%). The authors noted a considerable improvement in BP within the group of patients with the highest risk (defined as a BP ≥ 160/100) and a decrease in disparities within this group. The quality collaborative identified five key lessons to help guide future community initiatives: (a) anticipate a plateauing of response; (b) distinguish the needs of disparate populations and create subpopulation-specific strategies to address and reduce disparities; (c) recognize the variation across low SES practices; (d) remain open to the refinement of outcome measures; and (e) continually seek best practices and barriers to success. Overall, a large community-wide QI initiative, involving multiple different stakeholders, was associated with improvements in BP control and modest reductions in some targeted disparities.

The Moderating Effect of Job Satisfaction on Physicians' Motivation to Adhere to Financially Incentivized Clinical Practice Guidelines.

We examined moderating effects of professional satisfaction on physicians' motivation to adhere to diabetes guidelines associated with pay-for-performance incentives. We merged cross-sectional survey data on attitudes, from 156 primary physicians, with prospective medical record-sourced data on guideline adherence and census data on ambulatory-care population characteristics. We examined moderating effects by testing theory-driven models for satisfied versus discontented physicians, using partial least squares structural equation modeling. Results show that attitudes motivated, while norms suppressed, adherence to guidelines among discontented physicians. Separate models for satisfied versus discontented physicians revealed motivational differences. Satisfied physicians disregarded intrinsic and extrinsic influences and biases. Discontented physicians, alienated by social pressure, favored personal inclinations. To improve adherence to guidelines among discontented physicians, incentives should align with personal attitudes and incorporate promotional campaigns countering resentment of peer and organizational pressure.

The role of medical culture in the journey to resilience.

There is growing concern about the difficulty primary care practices are experiencing both recruiting and retaining practitioners. Frustrations stemming from integrating electronic medical records, satisfying external documentation requirements for oversight and billing, and the divide created between inpatient and ambulatory care teams all contribute to practitioner and staff burnout. Addressing the current culture of medical education and primary care is clearly an essential issue for health care leaders and medical educators.Using two experiences, a workshop on resilience with a large primary care practice group and a medical student studying for the United States Medical Licensing Examination Step 1, the author describes the cultural imperative, beginning in medical school, to sacrifice self-care for productivity and individual achievement. This approach has consequences for practitioners' levels of burnout and selecting primary care as a career. The author concludes by providing recommendations for both individual and organizational approaches to addressing these concerns.

Motivators and hygiene factors among physicians responding to explicit incentives to improve the value of care.

BACKGROUND: Physician's dissatisfaction is reported to be increasing, especially in primary care. The transition from fee-for-service to outcome-based reimbursements may make matters worse. PURPOSE/OBJECTIVE: To investigate influences of provider attitudes and practice settings on job satisfaction/dissatisfaction during transition to quality-based payment models, we assessed self-reported satisfaction/dissatisfaction with practice in a Rochester (New York)-area physician practice association in the process of implementing pay-for-performance. SUBJECTS/METHODS: We linked cross-sectional data for 215 survey respondents on satisfaction ratings and behavioral attitudes with medical record data on their clinical behavior and practices, and census data on their catchment population. Factors associated with the odds of being satisfied or dissatisfied were determined via predictive multivariable logistic regression modeling. RESULTS/CONCLUSIONS: Dissatisfied physicians were more likely to have larger-than-average patient panels, lower autonomy and/or control, and beliefs that quality incentives were hindering patient care. Satisfied physicians were more likely to have a higher sense of autonomy and control, smaller patient volumes, and a less complex patient mix. Efforts to maintain or improve satisfaction among physicians should focus on encouraging professional autonomy during transitions from volume-based to quality/outcomes-based payment systems. An optimum balance between accountability and autonomy/control might maximize both health care quality and job satisfaction.

Building bridges: future directions for medical error disclosure research.

OBJECTIVE: The disclosure of medical errors has attracted considerable research interest in recent years. However, the research to date has lacked interdisciplinary dialog, making translation of findings into medical practice challenging. This article lays out the disciplinary perspectives of the fields of medicine, ethics, law and communication on medical error disclosure and identifies gaps and tensions that occur at these interdisciplinary boundaries. METHODS: This article summarizes the discussion of an interdisciplinary error disclosure panel at the 2012 EACH Conference in St. Andrews, Scotland, in light of the current literature across four academic disciplines. RESULTS: Current medical, ethical, legal and communication perspectives on medical error disclosure are presented and discussed with particular emphasis on the interdisciplinary gaps and tensions. CONCLUSION: The authors encourage interdisciplinary collaborations that strive for a functional approach to understanding and improving the disclosure of medical errors with the ultimate goal to improve quality and promote safer medical care. PRACTICE IMPLICATIONS: Interdisciplinary collaborations are needed to reconcile the needs of the stakeholders involved in medical error disclosure. A particular challenge is the effective translation of error disclosure research into practice. Concrete research questions are provided throughout the manuscript to facilitate a resolution of the tensions that currently impede interdisciplinary progress.

The impact of a program in mindful communication on primary care physicians.

PURPOSE: In addition to structural transformations, deeper changes are needed to enhance physicians' sense of meaning and satisfaction with their work and their ability to respond creatively to a dynamically changing practice environment. The purpose of this research was to understand what aspects of a successful continuing education program in mindful communication contributed to physicians' well-being and the care they provide. METHOD: In 2008, the authors conducted in-depth, semistructured interviews with primary care physicians who had recently completed a 52-hour mindful communication program demonstrated to reduce psychological distress and burnout while improving empathy. Interviews with a random sample of 20 of the 46 physicians in the Rochester, New York, area who attended at least four of eight weekly sessions and four of eight monthly sessions were audio-recorded, transcribed, and analyzed qualitatively. The authors identified salient themes from the interviews. RESULTS: Participants reported three main themes: (1) sharing personal experiences from medical practice with colleagues reduced professional isolation, (2) mindfulness skills improved the participants' ability to be attentive and listen deeply to patients' concerns, respond to patients more effectively, and develop adaptive reserve, and (3) developing greater self-awareness was positive and transformative, yet participants struggled to give themselves permission to attend to their own personal growth. CONCLUSIONS: Interventions to improve the quality of primary care practice and practitioner well-being should promote a sense of community, specific mindfulness skills, and permission and time devoted to personal growth.

Creating community collaboration to improve the care of patients with high blood pressure: lessons from Rochester, New York.

Over the past two years, the business community of Monroe County, which includes Rochester, New York, has been engaging in a collaborative to improve outcomes for people with high blood pressure. As the employers examined the costs of care in the community, they recognized two important factors. First, the costs of care for the uninsured, the underinsured, and the Medicare population influence the business community's cost of care. Second, trying to redesign care just for their employees alone was not effective. This project is unique in that the stimulus and funding for community-wide action comes from the business community. They saw beyond the often unsuccessful short-term cost reduction programs and joined with a community-focused organization, the Finger Lakes Health Systems Agency, to construct a multi-year, multi-faceted intervention designed to encourage practice redesign and an invigorated community commitment to partnership and accountability. This report describes the process to date and hopefully will stimulate conversations about mechanisms to encourage similar collaboration within other communities.

Lost in translation: physicians' struggle with cost-reduction programs.

Relationships between health plans and the medical profession are often strained, leading to the inability to create a shared vision for the health care redesign needed to more effectively care for our population. Because of their respective stakeholders, health plans and providers naturally differ in perspective. However, this article suggests that it is the inability of stakeholders to find a common language to effectively communicate interests, needs, and proposed interventions that often derails progress toward common goals. The business and health plan leaders' focus on cost-containment and cost-efficiency predictably results in physician defensiveness and disengagement. At the same time, physicians' limited focus on improving quality to only reducing underuse, which in the short term increases costs, does not acknowledge cost concerns of business leaders and health plan executives. However, as divergent as these emphases might seem, there is potential for common ground with effective language translation. Effective translation has been proposed through the Institute of Medicine's definition of quality as reducing overuse, misuse, and underuse. Creating a common language provides seemingly opposing groups an opportunity to explore a shared vision. Using the language of clinical appropriateness and reducing unnecessary variation has resulted in agreement on clinical quality improvement projects from which each group can return to its own organizations and translate back into its familiar "stakeholder" language.

Engaging physicians in change: results of a safety net quality improvement program to reduce overuse.

Identifying, understanding, and addressing clinical variation is a useful tool to promote appropriate care while helping control health care costs. Although accurate, relevant, and useful data are important in the process, successfully engaging physicians to change behavior is often the most significant challenge. Using a commercially available variation analysis process, a California Medicaid managed care plan identified significant network practice pattern variation. A team of panel practitioners then developed a strategy to reduce overuse of 5 identified behaviors. The intervention was evaluated using a pre-post comparison of the panel's use of the 5 behaviors. During the preintervention period, narcotics, muscle relaxants, magnetic resonance imaging (MRI), and spinal injections increased between 8% and 18% per month. Postintervention, the trends reversed. The differences were statistically significant (P<.0001) for muscle relaxant use, narcotic use, overall MRI use, and spinal injections. Peer comparison data and respectful feedback was associated with significant change in patterns of overuse.

Provider attitudes associated with adherence to evidence-based clinical guidelines in a managed care setting.

In a cross-sectional observational study of Rochester (New York) primary care physicians (PCPs) enrolled in a pay-for-performance (P4P) collaboration, the authors investigated attitudinal factors associated with provider adherence to evidence-based clinical guidelines targeted by explicit incentives. The multivariable adherence model linked guideline adherence rates to provider attitudes among 186 survey respondents, adjusting for individual, practice, and community characteristics. Adherence was defined as the percentage of expected services that were delivered. Attitudes associated with adherence, independent of specialty and prior behavior, were financial salience (adjusted odds ratio [OR] = 3.6; 95% confidence interval [CI] = 1.7-8.4), peer cooperation (OR = 2.0; 95% CI = 1.0-4.0), control (OR = 0.5; 95% CI = 0.3-1.0), and autonomy regarding the health plan (OR = 0.3; 95% CI = 0.1-0.6). The most adherent providers perceived P4P as financially salient and felt supported by peers. Some PCPs might have perceived P4P and external interventions as challenging their autonomy and "crowding out" their intrinsic motivation, leading them to reduce efforts aimed at guideline adherence.

Association of an educational program in mindful communication with burnout, empathy, and attitudes among primary care physicians.

CONTEXT: Primary care physicians report high levels of distress, which is linked to burnout, attrition, and poorer quality of care. Programs to reduce burnout before it results in impairment are rare; data on these programs are scarce. OBJECTIVE: To determine whether an intensive educational program in mindfulness, communication, and self-awareness is associated with improvement in primary care physicians' well-being, psychological distress, burnout, and capacity for relating to patients. DESIGN, SETTING, AND PARTICIPANTS: Before-and-after study of 70 primary care physicians in Rochester, New York, in a continuing medical education (CME) course in 2007-2008. The course included mindfulness meditation, self-awareness exercises, narratives about meaningful clinical experiences, appreciative interviews, didactic material, and discussion. An 8-week intensive phase (2.5 h/wk, 7-hour retreat) was followed by a 10-month maintenance phase (2.5 h/mo). MAIN OUTCOME MEASURES: Mindfulness (2 subscales), burnout (3 subscales), empathy (3 subscales), psychosocial orientation, personality (5 factors), and mood (6 subscales) measured at baseline and at 2, 12, and 15 months. RESULTS: Over the course of the program and follow-up, participants demonstrated improvements in mindfulness (raw score, 45.2 to 54.1; raw score change [Delta], 8.9; 95% confidence interval [CI], 7.0 to 10.8); burnout (emotional exhaustion, 26.8 to 20.0; Delta = -6.8; 95% CI, -4.8 to -8.8; depersonalization, 8.4 to 5.9; Delta = -2.5; 95% CI, -1.4 to -3.6; and personal accomplishment, 40.2 to 42.6; Delta = 2.4; 95% CI, 1.2 to 3.6); empathy (116.6 to 121.2; Delta = 4.6; 95% CI, 2.2 to 7.0); physician belief scale (76.7 to 72.6; Delta = -4.1; 95% CI, -1.8 to -6.4); total mood disturbance (33.2 to 16.1; Delta = -17.1; 95% CI, -11 to -23.2), and personality (conscientiousness, 6.5 to 6.8; Delta = 0.3; 95% CI, 0.1 to 5 and emotional stability, 6.1 to 6.6; Delta = 0.5; 95% CI, 0.3 to 0.7). Improvements in mindfulness were correlated with improvements in total mood disturbance (r = -0.39, P < .001), perspective taking subscale of physician empathy (r = 0.31, P < .001), burnout (emotional exhaustion and personal accomplishment subscales, r = -0.32 and 0.33, respectively; P < .001), and personality factors (conscientiousness and emotional stability, r = 0.29 and 0.25, respectively; P < .001). CONCLUSIONS: Participation in a mindful communication program was associated with short-term and sustained improvements in well-being and attitudes associated with patient-centered care. Because before-and-after designs limit inferences about intervention effects, these findings warrant randomized trials involving a variety of practicing physicians.

Beyond the efficiency index: finding a better way to reduce overuse and increase efficiency in physician care.

Current strategies for addressing health care costs stress physician performance measurement and commonly use an efficiency index (EI). During seven years of conducting individual practitioner pay-for-performance (P4P), we found that using EIs hindered our work on reducing overuse of services. This paper offers an alternative approach through the identification of variation in key cost drivers. As proof of concept, we apply this model to hypertension care. We then describe a project that decreased apparent overuse of fiberoptic laryngoscopy among otorhinolaryngologists. Focusing directly on reducing overuse improves cost efficiency without the barriers imposed by EI methodology.