Choosing Wisely: Next Steps

The accountable care organization (ACO) concept, elucidated in 2006 as the development of partnerships between hospitals and physicians to coordinate and deliver efficient care,¹ seeks to remove existing barriers to improving value.² Some advocate this concept as a promising payment model that could successfully realign the current payment system to financially reward improvements in quality and efficiency that bend the cost curve.^3,4 Hospitalists fit well with this philosophy. As the fastest growing medical specialty in the history of American medicine, from a couple of thousand hospitalists in the mid-1990s to more than 50,000, the remarkable progression of hospitalists has ostensibly been driven partially by hospitals’ efforts to improve the value equation through enhanced efficiency in inpatient care. Importantly, hospitalists probably provide care for more than half of all hospitalized Medicare beneficiaries and increasingly patients in skilled nursing facilities (ie, SNFists).⁵ Along with primary care physicians, hospitalists thus represent an essential group of physicians needed to transform care delivery.

When the Affordable Care Act (ACA) established the Medicare Shared Savings Program (MSSP), ACOs leaped from being an intellectual concept^1,2 into a pragmatic health system strategy.^3,4 Following Medicare, various private health insurance plans and some state Medicaid programs entered into contracts with groups of healthcare providers (hospitals, physicians, or health systems) to serve as ACOs for their insured enrollees.⁶ Leavitt Partners’ ACO tracking database showed that the number of ACOs increased from 157 in March of 2012 to 782 in December of 2015.⁷

Until recently, the federal government’s commitment to having 50% of total Medicare spending via value-based payment models by 2018, coupled with endorsement from state Medicaid programs and commercial insurers, demonstrated strong support for continuation of ACOs. Unexpectedly on August 15, 2017, the Centers for Medicare & Medicaid Services (CMS) outlined a plan in its proposed rulemaking to cancel the Episode Payment Models and the Cardiac Rehabilitation incentive payment model, which were scheduled to commence on January 1, 2018. CMS also plans to scale back the mandatory Comprehensive Care for Joint Replacement (CCJR) bundled payment model from 67 selected geographic areas to 34. Although this proposed rulemaking created some equipoise in the healthcare industry regarding the future of value-based reimbursement approaches, cost containment and improved efficiency remain as major focuses of the federal government’s healthcare effort. Notably, CMS offers providers that are newly excluded from the CCJR model the opportunity to voluntarily participate in the program and is expected to increase opportunities for providers to participate in voluntary rather than large-scale mandatory episode payment model initiatives. In 2018, the agency also plans to develop new voluntary bundled payment models that will meet criteria to be considered an advanced alternative payment model for Quality Payment Program purposes.

Importantly, the value-based reimbursement movement was well underway before ACA legislation. Through ACA health reform, value-based reimbursement efforts were expanded through ACOs, bundled payments, value-based purchasing, the CMS Innovation Center and other initiatives. With health systems having an overflowing plate of activities, a wait-and-see attitude might seem reasonable at first. However, being unprepared for the inevitable shift to value-based reimbursement and reduced fee-for-service revenue places an organization at risk. A successful ACO requires system-level transformation, especially cultural and structural changes to achieve clinical integration. Being embedded in health system delivery, hospitalists can help shape a team-oriented culture and foster success in value-based payment models. This requires hospitalists to take a more active role in assessing and striking a balance between high-quality, cost-efficient care and financial risk inherent in ACO models.

The key to hospitalists fulfilling their value creation potential and becoming enablers for ACO success lies in developing a thorough understanding of the aspects of an ACO that promote efficient and effective care, while accounting for financial factors. Fundamentally, the ACO concept combines provider payment and delivery system reforms. Specifically, the definition of an ACO contains 3 factors: (1) a local healthcare organization (eg, hospital or multispecialty group of physicians) with a related set of providers that (2) can be held accountable for the cost and quality of care delivered to (3) a defined population. While the notion of accountability is not new, the locus of accountability is changed in the ACO model—emphasizing accountability at the level of actual care delivery with documentation of quality and cost outcomes. The ACO approach aims to address multiple, frequent, and recurring problems, including lack of financial incentives to improve quality and reduce cost, as well as the negative consequences of a pay-for-volume system—uncoordinated and fragmented care, overutilization of unnecessary tests and treatments, and poor patient experience all manifested as unwarranted geographic variation in practice patterns, clinical outcomes, and health spending. Participants in an ACO are rewarded financially if they can slow the growth of their patients’ healthcare costs while maintaining or improving the quality of care delivered. To succeed in this ACO world, hospitalists must assume greater prudence in the use of healthcare services while improving (or at a minimum, maintaining) patient outcomes, thus excising avoidable waste across the continuum of care.

More than half of ACOs include a hospital.⁸ However, whether hospital-led ACOs possess an advantage remains to be elucidated. Early reports indicated that physician-led ACOs saved more money.^9,10 However, others argue that hospitals¹¹ are better capitalized, have greater capacity for data sharing, and possess economies of scale that allow them to invest in more advanced technology, such as predictive modeling and/or simulation software. Such analytics can identify high-cost patients (ie, multiple comorbidities), super utilizers and populations lacking care, allowing ACOs to implement preventive measures to reduce unnecessary utilization. Recently released CMS MSSP 2016 performance data¹² showed that nearly half (45%) of physician-only ACOs earned shared savings, whereas 23% of ACOs that include hospitals earned shared savings. However, among all the ACOs that achieved savings, ACO entities that include hospitals generated the highest amount of shared savings (eg, Advocate, Hackensack Alliance, Cleveland Clinic, and AMITA Health). Notably, hospital-led ACOs tend to have much larger beneficiary populations than physician-led ACOs, which may create a scenario of higher risk but higher potential reward.

The emphasis on value over volume inherent in the development of ACOs occurs through employing care strategies implemented through changes in policies, and eventual structural and cultural changes. These changes require participating organizations to possess certain key competencies, including the following: 1) leadership that facilitates change; 2) organizational culture of teamwork; 3) collaborative relationships among providers; 4) information technology infrastructure for population management and care coordination; 5) infrastructure for monitoring, managing, and reporting quality; 6) ability to manage financial risk; 7) ability to receive and distribute payments or savings; and 8) resources for patient education and support.^2,3,13-16 Table 1 summarizes the broad range of roles that hospitalists can serve in delivering care to ACO populations.^17-19

Hospitalists’ active pursuit of nonclinical training and selection for administrative positions demonstrate their proclivity to provide these competencies. In addition to full-time clinician hospitalists, who can directly influence the delivery of high-value care to patients, hospitalists serve many other roles in hospitals and each can contribute differently based on their specialized expertise. Examples include the success of the Society of Hospital Medicine’s Leadership Academy; the acknowledged expertise of hospitalists in quality improvement (QI), informatics, teamwork, patient experience, care coordination and utilization; and advancement of hospitalists to senior leadership positions (eg, CQO, CMO, CEO). Given that nearly a third of healthcare expenditures are for hospital care,²⁰ hospitalists are in a unique position to foster ACO competencies while impacting the quality of care episodes associated with an index hospital stay.

Importantly, hospitalists cannot act as gatekeepers to restrict care. Managed care organizations and health maintenance organizations use of this approach in the 1990s to limit access to services in order to reduce costs led to unacceptable outcomes and numerous malpractice lawsuits. ACOs should aspire to deliver the most cost-effective high-quality care, and their performance should be monitored to ensure that they provide recommended services and timely access. The Medicare ACO contract holds the provider accountable for meeting 34 different quality measures (Supplemental Table 1), and hospitalists can influence outcomes for the majority. Especially through hospital and health system QI initiatives, hospitalists can directly impact and share accountability for measures ranging from care coordination to implementation of evidence-based care (eg, ACE inhibitors and beta blockers for heart failure) to patient and family caregiver experience.

Aligned with Medicare ACO quality measures, 5 high-impact target areas were identified for ACOs²¹: (1) Prevention and wellness; (2) Chronic conditions/care management; (3) Reduced hospitalizations; (4) Care transitions across the fragmented system; and (5) Multispecialty care coordination of complex patients. One essential element of a successful ACO is the ability to implement evidence-based medical guidelines and/or practices across the continuum of care for selected targeted initiatives. Optimizing care coordination/continuum requires team-based care, and hospitalists already routinely collaborate with nurses, social workers, case managers, pharmacists, and other stakeholders such as dieticians and physical therapists on inpatient care. Hospitalists are also experienced in facilitating communication and improving integration and coordination efficiencies among primary care providers and specialists, and between hospital care and post-acute care, as they coordinate post-hospital care and follow-up. This provides an opportunity to lead health system care coordination efforts, especially for complex and/or high-risk patients.^22,23 CMS MSSP 2016 performance data¹² showed that ACOs achieving shared savings had a decline in inpatient expenditures and utilization across several facility types (hospital, SNF, rehabilitation, long term). Postacute care management is critical to earning shared savings; SNF and Home Health expenditures fell by 18.3% and 9.7%, respectively, on average. We believe that hospitalists can have more influence over these cost areas by influencing treatment of hospitalized patients in a timely manner, discharge coordination, and selection of appropriate disposition locations. Hospitalists also play an integral role in ensuring the hospital performs well on quality metrics, including 30-day readmissions, hospital acquired conditions, and patient satisfaction. Examples below document the effectiveness of hospitalists in this new ACO era.

Care Transitions/Coordination

Before the Hospital Readmission Reduction Program (HRRP) delineated in the ACA, hospitalists developed Project BOOST (Better Outcomes by Optimizing Care Transitions) to improve hospital discharge care transition. The evidence-based foundation of this project led CMS to list Project BOOST as an example program that can reduce readmissions.²⁴ Through the dissemination and mentored implementation of Project BOOST to over 200 hospitals across the United States,²⁵ hospitalists contributed to the marked reduction in hospital readmission occurring since 2010.²⁶ Although hospital medicine began as a practice specific to the hospital setting, hospitalists’ skills generated growing demand for them in postacute facilities. SNF residents commonly come from hospitals postdischarge and suffer from multiple comorbidities and limitations in activities of daily living. Not surprisingly, SNF residents experience high rates of rehospitalizations.²⁷ Hospitalists can serve as a bridge between hospitals and SNFs and optimize this transition process to yield improved outcomes. Industry experts endorse this approach.²⁸ A recent study demonstrated a significant reduction in readmissions in 1 SNF (32.3% to 16.1%, odds ratio = 0.403, P < .001), by having a hospitalist-led team follow patients discharged from the hospital.²⁹

Chronic Conditions Management/High-Risk Patients

Interest in patients with multiple chronic comorbidities and social issues intensifies as healthcare systems focus limited resources on these high-risk patients to prevent the unnecessary use of costly services.^30,31 As health systems assume financial risk for health outcomes and costs of designated patient groups, they undertake efforts to understand the population they serve. Such efforts aim to identify patients with established high utilization patterns (or those at risk for high utilization). This knowledge enables targeted actions to provide access, treatment, and preventive interventions to avoid unneeded emergency and hospital services. Hospitalists commonly care for these patients and are positioned to lead the implementation of patient risk assessment and stratification, develop patient-centered care models across care settings, and act as a liaison with primary care. For frail elderly and seriously ill patients, the integration of hospitalists into palliative care provides several opportunities for improving the quality of care at the end of life.³² As patients and their family caregivers commonly do not address goals of care until faced with a life-threatening condition in the hospital, hospitalists represent ideal primary palliative care physicians to initiate these conversations.³³ A hospitalist communicating with a patient and/or their family caregiver about alleviating symptoms and clarifying patients’ preferences for care often yields decreases in ineffective healthcare utilization and better patient outcomes. The hospitalists’ ability to communicate with other providers within the hospital setting also allows them to better coordinate interdisciplinary care and prevent unnecessary and ineffective treatments and procedures.

De-Implementation/Waste Reduction

The largest inefficiencies in healthcare noted in the National Academy of Medicine report, Demanding Value from Our Health Care (2012), are failure to deliver known beneficial therapies or providing unnecessary or nonevidenced based services that do not improve outcomes, but come with associated risk and cost.³⁴ “De-implementation” of unnecessary diagnostic tests or ineffective or even harmful treatments by hospitalists represents a significant opportunity to reduce costs while maintaining or even improving the quality of care. The Society of Hospital Medicine joined the Choosing Wisely^® campaign and made 5 recommendations in adult care as an explicit starting point for eliminating waste in the hospital in 2013.³⁵ Since then, hospitalists have participated in multiple successful efforts to address overutilization of care; some published results include the following:

• decreased frequency of unnecessary common labs through a multifaceted hospitalist QI intervention;³⁶
• reduced length of stay and cost by appropriate use of telemetry;³⁷ and
• reduced unnecessary radiology testing by providing physicians with individualized audit and feedback reports.³⁸

Hundreds of ACOs now exist across the US, formed by a variety of providers including hospitals, physician groups, and integrated delivery systems. Provider groups range in size from primary care-focused physician groups with a handful of offices to large, multistate integrated delivery systems with dozens of hospitals and hundreds of office locations. Evaluations of ACO outcomes reveal mixed results.^9,39-53 Admittedly, assessments attempting to compare the magnitude of savings across ACO models are difficult given the variation in size, variability in specific efforts to influence utilization, and substantial turnover among participating beneficiaries.⁵⁴ Nonetheless, a newly published Office of Inspector General report⁵⁵ showed that most Medicare ACOs reduced spending and improved care quality (82% of the individual quality measures) over the first 3 years of the program, and savings increased with duration of an ACO program. The report also noted that considerable time and managerial resources are required to implement changes to improve quality and lower costs. While the political terrain ostensibly supports value-based care and the need to diminish the proportion of our nation’s gross domestic product dedicated to healthcare, health systems are navigating an environment that still largely rewards volume. Hospitalists may be ideal facilitators for this transitional period as they possess the clinical experience caring for complex patients with multiple comorbidities and quality improvement skills to lead efforts in this new ACO era.

Disclosures

The authors have nothing to disclose.

The accountable care organization (ACO) concept, elucidated in 2006 as the development of partnerships between hospitals and physicians to coordinate and deliver efficient care,¹ seeks to remove existing barriers to improving value.² Some advocate this concept as a promising payment model that could successfully realign the current payment system to financially reward improvements in quality and efficiency that bend the cost curve.^3,4 Hospitalists fit well with this philosophy. As the fastest growing medical specialty in the history of American medicine, from a couple of thousand hospitalists in the mid-1990s to more than 50,000, the remarkable progression of hospitalists has ostensibly been driven partially by hospitals’ efforts to improve the value equation through enhanced efficiency in inpatient care. Importantly, hospitalists probably provide care for more than half of all hospitalized Medicare beneficiaries and increasingly patients in skilled nursing facilities (ie, SNFists).⁵ Along with primary care physicians, hospitalists thus represent an essential group of physicians needed to transform care delivery.

When the Affordable Care Act (ACA) established the Medicare Shared Savings Program (MSSP), ACOs leaped from being an intellectual concept^1,2 into a pragmatic health system strategy.^3,4 Following Medicare, various private health insurance plans and some state Medicaid programs entered into contracts with groups of healthcare providers (hospitals, physicians, or health systems) to serve as ACOs for their insured enrollees.⁶ Leavitt Partners’ ACO tracking database showed that the number of ACOs increased from 157 in March of 2012 to 782 in December of 2015.⁷

Until recently, the federal government’s commitment to having 50% of total Medicare spending via value-based payment models by 2018, coupled with endorsement from state Medicaid programs and commercial insurers, demonstrated strong support for continuation of ACOs. Unexpectedly on August 15, 2017, the Centers for Medicare & Medicaid Services (CMS) outlined a plan in its proposed rulemaking to cancel the Episode Payment Models and the Cardiac Rehabilitation incentive payment model, which were scheduled to commence on January 1, 2018. CMS also plans to scale back the mandatory Comprehensive Care for Joint Replacement (CCJR) bundled payment model from 67 selected geographic areas to 34. Although this proposed rulemaking created some equipoise in the healthcare industry regarding the future of value-based reimbursement approaches, cost containment and improved efficiency remain as major focuses of the federal government’s healthcare effort. Notably, CMS offers providers that are newly excluded from the CCJR model the opportunity to voluntarily participate in the program and is expected to increase opportunities for providers to participate in voluntary rather than large-scale mandatory episode payment model initiatives. In 2018, the agency also plans to develop new voluntary bundled payment models that will meet criteria to be considered an advanced alternative payment model for Quality Payment Program purposes.

Importantly, the value-based reimbursement movement was well underway before ACA legislation. Through ACA health reform, value-based reimbursement efforts were expanded through ACOs, bundled payments, value-based purchasing, the CMS Innovation Center and other initiatives. With health systems having an overflowing plate of activities, a wait-and-see attitude might seem reasonable at first. However, being unprepared for the inevitable shift to value-based reimbursement and reduced fee-for-service revenue places an organization at risk. A successful ACO requires system-level transformation, especially cultural and structural changes to achieve clinical integration. Being embedded in health system delivery, hospitalists can help shape a team-oriented culture and foster success in value-based payment models. This requires hospitalists to take a more active role in assessing and striking a balance between high-quality, cost-efficient care and financial risk inherent in ACO models.

The key to hospitalists fulfilling their value creation potential and becoming enablers for ACO success lies in developing a thorough understanding of the aspects of an ACO that promote efficient and effective care, while accounting for financial factors. Fundamentally, the ACO concept combines provider payment and delivery system reforms. Specifically, the definition of an ACO contains 3 factors: (1) a local healthcare organization (eg, hospital or multispecialty group of physicians) with a related set of providers that (2) can be held accountable for the cost and quality of care delivered to (3) a defined population. While the notion of accountability is not new, the locus of accountability is changed in the ACO model—emphasizing accountability at the level of actual care delivery with documentation of quality and cost outcomes. The ACO approach aims to address multiple, frequent, and recurring problems, including lack of financial incentives to improve quality and reduce cost, as well as the negative consequences of a pay-for-volume system—uncoordinated and fragmented care, overutilization of unnecessary tests and treatments, and poor patient experience all manifested as unwarranted geographic variation in practice patterns, clinical outcomes, and health spending. Participants in an ACO are rewarded financially if they can slow the growth of their patients’ healthcare costs while maintaining or improving the quality of care delivered. To succeed in this ACO world, hospitalists must assume greater prudence in the use of healthcare services while improving (or at a minimum, maintaining) patient outcomes, thus excising avoidable waste across the continuum of care.

More than half of ACOs include a hospital.⁸ However, whether hospital-led ACOs possess an advantage remains to be elucidated. Early reports indicated that physician-led ACOs saved more money.^9,10 However, others argue that hospitals¹¹ are better capitalized, have greater capacity for data sharing, and possess economies of scale that allow them to invest in more advanced technology, such as predictive modeling and/or simulation software. Such analytics can identify high-cost patients (ie, multiple comorbidities), super utilizers and populations lacking care, allowing ACOs to implement preventive measures to reduce unnecessary utilization. Recently released CMS MSSP 2016 performance data¹² showed that nearly half (45%) of physician-only ACOs earned shared savings, whereas 23% of ACOs that include hospitals earned shared savings. However, among all the ACOs that achieved savings, ACO entities that include hospitals generated the highest amount of shared savings (eg, Advocate, Hackensack Alliance, Cleveland Clinic, and AMITA Health). Notably, hospital-led ACOs tend to have much larger beneficiary populations than physician-led ACOs, which may create a scenario of higher risk but higher potential reward.

The emphasis on value over volume inherent in the development of ACOs occurs through employing care strategies implemented through changes in policies, and eventual structural and cultural changes. These changes require participating organizations to possess certain key competencies, including the following: 1) leadership that facilitates change; 2) organizational culture of teamwork; 3) collaborative relationships among providers; 4) information technology infrastructure for population management and care coordination; 5) infrastructure for monitoring, managing, and reporting quality; 6) ability to manage financial risk; 7) ability to receive and distribute payments or savings; and 8) resources for patient education and support.^2,3,13-16 Table 1 summarizes the broad range of roles that hospitalists can serve in delivering care to ACO populations.^17-19

Hospitalists’ active pursuit of nonclinical training and selection for administrative positions demonstrate their proclivity to provide these competencies. In addition to full-time clinician hospitalists, who can directly influence the delivery of high-value care to patients, hospitalists serve many other roles in hospitals and each can contribute differently based on their specialized expertise. Examples include the success of the Society of Hospital Medicine’s Leadership Academy; the acknowledged expertise of hospitalists in quality improvement (QI), informatics, teamwork, patient experience, care coordination and utilization; and advancement of hospitalists to senior leadership positions (eg, CQO, CMO, CEO). Given that nearly a third of healthcare expenditures are for hospital care,²⁰ hospitalists are in a unique position to foster ACO competencies while impacting the quality of care episodes associated with an index hospital stay.

Importantly, hospitalists cannot act as gatekeepers to restrict care. Managed care organizations and health maintenance organizations use of this approach in the 1990s to limit access to services in order to reduce costs led to unacceptable outcomes and numerous malpractice lawsuits. ACOs should aspire to deliver the most cost-effective high-quality care, and their performance should be monitored to ensure that they provide recommended services and timely access. The Medicare ACO contract holds the provider accountable for meeting 34 different quality measures (Supplemental Table 1), and hospitalists can influence outcomes for the majority. Especially through hospital and health system QI initiatives, hospitalists can directly impact and share accountability for measures ranging from care coordination to implementation of evidence-based care (eg, ACE inhibitors and beta blockers for heart failure) to patient and family caregiver experience.

Aligned with Medicare ACO quality measures, 5 high-impact target areas were identified for ACOs²¹: (1) Prevention and wellness; (2) Chronic conditions/care management; (3) Reduced hospitalizations; (4) Care transitions across the fragmented system; and (5) Multispecialty care coordination of complex patients. One essential element of a successful ACO is the ability to implement evidence-based medical guidelines and/or practices across the continuum of care for selected targeted initiatives. Optimizing care coordination/continuum requires team-based care, and hospitalists already routinely collaborate with nurses, social workers, case managers, pharmacists, and other stakeholders such as dieticians and physical therapists on inpatient care. Hospitalists are also experienced in facilitating communication and improving integration and coordination efficiencies among primary care providers and specialists, and between hospital care and post-acute care, as they coordinate post-hospital care and follow-up. This provides an opportunity to lead health system care coordination efforts, especially for complex and/or high-risk patients.^22,23 CMS MSSP 2016 performance data¹² showed that ACOs achieving shared savings had a decline in inpatient expenditures and utilization across several facility types (hospital, SNF, rehabilitation, long term). Postacute care management is critical to earning shared savings; SNF and Home Health expenditures fell by 18.3% and 9.7%, respectively, on average. We believe that hospitalists can have more influence over these cost areas by influencing treatment of hospitalized patients in a timely manner, discharge coordination, and selection of appropriate disposition locations. Hospitalists also play an integral role in ensuring the hospital performs well on quality metrics, including 30-day readmissions, hospital acquired conditions, and patient satisfaction. Examples below document the effectiveness of hospitalists in this new ACO era.

Care Transitions/Coordination

Before the Hospital Readmission Reduction Program (HRRP) delineated in the ACA, hospitalists developed Project BOOST (Better Outcomes by Optimizing Care Transitions) to improve hospital discharge care transition. The evidence-based foundation of this project led CMS to list Project BOOST as an example program that can reduce readmissions.²⁴ Through the dissemination and mentored implementation of Project BOOST to over 200 hospitals across the United States,²⁵ hospitalists contributed to the marked reduction in hospital readmission occurring since 2010.²⁶ Although hospital medicine began as a practice specific to the hospital setting, hospitalists’ skills generated growing demand for them in postacute facilities. SNF residents commonly come from hospitals postdischarge and suffer from multiple comorbidities and limitations in activities of daily living. Not surprisingly, SNF residents experience high rates of rehospitalizations.²⁷ Hospitalists can serve as a bridge between hospitals and SNFs and optimize this transition process to yield improved outcomes. Industry experts endorse this approach.²⁸ A recent study demonstrated a significant reduction in readmissions in 1 SNF (32.3% to 16.1%, odds ratio = 0.403, P < .001), by having a hospitalist-led team follow patients discharged from the hospital.²⁹

Chronic Conditions Management/High-Risk Patients

Interest in patients with multiple chronic comorbidities and social issues intensifies as healthcare systems focus limited resources on these high-risk patients to prevent the unnecessary use of costly services.^30,31 As health systems assume financial risk for health outcomes and costs of designated patient groups, they undertake efforts to understand the population they serve. Such efforts aim to identify patients with established high utilization patterns (or those at risk for high utilization). This knowledge enables targeted actions to provide access, treatment, and preventive interventions to avoid unneeded emergency and hospital services. Hospitalists commonly care for these patients and are positioned to lead the implementation of patient risk assessment and stratification, develop patient-centered care models across care settings, and act as a liaison with primary care. For frail elderly and seriously ill patients, the integration of hospitalists into palliative care provides several opportunities for improving the quality of care at the end of life.³² As patients and their family caregivers commonly do not address goals of care until faced with a life-threatening condition in the hospital, hospitalists represent ideal primary palliative care physicians to initiate these conversations.³³ A hospitalist communicating with a patient and/or their family caregiver about alleviating symptoms and clarifying patients’ preferences for care often yields decreases in ineffective healthcare utilization and better patient outcomes. The hospitalists’ ability to communicate with other providers within the hospital setting also allows them to better coordinate interdisciplinary care and prevent unnecessary and ineffective treatments and procedures.

De-Implementation/Waste Reduction

The largest inefficiencies in healthcare noted in the National Academy of Medicine report, Demanding Value from Our Health Care (2012), are failure to deliver known beneficial therapies or providing unnecessary or nonevidenced based services that do not improve outcomes, but come with associated risk and cost.³⁴ “De-implementation” of unnecessary diagnostic tests or ineffective or even harmful treatments by hospitalists represents a significant opportunity to reduce costs while maintaining or even improving the quality of care. The Society of Hospital Medicine joined the Choosing Wisely^® campaign and made 5 recommendations in adult care as an explicit starting point for eliminating waste in the hospital in 2013.³⁵ Since then, hospitalists have participated in multiple successful efforts to address overutilization of care; some published results include the following:

• decreased frequency of unnecessary common labs through a multifaceted hospitalist QI intervention;³⁶
• reduced length of stay and cost by appropriate use of telemetry;³⁷ and
• reduced unnecessary radiology testing by providing physicians with individualized audit and feedback reports.³⁸

Hundreds of ACOs now exist across the US, formed by a variety of providers including hospitals, physician groups, and integrated delivery systems. Provider groups range in size from primary care-focused physician groups with a handful of offices to large, multistate integrated delivery systems with dozens of hospitals and hundreds of office locations. Evaluations of ACO outcomes reveal mixed results.^9,39-53 Admittedly, assessments attempting to compare the magnitude of savings across ACO models are difficult given the variation in size, variability in specific efforts to influence utilization, and substantial turnover among participating beneficiaries.⁵⁴ Nonetheless, a newly published Office of Inspector General report⁵⁵ showed that most Medicare ACOs reduced spending and improved care quality (82% of the individual quality measures) over the first 3 years of the program, and savings increased with duration of an ACO program. The report also noted that considerable time and managerial resources are required to implement changes to improve quality and lower costs. While the political terrain ostensibly supports value-based care and the need to diminish the proportion of our nation’s gross domestic product dedicated to healthcare, health systems are navigating an environment that still largely rewards volume. Hospitalists may be ideal facilitators for this transitional period as they possess the clinical experience caring for complex patients with multiple comorbidities and quality improvement skills to lead efforts in this new ACO era.

Disclosures

The authors have nothing to disclose.

The accountable care organization (ACO) concept, elucidated in 2006 as the development of partnerships between hospitals and physicians to coordinate and deliver efficient care,¹ seeks to remove existing barriers to improving value.² Some advocate this concept as a promising payment model that could successfully realign the current payment system to financially reward improvements in quality and efficiency that bend the cost curve.^3,4 Hospitalists fit well with this philosophy. As the fastest growing medical specialty in the history of American medicine, from a couple of thousand hospitalists in the mid-1990s to more than 50,000, the remarkable progression of hospitalists has ostensibly been driven partially by hospitals’ efforts to improve the value equation through enhanced efficiency in inpatient care. Importantly, hospitalists probably provide care for more than half of all hospitalized Medicare beneficiaries and increasingly patients in skilled nursing facilities (ie, SNFists).⁵ Along with primary care physicians, hospitalists thus represent an essential group of physicians needed to transform care delivery.

When the Affordable Care Act (ACA) established the Medicare Shared Savings Program (MSSP), ACOs leaped from being an intellectual concept^1,2 into a pragmatic health system strategy.^3,4 Following Medicare, various private health insurance plans and some state Medicaid programs entered into contracts with groups of healthcare providers (hospitals, physicians, or health systems) to serve as ACOs for their insured enrollees.⁶ Leavitt Partners’ ACO tracking database showed that the number of ACOs increased from 157 in March of 2012 to 782 in December of 2015.⁷

Until recently, the federal government’s commitment to having 50% of total Medicare spending via value-based payment models by 2018, coupled with endorsement from state Medicaid programs and commercial insurers, demonstrated strong support for continuation of ACOs. Unexpectedly on August 15, 2017, the Centers for Medicare & Medicaid Services (CMS) outlined a plan in its proposed rulemaking to cancel the Episode Payment Models and the Cardiac Rehabilitation incentive payment model, which were scheduled to commence on January 1, 2018. CMS also plans to scale back the mandatory Comprehensive Care for Joint Replacement (CCJR) bundled payment model from 67 selected geographic areas to 34. Although this proposed rulemaking created some equipoise in the healthcare industry regarding the future of value-based reimbursement approaches, cost containment and improved efficiency remain as major focuses of the federal government’s healthcare effort. Notably, CMS offers providers that are newly excluded from the CCJR model the opportunity to voluntarily participate in the program and is expected to increase opportunities for providers to participate in voluntary rather than large-scale mandatory episode payment model initiatives. In 2018, the agency also plans to develop new voluntary bundled payment models that will meet criteria to be considered an advanced alternative payment model for Quality Payment Program purposes.

Importantly, the value-based reimbursement movement was well underway before ACA legislation. Through ACA health reform, value-based reimbursement efforts were expanded through ACOs, bundled payments, value-based purchasing, the CMS Innovation Center and other initiatives. With health systems having an overflowing plate of activities, a wait-and-see attitude might seem reasonable at first. However, being unprepared for the inevitable shift to value-based reimbursement and reduced fee-for-service revenue places an organization at risk. A successful ACO requires system-level transformation, especially cultural and structural changes to achieve clinical integration. Being embedded in health system delivery, hospitalists can help shape a team-oriented culture and foster success in value-based payment models. This requires hospitalists to take a more active role in assessing and striking a balance between high-quality, cost-efficient care and financial risk inherent in ACO models.

The key to hospitalists fulfilling their value creation potential and becoming enablers for ACO success lies in developing a thorough understanding of the aspects of an ACO that promote efficient and effective care, while accounting for financial factors. Fundamentally, the ACO concept combines provider payment and delivery system reforms. Specifically, the definition of an ACO contains 3 factors: (1) a local healthcare organization (eg, hospital or multispecialty group of physicians) with a related set of providers that (2) can be held accountable for the cost and quality of care delivered to (3) a defined population. While the notion of accountability is not new, the locus of accountability is changed in the ACO model—emphasizing accountability at the level of actual care delivery with documentation of quality and cost outcomes. The ACO approach aims to address multiple, frequent, and recurring problems, including lack of financial incentives to improve quality and reduce cost, as well as the negative consequences of a pay-for-volume system—uncoordinated and fragmented care, overutilization of unnecessary tests and treatments, and poor patient experience all manifested as unwarranted geographic variation in practice patterns, clinical outcomes, and health spending. Participants in an ACO are rewarded financially if they can slow the growth of their patients’ healthcare costs while maintaining or improving the quality of care delivered. To succeed in this ACO world, hospitalists must assume greater prudence in the use of healthcare services while improving (or at a minimum, maintaining) patient outcomes, thus excising avoidable waste across the continuum of care.

More than half of ACOs include a hospital.⁸ However, whether hospital-led ACOs possess an advantage remains to be elucidated. Early reports indicated that physician-led ACOs saved more money.^9,10 However, others argue that hospitals¹¹ are better capitalized, have greater capacity for data sharing, and possess economies of scale that allow them to invest in more advanced technology, such as predictive modeling and/or simulation software. Such analytics can identify high-cost patients (ie, multiple comorbidities), super utilizers and populations lacking care, allowing ACOs to implement preventive measures to reduce unnecessary utilization. Recently released CMS MSSP 2016 performance data¹² showed that nearly half (45%) of physician-only ACOs earned shared savings, whereas 23% of ACOs that include hospitals earned shared savings. However, among all the ACOs that achieved savings, ACO entities that include hospitals generated the highest amount of shared savings (eg, Advocate, Hackensack Alliance, Cleveland Clinic, and AMITA Health). Notably, hospital-led ACOs tend to have much larger beneficiary populations than physician-led ACOs, which may create a scenario of higher risk but higher potential reward.

The emphasis on value over volume inherent in the development of ACOs occurs through employing care strategies implemented through changes in policies, and eventual structural and cultural changes. These changes require participating organizations to possess certain key competencies, including the following: 1) leadership that facilitates change; 2) organizational culture of teamwork; 3) collaborative relationships among providers; 4) information technology infrastructure for population management and care coordination; 5) infrastructure for monitoring, managing, and reporting quality; 6) ability to manage financial risk; 7) ability to receive and distribute payments or savings; and 8) resources for patient education and support.^2,3,13-16 Table 1 summarizes the broad range of roles that hospitalists can serve in delivering care to ACO populations.^17-19

Hospitalists’ active pursuit of nonclinical training and selection for administrative positions demonstrate their proclivity to provide these competencies. In addition to full-time clinician hospitalists, who can directly influence the delivery of high-value care to patients, hospitalists serve many other roles in hospitals and each can contribute differently based on their specialized expertise. Examples include the success of the Society of Hospital Medicine’s Leadership Academy; the acknowledged expertise of hospitalists in quality improvement (QI), informatics, teamwork, patient experience, care coordination and utilization; and advancement of hospitalists to senior leadership positions (eg, CQO, CMO, CEO). Given that nearly a third of healthcare expenditures are for hospital care,²⁰ hospitalists are in a unique position to foster ACO competencies while impacting the quality of care episodes associated with an index hospital stay.

Importantly, hospitalists cannot act as gatekeepers to restrict care. Managed care organizations and health maintenance organizations use of this approach in the 1990s to limit access to services in order to reduce costs led to unacceptable outcomes and numerous malpractice lawsuits. ACOs should aspire to deliver the most cost-effective high-quality care, and their performance should be monitored to ensure that they provide recommended services and timely access. The Medicare ACO contract holds the provider accountable for meeting 34 different quality measures (Supplemental Table 1), and hospitalists can influence outcomes for the majority. Especially through hospital and health system QI initiatives, hospitalists can directly impact and share accountability for measures ranging from care coordination to implementation of evidence-based care (eg, ACE inhibitors and beta blockers for heart failure) to patient and family caregiver experience.

Aligned with Medicare ACO quality measures, 5 high-impact target areas were identified for ACOs²¹: (1) Prevention and wellness; (2) Chronic conditions/care management; (3) Reduced hospitalizations; (4) Care transitions across the fragmented system; and (5) Multispecialty care coordination of complex patients. One essential element of a successful ACO is the ability to implement evidence-based medical guidelines and/or practices across the continuum of care for selected targeted initiatives. Optimizing care coordination/continuum requires team-based care, and hospitalists already routinely collaborate with nurses, social workers, case managers, pharmacists, and other stakeholders such as dieticians and physical therapists on inpatient care. Hospitalists are also experienced in facilitating communication and improving integration and coordination efficiencies among primary care providers and specialists, and between hospital care and post-acute care, as they coordinate post-hospital care and follow-up. This provides an opportunity to lead health system care coordination efforts, especially for complex and/or high-risk patients.^22,23 CMS MSSP 2016 performance data¹² showed that ACOs achieving shared savings had a decline in inpatient expenditures and utilization across several facility types (hospital, SNF, rehabilitation, long term). Postacute care management is critical to earning shared savings; SNF and Home Health expenditures fell by 18.3% and 9.7%, respectively, on average. We believe that hospitalists can have more influence over these cost areas by influencing treatment of hospitalized patients in a timely manner, discharge coordination, and selection of appropriate disposition locations. Hospitalists also play an integral role in ensuring the hospital performs well on quality metrics, including 30-day readmissions, hospital acquired conditions, and patient satisfaction. Examples below document the effectiveness of hospitalists in this new ACO era.

Care Transitions/Coordination

Before the Hospital Readmission Reduction Program (HRRP) delineated in the ACA, hospitalists developed Project BOOST (Better Outcomes by Optimizing Care Transitions) to improve hospital discharge care transition. The evidence-based foundation of this project led CMS to list Project BOOST as an example program that can reduce readmissions.²⁴ Through the dissemination and mentored implementation of Project BOOST to over 200 hospitals across the United States,²⁵ hospitalists contributed to the marked reduction in hospital readmission occurring since 2010.²⁶ Although hospital medicine began as a practice specific to the hospital setting, hospitalists’ skills generated growing demand for them in postacute facilities. SNF residents commonly come from hospitals postdischarge and suffer from multiple comorbidities and limitations in activities of daily living. Not surprisingly, SNF residents experience high rates of rehospitalizations.²⁷ Hospitalists can serve as a bridge between hospitals and SNFs and optimize this transition process to yield improved outcomes. Industry experts endorse this approach.²⁸ A recent study demonstrated a significant reduction in readmissions in 1 SNF (32.3% to 16.1%, odds ratio = 0.403, P < .001), by having a hospitalist-led team follow patients discharged from the hospital.²⁹

Chronic Conditions Management/High-Risk Patients

Interest in patients with multiple chronic comorbidities and social issues intensifies as healthcare systems focus limited resources on these high-risk patients to prevent the unnecessary use of costly services.^30,31 As health systems assume financial risk for health outcomes and costs of designated patient groups, they undertake efforts to understand the population they serve. Such efforts aim to identify patients with established high utilization patterns (or those at risk for high utilization). This knowledge enables targeted actions to provide access, treatment, and preventive interventions to avoid unneeded emergency and hospital services. Hospitalists commonly care for these patients and are positioned to lead the implementation of patient risk assessment and stratification, develop patient-centered care models across care settings, and act as a liaison with primary care. For frail elderly and seriously ill patients, the integration of hospitalists into palliative care provides several opportunities for improving the quality of care at the end of life.³² As patients and their family caregivers commonly do not address goals of care until faced with a life-threatening condition in the hospital, hospitalists represent ideal primary palliative care physicians to initiate these conversations.³³ A hospitalist communicating with a patient and/or their family caregiver about alleviating symptoms and clarifying patients’ preferences for care often yields decreases in ineffective healthcare utilization and better patient outcomes. The hospitalists’ ability to communicate with other providers within the hospital setting also allows them to better coordinate interdisciplinary care and prevent unnecessary and ineffective treatments and procedures.

De-Implementation/Waste Reduction

The largest inefficiencies in healthcare noted in the National Academy of Medicine report, Demanding Value from Our Health Care (2012), are failure to deliver known beneficial therapies or providing unnecessary or nonevidenced based services that do not improve outcomes, but come with associated risk and cost.³⁴ “De-implementation” of unnecessary diagnostic tests or ineffective or even harmful treatments by hospitalists represents a significant opportunity to reduce costs while maintaining or even improving the quality of care. The Society of Hospital Medicine joined the Choosing Wisely^® campaign and made 5 recommendations in adult care as an explicit starting point for eliminating waste in the hospital in 2013.³⁵ Since then, hospitalists have participated in multiple successful efforts to address overutilization of care; some published results include the following:

• decreased frequency of unnecessary common labs through a multifaceted hospitalist QI intervention;³⁶
• reduced length of stay and cost by appropriate use of telemetry;³⁷ and
• reduced unnecessary radiology testing by providing physicians with individualized audit and feedback reports.³⁸

Hundreds of ACOs now exist across the US, formed by a variety of providers including hospitals, physician groups, and integrated delivery systems. Provider groups range in size from primary care-focused physician groups with a handful of offices to large, multistate integrated delivery systems with dozens of hospitals and hundreds of office locations. Evaluations of ACO outcomes reveal mixed results.^9,39-53 Admittedly, assessments attempting to compare the magnitude of savings across ACO models are difficult given the variation in size, variability in specific efforts to influence utilization, and substantial turnover among participating beneficiaries.⁵⁴ Nonetheless, a newly published Office of Inspector General report⁵⁵ showed that most Medicare ACOs reduced spending and improved care quality (82% of the individual quality measures) over the first 3 years of the program, and savings increased with duration of an ACO program. The report also noted that considerable time and managerial resources are required to implement changes to improve quality and lower costs. While the political terrain ostensibly supports value-based care and the need to diminish the proportion of our nation’s gross domestic product dedicated to healthcare, health systems are navigating an environment that still largely rewards volume. Hospitalists may be ideal facilitators for this transitional period as they possess the clinical experience caring for complex patients with multiple comorbidities and quality improvement skills to lead efforts in this new ACO era.

Disclosures

The authors have nothing to disclose.

Palliative care is specialized medical care focused on providing relief from the symptoms, pain, and stress of a serious illness. The goal is to improve the quality of life for both the patient and the family. In all settings, palliative care has been found to improve patients’ quality of life,^1,2 improve family satisfaction and well-being,³ reduce resource utilization and costs,⁴ and, in some studies, increase the length of life for seriously ill patients.⁵

Given the frequency with which seriously ill patients are hospitalized, hospitalists are well positioned to identify those who could benefit from palliative care interventions.⁶ Hospitalists routinely use primary palliative care skills, including pain and symptom management and skilled care planning conversations. For complex cases, such as patients with intractable symptoms or major family conflict, hospitalists may refer to specialist palliative care teams for consultation.

The Society of Hospital Medicine (SHM) defines the key primary palliative care responsibilities for hospitalists as (1) leading discussions on the goals of care and advance care planning with patients and families, (2) screening and treating common physical symptoms, and (3) referring patients to community services to provide support postdischarge.⁷ According to data in the National Palliative Care Registry,⁸ 48% of all palliative care referrals in 2015 came from hospitalists, which is more than double the percentage of referrals from any other specialty.⁹

In a recent survey conducted by SHM about serious illness communication, 53% of hospitalists reported concerns about a patient or family’s understanding of their prognosis, and 50% indicated that they do not feel confident managing family conflict.¹⁰

Context

Patients with multiple serious chronic conditions are often forced to rely on emergency services when crises, such as uncontrolled pain or dyspnea exacerbation, occur after hours, resulting in the revolving-door hospitalizations that typically characterize their care.¹¹ As the prevalence of serious illness rises and the shift to value-based payment accelerates, hospitals are under increasing pressure to deliver efficient and high-quality services that meet the needs of seriously ill patients. The integration of standardized palliative care screening and assessment enables hospitalists and other providers to identify high-need individuals and match services and delivery models to needs, whether it be respite care for an exhausted and overwhelmed family caregiver or a home protocol for managing recurrent dyspnea crises for a patient with chronic obstructive pulmonary disease (COPD). This process improves the quality of care and quality of life, and in doing so, prevents the need for costly crisis care.

Reducing Readmissions

By identifying patients in need of extra symptom management support, or those at a turning point requiring discussion about achievable priorities for care, hospitalists can avert crises for patients earlier in the disease trajectory either by managing the patient’s palliative needs themselves or by connecting patients with specialty palliative care services as needed. This leads to a better quality of life (and survival in some studies) for both patients and their families^1,3,5 and reduces unnecessary emergency department (ED) and hospital use.¹² Hospitalists providing palliative care can also reduce readmissions by improving care coordination, including clinical communication and medication reconciliation after discharge.¹³

A 2015 Harvard Business Review study found that the quality of communication in the hospital is the strongest independent predictor of readmissions when combined with process-of-care improvements, such as standardized patient screening and assessment of family caregiver capacity.¹⁴ While medical education prepares physicians to deliver evidence-based medical care, it currently offers little to no training in communication skills, despite mounting evidence that this is a critical component of quality healthcare.

Cost Savings

Hospital palliative care teams are associated with significant hospital cost savings that result from aligning care with patient priorities, leading, in turn, to reduced nonbeneficial hospital imaging, medications, procedures, and length of stay.¹⁵ See the table^16,17 for examples of cost and quality outcomes of specialist palliative care provision and evidence supporting each outcome.^18-25

Multiple studies consistently demonstrate that inpatient palliative care teams reduce hospital costs.²⁶ One randomized controlled trial investigating the impact of an inpatient palliative care service found that patients who received care from the palliative care team reported greater satisfaction with their care, had fewer intensive care unit admissions, had more advanced directives at hospital discharge, longer hospice length of stay, and lower total healthcare costs (a net difference of $6766 per patient).²³

Research shows that the earlier palliative care is provided, the greater the impact on the subsequent course of care,²⁷ suggesting that hospitalists who provide frontline palliative care interventions as early as possible in a seriously ill patient’s stay will be able to provide higher quality care with lower overall costs. Notably, the majority of research on cost savings associated with palliative care has focused on the impact of specialist palliative care teams, and further research is needed to understand the economic impact of primary palliative care provision.

Improving Satisfaction

Shifting to value-based payment means that the patient and family experience determine an increasingly large percentage of hospital and provider reimbursement. Palliative care approaches, such as family caregiver assessment and support, access to 24/7 assistance after discharge, and person-centered care by an interdisciplinary team, improve performance in all of these measures. Communication skills training improves patient satisfaction scores, and skilled discussions about achievable priorities for care are associated with better quality of life, reduced nonbeneficial and burdensome treatments, and an increase in goal-concordant care.¹⁹ Communication skills training has also been shown to reduce burnout and improve empathy among physicians.^28,29

Though more evidence is needed to understand the impact of primary palliative care provision by hospitalists, the strong evidence on the benefits of specialty palliative care suggests that the skilled provision of primary palliative care by hospitalists will result in higher quality, higher value care. A number of training options exist for midcareer hospital medicine clinicians, including both in-person and online training in communication and other palliative care skills.

• The Center to Advance Palliative Care (CAPC) is a membership organization that offers online continuing education unit and continuing medical education courses on communication skills, pain and symptom management, caregiver support, and care coordination. CAPC also offers courses on palliative interventions for patients with dementia, COPD, and heart failure.
• SHM is actively invested in engaging hospitalists in palliative care skills training. SHM provides free toolkits on a variety of topics within the palliative care domain, including pain management, postacute care transitions, and opioid safety. The recently released Serious Illness Communication toolkit offers background on the role of hospitalists in palliative care provision, a pathway for fitting goals-of-care conversations into hospitalist workflow and recommended metrics and training resources. SHM also uses a mentored implementation model in which expert physicians mentor hospital team members on best practices in palliative care. SHM’s Palliative Care Task Force seeks to identify educational activities for hospitalists and create opportunities to integrate palliative care in hospital medicine.³⁰
• The Serious Illness Care Program at Ariadne Labs in Boston aims to facilitate conversations between clinicians and seriously ill patients through its Serious Illness Conversation Guide, combined with technical assistance on workflow redesign to help clinicians conduct and document serious illness conversations.
• VitalTalk specializes in clinical communication education. Through online and in-person train-the-trainer programs, VitalTalk equips clinicians to lead communication training programs at their home institutions.
• The Education in Palliative and End-of-Life Care Program and End-of-Life Nursing Education Consortium (ELNEC) uses a train-the-trainer approach to educate providers in palliative care clinical competencies and increase the reach of primary palliative care provision. ELNEC workshops are complemented by a curriculum of online clinical training modules.

Though palliative care skills training is a necessary first step, hospitalists also cite lack of time, difficulty finding records of previous patient discussions, and frequent handoffs as among the barriers to integrating palliative care into their practice.¹⁰ Studies examining the process of palliative care and hospital culture change have found that barriers to palliative care integration include a culture of aggressive care in EDs, lack of standardized patient identification criteria, and limited knowledge about and staffing for palliative care.³¹ These data indicate the need for system changes that enable hospitalists to operationalize palliative care principles.

Health systems must implement systems and processes that routinize palliative care, making it part of the mainstream course of care for seriously ill patients and their caregivers. This includes developing systems for the identification of patients with palliative care needs, embedding palliative care assessment and referral into clinical workflows, and enabling standardized palliative care documentation in electronic medical records. While palliative care skills training is essential, investment in systems change is no less critical to embedding palliative care practices in clinical norms across specialties.

Hospitalists can use a palliative approach to improve care quality and quality of life for seriously ill patients while helping to avoid preventable and unnecessary 911 calls, ED visits, and hospitalizations. The shift towards value-based payment is a strong incentive for hospitals and hospitalists to direct resources toward practices that improve the quality of life and care for the highest-need patients and their families. When equipped with the tools they need to provide palliative care, either themselves or in collaboration with palliative care teams, hospitalists have the opportunity to profoundly redirect the experience of care for seriously ill patients and their families.

Disclosure

The authors declared no conflicts of interest.

Palliative care is specialized medical care focused on providing relief from the symptoms, pain, and stress of a serious illness. The goal is to improve the quality of life for both the patient and the family. In all settings, palliative care has been found to improve patients’ quality of life,^1,2 improve family satisfaction and well-being,³ reduce resource utilization and costs,⁴ and, in some studies, increase the length of life for seriously ill patients.⁵

Given the frequency with which seriously ill patients are hospitalized, hospitalists are well positioned to identify those who could benefit from palliative care interventions.⁶ Hospitalists routinely use primary palliative care skills, including pain and symptom management and skilled care planning conversations. For complex cases, such as patients with intractable symptoms or major family conflict, hospitalists may refer to specialist palliative care teams for consultation.

The Society of Hospital Medicine (SHM) defines the key primary palliative care responsibilities for hospitalists as (1) leading discussions on the goals of care and advance care planning with patients and families, (2) screening and treating common physical symptoms, and (3) referring patients to community services to provide support postdischarge.⁷ According to data in the National Palliative Care Registry,⁸ 48% of all palliative care referrals in 2015 came from hospitalists, which is more than double the percentage of referrals from any other specialty.⁹

In a recent survey conducted by SHM about serious illness communication, 53% of hospitalists reported concerns about a patient or family’s understanding of their prognosis, and 50% indicated that they do not feel confident managing family conflict.¹⁰

Context

Patients with multiple serious chronic conditions are often forced to rely on emergency services when crises, such as uncontrolled pain or dyspnea exacerbation, occur after hours, resulting in the revolving-door hospitalizations that typically characterize their care.¹¹ As the prevalence of serious illness rises and the shift to value-based payment accelerates, hospitals are under increasing pressure to deliver efficient and high-quality services that meet the needs of seriously ill patients. The integration of standardized palliative care screening and assessment enables hospitalists and other providers to identify high-need individuals and match services and delivery models to needs, whether it be respite care for an exhausted and overwhelmed family caregiver or a home protocol for managing recurrent dyspnea crises for a patient with chronic obstructive pulmonary disease (COPD). This process improves the quality of care and quality of life, and in doing so, prevents the need for costly crisis care.

Reducing Readmissions

By identifying patients in need of extra symptom management support, or those at a turning point requiring discussion about achievable priorities for care, hospitalists can avert crises for patients earlier in the disease trajectory either by managing the patient’s palliative needs themselves or by connecting patients with specialty palliative care services as needed. This leads to a better quality of life (and survival in some studies) for both patients and their families^1,3,5 and reduces unnecessary emergency department (ED) and hospital use.¹² Hospitalists providing palliative care can also reduce readmissions by improving care coordination, including clinical communication and medication reconciliation after discharge.¹³

A 2015 Harvard Business Review study found that the quality of communication in the hospital is the strongest independent predictor of readmissions when combined with process-of-care improvements, such as standardized patient screening and assessment of family caregiver capacity.¹⁴ While medical education prepares physicians to deliver evidence-based medical care, it currently offers little to no training in communication skills, despite mounting evidence that this is a critical component of quality healthcare.

Cost Savings

Hospital palliative care teams are associated with significant hospital cost savings that result from aligning care with patient priorities, leading, in turn, to reduced nonbeneficial hospital imaging, medications, procedures, and length of stay.¹⁵ See the table^16,17 for examples of cost and quality outcomes of specialist palliative care provision and evidence supporting each outcome.^18-25

Multiple studies consistently demonstrate that inpatient palliative care teams reduce hospital costs.²⁶ One randomized controlled trial investigating the impact of an inpatient palliative care service found that patients who received care from the palliative care team reported greater satisfaction with their care, had fewer intensive care unit admissions, had more advanced directives at hospital discharge, longer hospice length of stay, and lower total healthcare costs (a net difference of $6766 per patient).²³

Research shows that the earlier palliative care is provided, the greater the impact on the subsequent course of care,²⁷ suggesting that hospitalists who provide frontline palliative care interventions as early as possible in a seriously ill patient’s stay will be able to provide higher quality care with lower overall costs. Notably, the majority of research on cost savings associated with palliative care has focused on the impact of specialist palliative care teams, and further research is needed to understand the economic impact of primary palliative care provision.

Improving Satisfaction

Shifting to value-based payment means that the patient and family experience determine an increasingly large percentage of hospital and provider reimbursement. Palliative care approaches, such as family caregiver assessment and support, access to 24/7 assistance after discharge, and person-centered care by an interdisciplinary team, improve performance in all of these measures. Communication skills training improves patient satisfaction scores, and skilled discussions about achievable priorities for care are associated with better quality of life, reduced nonbeneficial and burdensome treatments, and an increase in goal-concordant care.¹⁹ Communication skills training has also been shown to reduce burnout and improve empathy among physicians.^28,29

Though more evidence is needed to understand the impact of primary palliative care provision by hospitalists, the strong evidence on the benefits of specialty palliative care suggests that the skilled provision of primary palliative care by hospitalists will result in higher quality, higher value care. A number of training options exist for midcareer hospital medicine clinicians, including both in-person and online training in communication and other palliative care skills.

• The Center to Advance Palliative Care (CAPC) is a membership organization that offers online continuing education unit and continuing medical education courses on communication skills, pain and symptom management, caregiver support, and care coordination. CAPC also offers courses on palliative interventions for patients with dementia, COPD, and heart failure.
• SHM is actively invested in engaging hospitalists in palliative care skills training. SHM provides free toolkits on a variety of topics within the palliative care domain, including pain management, postacute care transitions, and opioid safety. The recently released Serious Illness Communication toolkit offers background on the role of hospitalists in palliative care provision, a pathway for fitting goals-of-care conversations into hospitalist workflow and recommended metrics and training resources. SHM also uses a mentored implementation model in which expert physicians mentor hospital team members on best practices in palliative care. SHM’s Palliative Care Task Force seeks to identify educational activities for hospitalists and create opportunities to integrate palliative care in hospital medicine.³⁰
• The Serious Illness Care Program at Ariadne Labs in Boston aims to facilitate conversations between clinicians and seriously ill patients through its Serious Illness Conversation Guide, combined with technical assistance on workflow redesign to help clinicians conduct and document serious illness conversations.
• VitalTalk specializes in clinical communication education. Through online and in-person train-the-trainer programs, VitalTalk equips clinicians to lead communication training programs at their home institutions.
• The Education in Palliative and End-of-Life Care Program and End-of-Life Nursing Education Consortium (ELNEC) uses a train-the-trainer approach to educate providers in palliative care clinical competencies and increase the reach of primary palliative care provision. ELNEC workshops are complemented by a curriculum of online clinical training modules.

Though palliative care skills training is a necessary first step, hospitalists also cite lack of time, difficulty finding records of previous patient discussions, and frequent handoffs as among the barriers to integrating palliative care into their practice.¹⁰ Studies examining the process of palliative care and hospital culture change have found that barriers to palliative care integration include a culture of aggressive care in EDs, lack of standardized patient identification criteria, and limited knowledge about and staffing for palliative care.³¹ These data indicate the need for system changes that enable hospitalists to operationalize palliative care principles.

Health systems must implement systems and processes that routinize palliative care, making it part of the mainstream course of care for seriously ill patients and their caregivers. This includes developing systems for the identification of patients with palliative care needs, embedding palliative care assessment and referral into clinical workflows, and enabling standardized palliative care documentation in electronic medical records. While palliative care skills training is essential, investment in systems change is no less critical to embedding palliative care practices in clinical norms across specialties.

Hospitalists can use a palliative approach to improve care quality and quality of life for seriously ill patients while helping to avoid preventable and unnecessary 911 calls, ED visits, and hospitalizations. The shift towards value-based payment is a strong incentive for hospitals and hospitalists to direct resources toward practices that improve the quality of life and care for the highest-need patients and their families. When equipped with the tools they need to provide palliative care, either themselves or in collaboration with palliative care teams, hospitalists have the opportunity to profoundly redirect the experience of care for seriously ill patients and their families.

Disclosure

The authors declared no conflicts of interest.

Palliative care is specialized medical care focused on providing relief from the symptoms, pain, and stress of a serious illness. The goal is to improve the quality of life for both the patient and the family. In all settings, palliative care has been found to improve patients’ quality of life,^1,2 improve family satisfaction and well-being,³ reduce resource utilization and costs,⁴ and, in some studies, increase the length of life for seriously ill patients.⁵

Given the frequency with which seriously ill patients are hospitalized, hospitalists are well positioned to identify those who could benefit from palliative care interventions.⁶ Hospitalists routinely use primary palliative care skills, including pain and symptom management and skilled care planning conversations. For complex cases, such as patients with intractable symptoms or major family conflict, hospitalists may refer to specialist palliative care teams for consultation.

The Society of Hospital Medicine (SHM) defines the key primary palliative care responsibilities for hospitalists as (1) leading discussions on the goals of care and advance care planning with patients and families, (2) screening and treating common physical symptoms, and (3) referring patients to community services to provide support postdischarge.⁷ According to data in the National Palliative Care Registry,⁸ 48% of all palliative care referrals in 2015 came from hospitalists, which is more than double the percentage of referrals from any other specialty.⁹

In a recent survey conducted by SHM about serious illness communication, 53% of hospitalists reported concerns about a patient or family’s understanding of their prognosis, and 50% indicated that they do not feel confident managing family conflict.¹⁰

Context

Patients with multiple serious chronic conditions are often forced to rely on emergency services when crises, such as uncontrolled pain or dyspnea exacerbation, occur after hours, resulting in the revolving-door hospitalizations that typically characterize their care.¹¹ As the prevalence of serious illness rises and the shift to value-based payment accelerates, hospitals are under increasing pressure to deliver efficient and high-quality services that meet the needs of seriously ill patients. The integration of standardized palliative care screening and assessment enables hospitalists and other providers to identify high-need individuals and match services and delivery models to needs, whether it be respite care for an exhausted and overwhelmed family caregiver or a home protocol for managing recurrent dyspnea crises for a patient with chronic obstructive pulmonary disease (COPD). This process improves the quality of care and quality of life, and in doing so, prevents the need for costly crisis care.

Reducing Readmissions

By identifying patients in need of extra symptom management support, or those at a turning point requiring discussion about achievable priorities for care, hospitalists can avert crises for patients earlier in the disease trajectory either by managing the patient’s palliative needs themselves or by connecting patients with specialty palliative care services as needed. This leads to a better quality of life (and survival in some studies) for both patients and their families^1,3,5 and reduces unnecessary emergency department (ED) and hospital use.¹² Hospitalists providing palliative care can also reduce readmissions by improving care coordination, including clinical communication and medication reconciliation after discharge.¹³

A 2015 Harvard Business Review study found that the quality of communication in the hospital is the strongest independent predictor of readmissions when combined with process-of-care improvements, such as standardized patient screening and assessment of family caregiver capacity.¹⁴ While medical education prepares physicians to deliver evidence-based medical care, it currently offers little to no training in communication skills, despite mounting evidence that this is a critical component of quality healthcare.

Cost Savings

Hospital palliative care teams are associated with significant hospital cost savings that result from aligning care with patient priorities, leading, in turn, to reduced nonbeneficial hospital imaging, medications, procedures, and length of stay.¹⁵ See the table^16,17 for examples of cost and quality outcomes of specialist palliative care provision and evidence supporting each outcome.^18-25

Multiple studies consistently demonstrate that inpatient palliative care teams reduce hospital costs.²⁶ One randomized controlled trial investigating the impact of an inpatient palliative care service found that patients who received care from the palliative care team reported greater satisfaction with their care, had fewer intensive care unit admissions, had more advanced directives at hospital discharge, longer hospice length of stay, and lower total healthcare costs (a net difference of $6766 per patient).²³

Research shows that the earlier palliative care is provided, the greater the impact on the subsequent course of care,²⁷ suggesting that hospitalists who provide frontline palliative care interventions as early as possible in a seriously ill patient’s stay will be able to provide higher quality care with lower overall costs. Notably, the majority of research on cost savings associated with palliative care has focused on the impact of specialist palliative care teams, and further research is needed to understand the economic impact of primary palliative care provision.

Improving Satisfaction

Shifting to value-based payment means that the patient and family experience determine an increasingly large percentage of hospital and provider reimbursement. Palliative care approaches, such as family caregiver assessment and support, access to 24/7 assistance after discharge, and person-centered care by an interdisciplinary team, improve performance in all of these measures. Communication skills training improves patient satisfaction scores, and skilled discussions about achievable priorities for care are associated with better quality of life, reduced nonbeneficial and burdensome treatments, and an increase in goal-concordant care.¹⁹ Communication skills training has also been shown to reduce burnout and improve empathy among physicians.^28,29

Though more evidence is needed to understand the impact of primary palliative care provision by hospitalists, the strong evidence on the benefits of specialty palliative care suggests that the skilled provision of primary palliative care by hospitalists will result in higher quality, higher value care. A number of training options exist for midcareer hospital medicine clinicians, including both in-person and online training in communication and other palliative care skills.

• The Center to Advance Palliative Care (CAPC) is a membership organization that offers online continuing education unit and continuing medical education courses on communication skills, pain and symptom management, caregiver support, and care coordination. CAPC also offers courses on palliative interventions for patients with dementia, COPD, and heart failure.
• SHM is actively invested in engaging hospitalists in palliative care skills training. SHM provides free toolkits on a variety of topics within the palliative care domain, including pain management, postacute care transitions, and opioid safety. The recently released Serious Illness Communication toolkit offers background on the role of hospitalists in palliative care provision, a pathway for fitting goals-of-care conversations into hospitalist workflow and recommended metrics and training resources. SHM also uses a mentored implementation model in which expert physicians mentor hospital team members on best practices in palliative care. SHM’s Palliative Care Task Force seeks to identify educational activities for hospitalists and create opportunities to integrate palliative care in hospital medicine.³⁰
• The Serious Illness Care Program at Ariadne Labs in Boston aims to facilitate conversations between clinicians and seriously ill patients through its Serious Illness Conversation Guide, combined with technical assistance on workflow redesign to help clinicians conduct and document serious illness conversations.
• VitalTalk specializes in clinical communication education. Through online and in-person train-the-trainer programs, VitalTalk equips clinicians to lead communication training programs at their home institutions.
• The Education in Palliative and End-of-Life Care Program and End-of-Life Nursing Education Consortium (ELNEC) uses a train-the-trainer approach to educate providers in palliative care clinical competencies and increase the reach of primary palliative care provision. ELNEC workshops are complemented by a curriculum of online clinical training modules.

Though palliative care skills training is a necessary first step, hospitalists also cite lack of time, difficulty finding records of previous patient discussions, and frequent handoffs as among the barriers to integrating palliative care into their practice.¹⁰ Studies examining the process of palliative care and hospital culture change have found that barriers to palliative care integration include a culture of aggressive care in EDs, lack of standardized patient identification criteria, and limited knowledge about and staffing for palliative care.³¹ These data indicate the need for system changes that enable hospitalists to operationalize palliative care principles.

Health systems must implement systems and processes that routinize palliative care, making it part of the mainstream course of care for seriously ill patients and their caregivers. This includes developing systems for the identification of patients with palliative care needs, embedding palliative care assessment and referral into clinical workflows, and enabling standardized palliative care documentation in electronic medical records. While palliative care skills training is essential, investment in systems change is no less critical to embedding palliative care practices in clinical norms across specialties.

Hospitalists can use a palliative approach to improve care quality and quality of life for seriously ill patients while helping to avoid preventable and unnecessary 911 calls, ED visits, and hospitalizations. The shift towards value-based payment is a strong incentive for hospitals and hospitalists to direct resources toward practices that improve the quality of life and care for the highest-need patients and their families. When equipped with the tools they need to provide palliative care, either themselves or in collaboration with palliative care teams, hospitalists have the opportunity to profoundly redirect the experience of care for seriously ill patients and their families.

Disclosure

The authors declared no conflicts of interest.

© 2017 Society of Hospital Medicine

Strategies are needed to empower frontline clinicians to work with organizational leadership to reduce healthcare costs and improve high-value care. Caring Wisely^® is a program developed by the University of California, San Francisco’s (UCSF) Center for Healthcare Value (CHV), aimed at engaging frontline clinicians and staff, connecting them with implementation experts, and supporting the development of targeted interventions to improve value. Financial savings from the program more than cover program costs. Caring Wisely^® provides an institutional model for implementing robust interventions to address areas of low-value care.

Launched in 2013, the annual Caring Wisely^® program consists of 3 stages for identifying projects that meet the following criteria:

• Potential to measurably reduce UCSF Health’s costs of care without transferring costs to patients, insurers, or other providers
• Plan for ensuring that health outcomes are maintained or improved
• Envision disseminating the intervention within and beyond UCSF
• Demonstrate commitment and engagement of clinical leadership and frontline staff.

The first stage is the Ideas Contest, a UCSF Health-wide call (to learn more about UCSF Health: https://www.ucsf.edu/sites/default/files/052516_About_UCSF.pdf) to identify areas that may be targeted to reduce unnecessary services, inefficiencies, and healthcare costs. We use a crowdsourcing platform—Open Proposals—to solicit the best ideas from frontline clinicians and staff.¹ Open Proposals is a secure, web-based platform for transparent and collaborative proposal development that displays threads of comments, responses, and revisions, and allows submissions to be “liked.” Open Proposals is managed by the UCSF Clinical and Translational Science Institute, funded by the National Center for Advancing Translational Sciences (Grant Number UL1 TR000004) at the National Institutes of Health. Using institutional e-mail lists for faculty, staff and residents, as well as described at monthly managers and directors meetings, the Ideas Contest is announced each year by the Chief Medical Officer and the CHV leadership. The Caring Wisely^® Executive Steering Committee, which consists of CHV and senior UCSF Health system leaders, selects the top 5-10 ideas based on the above criteria. Each winning idea receives a $100 gift certificate for a popular restaurant in San Francisco, and the list of winners is announced to the entire UCSF community.

The second stage is the Request for Proposals. The Caring Wisely^® program solicits proposals that outline implementation plans to target specific areas identified through the Ideas Contest. Finalists from the Ideas Contest are encouraged to submit proposals that address the problem they identified, but anyone affiliated with UCSF Health may submit a proposal on a winning idea. There is an approximately 4-week open submission period during which applicants submit brief 2-page proposals on the Open Proposal platform. This is followed by a period of optimization that leverages the social media aspect of the Open Proposals platform in which the UCSF Health community asks clarifying questions, make suggestions, and modifications can be made to the proposals. All submissions receive written feedback from at least one Steering Committee member. In addition, the Caring Wisely^® Director directly invites relevant UCSF colleagues, administrators, or program leaders to comment on proposals and make suggestions for improvement. Plans for assessing financial and health care delivery impacts are developed in collaboration with the UCSF Health Finance department. UCSF Health managers and leaders who are stakeholders in project proposal areas are consulted to provide input and finalize proposal plans, including the identification of existing personnel who can support and drive the project forward. Proposers use this feedback to revise their applications throughout this stage.

The third stage is Project Implementation. The Caring Wisely^® Executive Steering Committee selects up to 3 winners from the submitted proposals. Using the program criteria above, each project is scored independently, discussed in committee, and rescored to identify the top proposals. Each selected project receives a maximum budget of $50,000 that can be used for project materials, activities, and salary support for project leaders or staff. In addition to funding, each project team receives input from the implementation science team to co-develop and implement the intervention with a goal of creating a first-test-of-change within 3-6 months. A key feature of Caring Wisely^® is the partnership between project teams and the Caring Wisely^® implementation team, which includes a director, program manager, data analysts, and implementation scientists (Table 1).

LIST OF ABBREVIATIONS

UCSF—University of California, San Francisco; PRECEDE—Predisposing, Reinforcing, and Enabling Constructs in Educational Diagnosis and Evaluation; PROCEED—Policy, Regulatory and Organizational Constructs in Educational and Environmental Development

Acknowledgments

Other participants in blood transfusion reduction project (D. Johnson, K. Curcione); IV-to-PO Switch (C. Tsourounis, A. Pollock); Surgical Supply Cost Reduction (C. Zygourakis); Perioperative Efficiency (L. Hampson); CT for PE Risk Prediction (E. Weber); ERAS Pathways (L. Chen); Neonatal Sepsis Risk Prediction (T. Newman); Post-Operative Debrief (S. Imershein). Caring Wisely Executive Steering Committee (J. Adler, S. Antrum, A Auerbach, J. Bennan, M. Blum, C. Ritchie, C. Tsourounis). This Center for Healthcare Value is funded in part by a grant from the Grove Foundation. We appreciate additional review and comments to the manuscript provided by George Sawaya and Adams Dudley.

Disclosures 

Christopher Moriates has accepted royalties from McGraw-Hill for textbook, Understanding Value-Based Healthcare. Alvin Rajkomar has received fees as a research adviser from Google, Inc.

© 2017 Society of Hospital Medicine

Strategies are needed to empower frontline clinicians to work with organizational leadership to reduce healthcare costs and improve high-value care. Caring Wisely^® is a program developed by the University of California, San Francisco’s (UCSF) Center for Healthcare Value (CHV), aimed at engaging frontline clinicians and staff, connecting them with implementation experts, and supporting the development of targeted interventions to improve value. Financial savings from the program more than cover program costs. Caring Wisely^® provides an institutional model for implementing robust interventions to address areas of low-value care.

Launched in 2013, the annual Caring Wisely^® program consists of 3 stages for identifying projects that meet the following criteria:

• Potential to measurably reduce UCSF Health’s costs of care without transferring costs to patients, insurers, or other providers
• Plan for ensuring that health outcomes are maintained or improved
• Envision disseminating the intervention within and beyond UCSF
• Demonstrate commitment and engagement of clinical leadership and frontline staff.

The first stage is the Ideas Contest, a UCSF Health-wide call (to learn more about UCSF Health: https://www.ucsf.edu/sites/default/files/052516_About_UCSF.pdf) to identify areas that may be targeted to reduce unnecessary services, inefficiencies, and healthcare costs. We use a crowdsourcing platform—Open Proposals—to solicit the best ideas from frontline clinicians and staff.¹ Open Proposals is a secure, web-based platform for transparent and collaborative proposal development that displays threads of comments, responses, and revisions, and allows submissions to be “liked.” Open Proposals is managed by the UCSF Clinical and Translational Science Institute, funded by the National Center for Advancing Translational Sciences (Grant Number UL1 TR000004) at the National Institutes of Health. Using institutional e-mail lists for faculty, staff and residents, as well as described at monthly managers and directors meetings, the Ideas Contest is announced each year by the Chief Medical Officer and the CHV leadership. The Caring Wisely^® Executive Steering Committee, which consists of CHV and senior UCSF Health system leaders, selects the top 5-10 ideas based on the above criteria. Each winning idea receives a $100 gift certificate for a popular restaurant in San Francisco, and the list of winners is announced to the entire UCSF community.

The second stage is the Request for Proposals. The Caring Wisely^® program solicits proposals that outline implementation plans to target specific areas identified through the Ideas Contest. Finalists from the Ideas Contest are encouraged to submit proposals that address the problem they identified, but anyone affiliated with UCSF Health may submit a proposal on a winning idea. There is an approximately 4-week open submission period during which applicants submit brief 2-page proposals on the Open Proposal platform. This is followed by a period of optimization that leverages the social media aspect of the Open Proposals platform in which the UCSF Health community asks clarifying questions, make suggestions, and modifications can be made to the proposals. All submissions receive written feedback from at least one Steering Committee member. In addition, the Caring Wisely^® Director directly invites relevant UCSF colleagues, administrators, or program leaders to comment on proposals and make suggestions for improvement. Plans for assessing financial and health care delivery impacts are developed in collaboration with the UCSF Health Finance department. UCSF Health managers and leaders who are stakeholders in project proposal areas are consulted to provide input and finalize proposal plans, including the identification of existing personnel who can support and drive the project forward. Proposers use this feedback to revise their applications throughout this stage.

The third stage is Project Implementation. The Caring Wisely^® Executive Steering Committee selects up to 3 winners from the submitted proposals. Using the program criteria above, each project is scored independently, discussed in committee, and rescored to identify the top proposals. Each selected project receives a maximum budget of $50,000 that can be used for project materials, activities, and salary support for project leaders or staff. In addition to funding, each project team receives input from the implementation science team to co-develop and implement the intervention with a goal of creating a first-test-of-change within 3-6 months. A key feature of Caring Wisely^® is the partnership between project teams and the Caring Wisely^® implementation team, which includes a director, program manager, data analysts, and implementation scientists (Table 1).

LIST OF ABBREVIATIONS

UCSF—University of California, San Francisco; PRECEDE—Predisposing, Reinforcing, and Enabling Constructs in Educational Diagnosis and Evaluation; PROCEED—Policy, Regulatory and Organizational Constructs in Educational and Environmental Development

Acknowledgments

Other participants in blood transfusion reduction project (D. Johnson, K. Curcione); IV-to-PO Switch (C. Tsourounis, A. Pollock); Surgical Supply Cost Reduction (C. Zygourakis); Perioperative Efficiency (L. Hampson); CT for PE Risk Prediction (E. Weber); ERAS Pathways (L. Chen); Neonatal Sepsis Risk Prediction (T. Newman); Post-Operative Debrief (S. Imershein). Caring Wisely Executive Steering Committee (J. Adler, S. Antrum, A Auerbach, J. Bennan, M. Blum, C. Ritchie, C. Tsourounis). This Center for Healthcare Value is funded in part by a grant from the Grove Foundation. We appreciate additional review and comments to the manuscript provided by George Sawaya and Adams Dudley.

Disclosures 

Christopher Moriates has accepted royalties from McGraw-Hill for textbook, Understanding Value-Based Healthcare. Alvin Rajkomar has received fees as a research adviser from Google, Inc.

© 2017 Society of Hospital Medicine

Strategies are needed to empower frontline clinicians to work with organizational leadership to reduce healthcare costs and improve high-value care. Caring Wisely^® is a program developed by the University of California, San Francisco’s (UCSF) Center for Healthcare Value (CHV), aimed at engaging frontline clinicians and staff, connecting them with implementation experts, and supporting the development of targeted interventions to improve value. Financial savings from the program more than cover program costs. Caring Wisely^® provides an institutional model for implementing robust interventions to address areas of low-value care.

Launched in 2013, the annual Caring Wisely^® program consists of 3 stages for identifying projects that meet the following criteria:

• Potential to measurably reduce UCSF Health’s costs of care without transferring costs to patients, insurers, or other providers
• Plan for ensuring that health outcomes are maintained or improved
• Envision disseminating the intervention within and beyond UCSF
• Demonstrate commitment and engagement of clinical leadership and frontline staff.

The first stage is the Ideas Contest, a UCSF Health-wide call (to learn more about UCSF Health: https://www.ucsf.edu/sites/default/files/052516_About_UCSF.pdf) to identify areas that may be targeted to reduce unnecessary services, inefficiencies, and healthcare costs. We use a crowdsourcing platform—Open Proposals—to solicit the best ideas from frontline clinicians and staff.¹ Open Proposals is a secure, web-based platform for transparent and collaborative proposal development that displays threads of comments, responses, and revisions, and allows submissions to be “liked.” Open Proposals is managed by the UCSF Clinical and Translational Science Institute, funded by the National Center for Advancing Translational Sciences (Grant Number UL1 TR000004) at the National Institutes of Health. Using institutional e-mail lists for faculty, staff and residents, as well as described at monthly managers and directors meetings, the Ideas Contest is announced each year by the Chief Medical Officer and the CHV leadership. The Caring Wisely^® Executive Steering Committee, which consists of CHV and senior UCSF Health system leaders, selects the top 5-10 ideas based on the above criteria. Each winning idea receives a $100 gift certificate for a popular restaurant in San Francisco, and the list of winners is announced to the entire UCSF community.

The second stage is the Request for Proposals. The Caring Wisely^® program solicits proposals that outline implementation plans to target specific areas identified through the Ideas Contest. Finalists from the Ideas Contest are encouraged to submit proposals that address the problem they identified, but anyone affiliated with UCSF Health may submit a proposal on a winning idea. There is an approximately 4-week open submission period during which applicants submit brief 2-page proposals on the Open Proposal platform. This is followed by a period of optimization that leverages the social media aspect of the Open Proposals platform in which the UCSF Health community asks clarifying questions, make suggestions, and modifications can be made to the proposals. All submissions receive written feedback from at least one Steering Committee member. In addition, the Caring Wisely^® Director directly invites relevant UCSF colleagues, administrators, or program leaders to comment on proposals and make suggestions for improvement. Plans for assessing financial and health care delivery impacts are developed in collaboration with the UCSF Health Finance department. UCSF Health managers and leaders who are stakeholders in project proposal areas are consulted to provide input and finalize proposal plans, including the identification of existing personnel who can support and drive the project forward. Proposers use this feedback to revise their applications throughout this stage.

The third stage is Project Implementation. The Caring Wisely^® Executive Steering Committee selects up to 3 winners from the submitted proposals. Using the program criteria above, each project is scored independently, discussed in committee, and rescored to identify the top proposals. Each selected project receives a maximum budget of $50,000 that can be used for project materials, activities, and salary support for project leaders or staff. In addition to funding, each project team receives input from the implementation science team to co-develop and implement the intervention with a goal of creating a first-test-of-change within 3-6 months. A key feature of Caring Wisely^® is the partnership between project teams and the Caring Wisely^® implementation team, which includes a director, program manager, data analysts, and implementation scientists (Table 1).

LIST OF ABBREVIATIONS

UCSF—University of California, San Francisco; PRECEDE—Predisposing, Reinforcing, and Enabling Constructs in Educational Diagnosis and Evaluation; PROCEED—Policy, Regulatory and Organizational Constructs in Educational and Environmental Development

Acknowledgments

Other participants in blood transfusion reduction project (D. Johnson, K. Curcione); IV-to-PO Switch (C. Tsourounis, A. Pollock); Surgical Supply Cost Reduction (C. Zygourakis); Perioperative Efficiency (L. Hampson); CT for PE Risk Prediction (E. Weber); ERAS Pathways (L. Chen); Neonatal Sepsis Risk Prediction (T. Newman); Post-Operative Debrief (S. Imershein). Caring Wisely Executive Steering Committee (J. Adler, S. Antrum, A Auerbach, J. Bennan, M. Blum, C. Ritchie, C. Tsourounis). This Center for Healthcare Value is funded in part by a grant from the Grove Foundation. We appreciate additional review and comments to the manuscript provided by George Sawaya and Adams Dudley.

Disclosures 

Christopher Moriates has accepted royalties from McGraw-Hill for textbook, Understanding Value-Based Healthcare. Alvin Rajkomar has received fees as a research adviser from Google, Inc.

For over 3 decades, AcademyHealth and its predecessor organizations and members have been studying how the healthcare system works and ways to improve health outcomes. The value of health services research (HSR) training programs that emphasize learning opportunities in delivery system settings was initially articulated at the 2009 AcademyHealth Summit on the Future of HSR Data and Methods.¹ Two years later, the need for such programs was reiterated as a priority for AcademyHealth’s HSR Learning Consortium in their strategic plan.² While HSR methods have become increasingly sophisticated, historical approaches largely relied on extant (usually academic-based) researchers.

To realize the goal of building learning health systems (considered here to be entities where applied, operationally relevant research is systematically designed, generated, and translated into high-quality care delivery), many healthcare organizations have begun to use researchers as an internal resource to inform and support higher quality and more efficient care delivery operations. However, there is a current dearth of scientists trained in research disciplines (eg, comparative effectiveness research, patient-centered outcomes research, implementation science) more directly applicable to operational settings.^3,4 Conducting research within these “real-world” environments is challenging for a variety of well-documented reasons,^5,6 and many important questions cannot be answered using traditional study designs and/or methodologies. Until more researchers are trained in research approaches that align better with care delivery needs, the field will continue to fall short of addressing topics identified by the National Academy of Medicine (NAM; formerly the Institute of Medicine) as priorities for real system improvement.

While researchers in academic and consulting settings play critical roles in knowledge generation, a substantial area for expansion is support for “embedded researchers” who work more directly with operational leaders and understand local context, data, and organizational-level goals of delivery systems. AcademyHealth’s Delivery System Science Fellowship (DSSF) was developed to forge a stronger link between rigorous research practice and pragmatic aspects of care delivery.

Since inception of the DSSF, national attention has further emphasized the need for specialized, experiential learning with specific competencies that extend formal HSR training. The Agency for Healthcare Research and Quality (AHRQ) is currently convening a Technical Expert Panel to guide Training the Next Generation of Learning Health System Researchers as part of its larger effort to provide support for evidence generation and uptake in these applied settings (see http://www.ahrq.gov/news/blog/ahrqviews/supporting-learning-health-systems.html for more information). This work is reinforced by an ongoing project at AcademyHealth focused on Understanding the Current Health Services Research Workforce and Maximizing Its Future,⁷ partially sponsored by AHRQ. These efforts aim to inform AHRQ-funded career and training program requirements in order to build a workforce in partnership with academia and delivery organizations in support of developing high-functioning researchers directly positioned to drive progress toward learning healthcare systems.

The AcademyHealth DSSF Program is a pioneering effort designed to meet the needs of learning healthcare systems for a human capital resource capable of generating insights from operational data and deploying this knowledge effectively. Established in 2012 in partnership with 3 initial host sites, the DSSF provides a paid, postdoctoral training opportunity to help highly qualified, early-career researchers gain applied experience in delivery system settings.⁸ The goal is to provide hands-on experience and professional leadership opportunities to enhance the array of skills needed to generate and apply evidence in delivery systems. The long-term program objective is for graduates to employ the methods and training garnered during the DSSF to produce new, practical insights required to transform healthcare delivery and achieve the “Triple Aim.”⁹

Sixteen delivery systems have participated in the DSSF program over the course of 5 years. These organizations represent a diverse group of innovative, high-performing systems that serve populations across the rural-urban continuum. Host site preceptors are nationally recognized experts in areas such as health economics, comparative effectiveness, pragmatic trials, clinical decision support, and implementation science. The fellowship is guided by an advisory committee that provides strategic direction and plays a key role in selecting fellows. AcademyHealth partners with 8 to 10 health systems annually, accepting new partnerships as interest and availability allows. The Figure summarizes program inputs, elements, antecedents, outputs, and intended outcomes. As a relatively new and evolving program, the DSSF is using a disciplined approach to assess both mid- and long-term outcomes. The Table is a comparative matrix that depicts the range in areas of investment offered by a sample of host sites during the fellowship program. Complementing development of the common core competencies and exposures presented in the Table, specific project choice at a host site is mutually determined according to system needs and the fellow’s interests.

To apply for DSSF, researchers must hold a doctoral degree in any relevant aspect of clinical medicine, HSR, or a related field. The review committee evaluates applicants based on their qualifications, a clear statement of professional goals, appropriateness for placement, the quality of a writing sample, and letters of recommendation. Host sites select a fellow based on their individual preferences and recommendations from the review committee. The minimum duration of the fellowship is 1 year, during which the fellow works full time at the host site. Host sites provide the fellows’ salary and benefits, financial support to attend AcademyHealth’s Annual Research Meeting, and mentorship and/or training. To ensure general continuity across sites, each fellow’s work focuses on “delivery system science (DSS),” with a significant part of the work intended for public dissemination (eg, a conference presentation) or publication in a peer-reviewed journal.

Host sites additionally provide AcademyHealth financial support to manage the process of recruiting promising candidates. AcademyHealth manages and convenes the advisory committee proceedings, facilitates the application cycle (including peer review of applicants), markets the fellowship, guides the interview and match process, and promotes placement of fellows upon program completion. AcademyHealth also convenes active and graduate fellows to foster engagement and professional development.

Program Level

AcademyHealth administers an annual evaluation to assess the program, understand impact on the fellow’s professional development and growth, track publications, and inform programmatic goals. To date, we have identified over 50 peer-reviewed publications resulting from work conducted through the fellowship (visit http://www.academyhealth.org/dssfpublications for a full listing of publications stemming from the DSSF program). As an example of continuous program improvement, this year staff implemented a fellow-led monthly call in response to requests to connect fellows. This has proven to be a useful response for fellows to understand how to enhance their own experience by learning from fellows in other systems to incorporate focused areas of development via cross-system sharing. As an indicator of continued value, of the 16 sites that have participated to date, 10 have participated in the DSSF for more than 1 cycle; 3 are new host sites currently participating in their first year of the program; and 3 host sites participated for 1 year. The 3 inaugural host sites that helped launch the DSSF continue to serve as host sites to date.

As a marker of longitudinal success, staff will continue to follow up with preceptors and fellows to understand fellows’ contributions to the host site and the field, as well as impact on the fellow career trajectory. Of the 19 fellow alumni to date, 8 have moved on to academic or research positions, and 11 have remained in care delivery systems to provide local expertise in study design, execution, and evidence uptake.

The program has also made some general contributions to advance the discipline of delivery system science, including:

1. Defining DSS and clarifying training needs for “embedded researchers” and health system analysts. To characterize the fellowship, AcademyHealth and the program advisory committee jointly developed the following definition for delivery system science (DSS):

“DSS includes research that seeks to understand how delivery systems operate, influence, change, and respond to external stimulus, among other topics. DSS may include efforts to examine how and under what circumstances interventions work and how delivery systems effectively implement evidence-based innovations. For the DSSF, DSS is conducted by researchers who are ‘embedded’ in delivery systems and respond to the decision-making needs of those systems.”

Additionally, closer connections with DSS leaders have led to a better understanding of challenges, opportunities, and needs of delivery systems.^10,11

2. Cultivating a network of delivery systems and system leaders interested in expanding the cadre of embedded researchers, and trainees who intend to build careers in DSS. The DSSF also aims to enhance fellows’ skills and knowledge base, career opportunities, and professional network. To extend these relationships and support delivery system analytics, AcademyHealth worked with preceptors and fellows to inform creation of a new Community of Practice supported by AcademyHealth’s EDM Forum and guide planning for AcademyHealth’s Concordium conference to provide a national meeting to showcase DSS.

3. Strategic planning to ensure sustainable support for embedded research within delivery systems. Substantial interest in the program developed quickly, with rapid learning over the first few cycles to refine the program to meet host sites’ and fellows’ needs. Both efforts were critical to demonstrate that the DSSF fulfills an important need for our health system partners and members. As indicated previously, strong, sustained interest from prospective host sites and applicants demonstrates the program has created a win-win to jointly assess fit while building skills and supporting continuous learning.

Likewise, Lisa Simpson, President and CEO of AcademyHealth, and Lucy Savitz, DSSF host site preceptor at Intermountain Healthcare, participated in the Canadian Institutes of Health Research (CIHR) Invitational Workshop, “Modernizing Health Services and Policy Research Training in Canada” in March 2016. Shared learning largely informed by the DSSF led to CIHR creating a similar fellowship program with initial awards to be made in 2017 (see https://www.researchnet-recherchenet.ca/rnr16/vwOpprtntyDtls.do?prog=2540&view=browseActive&sponsor=CIHR-8&type=EXACT&resultCount=25 for more information). We are working to thread these efforts together in a way to leverage our learning community of government agencies, academia, and employers as a long-term funding stream for training in delivery science.

Participant Host Site Level

Two selected examples of how DSSF researchers have engaged high-priority topics that contributed to health system operations are provided here.

Kaiser Permanente Southern California: Assessing adherence with “Choosing Wisely” recommendations in oncology. In partnership with preceptor Dr. Michael Gould, 2013-2014 DSSF fellow Dr. Erin Hahn worked with the Kaiser Permanente Southern California (KPSC) Care Improvement Research Team to lead a project addressing several KPSC priority areas. Focusing on “Choosing Wisely” recommendations from the American Society of Clinical Oncology,¹² the project evaluated appropriateness of imaging and laboratory services for early-stage cancer patients and survivors between and within 2 integrated health systems, Kaiser Permanente (KP) and Intermountain Healthcare.^13,14 Results were presented to KP national leaders, including an external health policy advisory board. In close collaboration with clinical and operational leaders in medical oncology, this multiregional, multisystem project is contributing to targeted quality improvement efforts and improved healthcare value, including audit and feedback of nonrecommended labs.

Dr. Hahn subsequently received a KPSC Incubator Award, a competitive internal grant, to further study factors associated with use of nonrecommended surveillance lab tests for early-stage breast cancer patients. The study focused on medical oncologists within KPSC, categorizing them as high or low utilizers of the tests.¹⁵ Results indicate that high utilizers perceive that the tests help manage patient anxiety about recurrence, while acknowledging that the tests do not provide clinical utility. These findings are contributing to the development of targeted survivorship services across the organization.

Intermountain Healthcare: Formative evaluation of large-scale implementation of shared decision-making. Preceptor Dr. Lucy Savitz assembled a team to conduct a formative evaluation of Intermountain Healthcare’s efforts to implement shared decision-making (SDM) as part of its Center for Medicare and Medicaid Innovation Challenge Award. The 2015-2017 DSSF fellow at Intermountain Healthcare, Dr. Kim Brunisholz, served as a core member of the project team, focusing primarily on a mixed-methods evaluation of the SDM program.

Dr. Brunisholz engaged operational leads, clinical teams, patient and family advisory councils, and senior executives to conduct the program assessment. Results demonstrated significant variation in invited participation in SDM among eligible patient populations: preference sensitive conditions (1 in 30 patients), oncology-related diagnosis (1 in 3 patients), and chronic conditions (1 in 74 patients). Provisional analysis of patient-level clinical outcomes demonstrated that among those invited to the SDM program compared to those that were not, total joint replacement was decreased (10.1% vs 17.3%; P < 0.001) and a trend towards breast conservation emerged (61.8% vs 56.4%; P = 0.10). No difference in treatment choice for lower back pain was observed. Qualitative program analysis suggested need for improvements in the areas of (1) routine and continuous staff training, (2) workflow standardization, and (3) active data monitoring with meaningful, actionable feedback to caregivers. In response to these results, a chartered SDM Steering Committee was created (Dr. Brunisholz is a member of that group) to develop a strategic plan for SDM, with an accompanying organizational response to reimplement SDM in a targeted manner. Learning from this program is being leveraged to support a subproject analysis on a large scale using data from the High Value Healthcare Collaborative as part of an AHRQ-funded Center of Excellence award. (See https://www.ahrq.gov/news/newsroom/press-releases/2015/pcorawards.html. For more information on the High Value Healthcare Collaborative, please visit: https://www.highvaluehealthcare.org.)

Moving forward, the DSSF will continue working with progressive delivery systems. Partnerships between organizations that are interested in integrating rigorous research practice to drive continuous system improvement and maximize the value of care will have substantial need for technical skills and analytic capacity. They will also need to ensure that researchers working in their systems have sufficient understanding of cultural and political context within the organization to be effective leaders who can manage change.

AcademyHealth created the DSSF in response to the field’s request to build a research workforce that reflects the vision for a 21st Century Health System, as laid out by the NAM.¹⁶ We anticipate that as the US Department of Health & Human Services’ goals for payment reform and new measures to promote quality and high-value care are implemented, the DSSF trainees’ skill set will be increasingly valuable and will provide needed thought leadership on strategies to generate and apply evidence in practice.

Disclosure

Ms. Kanani received funding from Intermountain Healthcare, Kaiser Permanente Southern California for support for the Delivery System Science Fellowship. Drs. Hahn, Gould, and Brunisholz have no conflicts to disclose. Dr. Savitz has received funding from HRQ COE, PCORI LHSNet; received funding for lectures from the Institute from Healthcare Improvement, Department of Epidemiology, University of Utah; received funding for travel, accommodations, and meeting expenses from AHRQ NAC, EDM Forum, AH CAPP, AARP NPC, and PROM TEP; and received additional funding from Dartmouth University. Dr. Holve received funding from Intermountain Healthcare, Kaiser Permanente Southern California for support for the Delivery System Science Fellowship, provided by our delivery system partners, several of whom are coauthors on this manuscript.

For over 3 decades, AcademyHealth and its predecessor organizations and members have been studying how the healthcare system works and ways to improve health outcomes. The value of health services research (HSR) training programs that emphasize learning opportunities in delivery system settings was initially articulated at the 2009 AcademyHealth Summit on the Future of HSR Data and Methods.¹ Two years later, the need for such programs was reiterated as a priority for AcademyHealth’s HSR Learning Consortium in their strategic plan.² While HSR methods have become increasingly sophisticated, historical approaches largely relied on extant (usually academic-based) researchers.

To realize the goal of building learning health systems (considered here to be entities where applied, operationally relevant research is systematically designed, generated, and translated into high-quality care delivery), many healthcare organizations have begun to use researchers as an internal resource to inform and support higher quality and more efficient care delivery operations. However, there is a current dearth of scientists trained in research disciplines (eg, comparative effectiveness research, patient-centered outcomes research, implementation science) more directly applicable to operational settings.^3,4 Conducting research within these “real-world” environments is challenging for a variety of well-documented reasons,^5,6 and many important questions cannot be answered using traditional study designs and/or methodologies. Until more researchers are trained in research approaches that align better with care delivery needs, the field will continue to fall short of addressing topics identified by the National Academy of Medicine (NAM; formerly the Institute of Medicine) as priorities for real system improvement.

While researchers in academic and consulting settings play critical roles in knowledge generation, a substantial area for expansion is support for “embedded researchers” who work more directly with operational leaders and understand local context, data, and organizational-level goals of delivery systems. AcademyHealth’s Delivery System Science Fellowship (DSSF) was developed to forge a stronger link between rigorous research practice and pragmatic aspects of care delivery.

Since inception of the DSSF, national attention has further emphasized the need for specialized, experiential learning with specific competencies that extend formal HSR training. The Agency for Healthcare Research and Quality (AHRQ) is currently convening a Technical Expert Panel to guide Training the Next Generation of Learning Health System Researchers as part of its larger effort to provide support for evidence generation and uptake in these applied settings (see http://www.ahrq.gov/news/blog/ahrqviews/supporting-learning-health-systems.html for more information). This work is reinforced by an ongoing project at AcademyHealth focused on Understanding the Current Health Services Research Workforce and Maximizing Its Future,⁷ partially sponsored by AHRQ. These efforts aim to inform AHRQ-funded career and training program requirements in order to build a workforce in partnership with academia and delivery organizations in support of developing high-functioning researchers directly positioned to drive progress toward learning healthcare systems.

The AcademyHealth DSSF Program is a pioneering effort designed to meet the needs of learning healthcare systems for a human capital resource capable of generating insights from operational data and deploying this knowledge effectively. Established in 2012 in partnership with 3 initial host sites, the DSSF provides a paid, postdoctoral training opportunity to help highly qualified, early-career researchers gain applied experience in delivery system settings.⁸ The goal is to provide hands-on experience and professional leadership opportunities to enhance the array of skills needed to generate and apply evidence in delivery systems. The long-term program objective is for graduates to employ the methods and training garnered during the DSSF to produce new, practical insights required to transform healthcare delivery and achieve the “Triple Aim.”⁹

Sixteen delivery systems have participated in the DSSF program over the course of 5 years. These organizations represent a diverse group of innovative, high-performing systems that serve populations across the rural-urban continuum. Host site preceptors are nationally recognized experts in areas such as health economics, comparative effectiveness, pragmatic trials, clinical decision support, and implementation science. The fellowship is guided by an advisory committee that provides strategic direction and plays a key role in selecting fellows. AcademyHealth partners with 8 to 10 health systems annually, accepting new partnerships as interest and availability allows. The Figure summarizes program inputs, elements, antecedents, outputs, and intended outcomes. As a relatively new and evolving program, the DSSF is using a disciplined approach to assess both mid- and long-term outcomes. The Table is a comparative matrix that depicts the range in areas of investment offered by a sample of host sites during the fellowship program. Complementing development of the common core competencies and exposures presented in the Table, specific project choice at a host site is mutually determined according to system needs and the fellow’s interests.

To apply for DSSF, researchers must hold a doctoral degree in any relevant aspect of clinical medicine, HSR, or a related field. The review committee evaluates applicants based on their qualifications, a clear statement of professional goals, appropriateness for placement, the quality of a writing sample, and letters of recommendation. Host sites select a fellow based on their individual preferences and recommendations from the review committee. The minimum duration of the fellowship is 1 year, during which the fellow works full time at the host site. Host sites provide the fellows’ salary and benefits, financial support to attend AcademyHealth’s Annual Research Meeting, and mentorship and/or training. To ensure general continuity across sites, each fellow’s work focuses on “delivery system science (DSS),” with a significant part of the work intended for public dissemination (eg, a conference presentation) or publication in a peer-reviewed journal.

Host sites additionally provide AcademyHealth financial support to manage the process of recruiting promising candidates. AcademyHealth manages and convenes the advisory committee proceedings, facilitates the application cycle (including peer review of applicants), markets the fellowship, guides the interview and match process, and promotes placement of fellows upon program completion. AcademyHealth also convenes active and graduate fellows to foster engagement and professional development.

Program Level

AcademyHealth administers an annual evaluation to assess the program, understand impact on the fellow’s professional development and growth, track publications, and inform programmatic goals. To date, we have identified over 50 peer-reviewed publications resulting from work conducted through the fellowship (visit http://www.academyhealth.org/dssfpublications for a full listing of publications stemming from the DSSF program). As an example of continuous program improvement, this year staff implemented a fellow-led monthly call in response to requests to connect fellows. This has proven to be a useful response for fellows to understand how to enhance their own experience by learning from fellows in other systems to incorporate focused areas of development via cross-system sharing. As an indicator of continued value, of the 16 sites that have participated to date, 10 have participated in the DSSF for more than 1 cycle; 3 are new host sites currently participating in their first year of the program; and 3 host sites participated for 1 year. The 3 inaugural host sites that helped launch the DSSF continue to serve as host sites to date.

As a marker of longitudinal success, staff will continue to follow up with preceptors and fellows to understand fellows’ contributions to the host site and the field, as well as impact on the fellow career trajectory. Of the 19 fellow alumni to date, 8 have moved on to academic or research positions, and 11 have remained in care delivery systems to provide local expertise in study design, execution, and evidence uptake.

The program has also made some general contributions to advance the discipline of delivery system science, including:

1. Defining DSS and clarifying training needs for “embedded researchers” and health system analysts. To characterize the fellowship, AcademyHealth and the program advisory committee jointly developed the following definition for delivery system science (DSS):

“DSS includes research that seeks to understand how delivery systems operate, influence, change, and respond to external stimulus, among other topics. DSS may include efforts to examine how and under what circumstances interventions work and how delivery systems effectively implement evidence-based innovations. For the DSSF, DSS is conducted by researchers who are ‘embedded’ in delivery systems and respond to the decision-making needs of those systems.”

Additionally, closer connections with DSS leaders have led to a better understanding of challenges, opportunities, and needs of delivery systems.^10,11

2. Cultivating a network of delivery systems and system leaders interested in expanding the cadre of embedded researchers, and trainees who intend to build careers in DSS. The DSSF also aims to enhance fellows’ skills and knowledge base, career opportunities, and professional network. To extend these relationships and support delivery system analytics, AcademyHealth worked with preceptors and fellows to inform creation of a new Community of Practice supported by AcademyHealth’s EDM Forum and guide planning for AcademyHealth’s Concordium conference to provide a national meeting to showcase DSS.

3. Strategic planning to ensure sustainable support for embedded research within delivery systems. Substantial interest in the program developed quickly, with rapid learning over the first few cycles to refine the program to meet host sites’ and fellows’ needs. Both efforts were critical to demonstrate that the DSSF fulfills an important need for our health system partners and members. As indicated previously, strong, sustained interest from prospective host sites and applicants demonstrates the program has created a win-win to jointly assess fit while building skills and supporting continuous learning.

Likewise, Lisa Simpson, President and CEO of AcademyHealth, and Lucy Savitz, DSSF host site preceptor at Intermountain Healthcare, participated in the Canadian Institutes of Health Research (CIHR) Invitational Workshop, “Modernizing Health Services and Policy Research Training in Canada” in March 2016. Shared learning largely informed by the DSSF led to CIHR creating a similar fellowship program with initial awards to be made in 2017 (see https://www.researchnet-recherchenet.ca/rnr16/vwOpprtntyDtls.do?prog=2540&view=browseActive&sponsor=CIHR-8&type=EXACT&resultCount=25 for more information). We are working to thread these efforts together in a way to leverage our learning community of government agencies, academia, and employers as a long-term funding stream for training in delivery science.

Participant Host Site Level

Two selected examples of how DSSF researchers have engaged high-priority topics that contributed to health system operations are provided here.

Kaiser Permanente Southern California: Assessing adherence with “Choosing Wisely” recommendations in oncology. In partnership with preceptor Dr. Michael Gould, 2013-2014 DSSF fellow Dr. Erin Hahn worked with the Kaiser Permanente Southern California (KPSC) Care Improvement Research Team to lead a project addressing several KPSC priority areas. Focusing on “Choosing Wisely” recommendations from the American Society of Clinical Oncology,¹² the project evaluated appropriateness of imaging and laboratory services for early-stage cancer patients and survivors between and within 2 integrated health systems, Kaiser Permanente (KP) and Intermountain Healthcare.^13,14 Results were presented to KP national leaders, including an external health policy advisory board. In close collaboration with clinical and operational leaders in medical oncology, this multiregional, multisystem project is contributing to targeted quality improvement efforts and improved healthcare value, including audit and feedback of nonrecommended labs.

Dr. Hahn subsequently received a KPSC Incubator Award, a competitive internal grant, to further study factors associated with use of nonrecommended surveillance lab tests for early-stage breast cancer patients. The study focused on medical oncologists within KPSC, categorizing them as high or low utilizers of the tests.¹⁵ Results indicate that high utilizers perceive that the tests help manage patient anxiety about recurrence, while acknowledging that the tests do not provide clinical utility. These findings are contributing to the development of targeted survivorship services across the organization.

Intermountain Healthcare: Formative evaluation of large-scale implementation of shared decision-making. Preceptor Dr. Lucy Savitz assembled a team to conduct a formative evaluation of Intermountain Healthcare’s efforts to implement shared decision-making (SDM) as part of its Center for Medicare and Medicaid Innovation Challenge Award. The 2015-2017 DSSF fellow at Intermountain Healthcare, Dr. Kim Brunisholz, served as a core member of the project team, focusing primarily on a mixed-methods evaluation of the SDM program.

Dr. Brunisholz engaged operational leads, clinical teams, patient and family advisory councils, and senior executives to conduct the program assessment. Results demonstrated significant variation in invited participation in SDM among eligible patient populations: preference sensitive conditions (1 in 30 patients), oncology-related diagnosis (1 in 3 patients), and chronic conditions (1 in 74 patients). Provisional analysis of patient-level clinical outcomes demonstrated that among those invited to the SDM program compared to those that were not, total joint replacement was decreased (10.1% vs 17.3%; P < 0.001) and a trend towards breast conservation emerged (61.8% vs 56.4%; P = 0.10). No difference in treatment choice for lower back pain was observed. Qualitative program analysis suggested need for improvements in the areas of (1) routine and continuous staff training, (2) workflow standardization, and (3) active data monitoring with meaningful, actionable feedback to caregivers. In response to these results, a chartered SDM Steering Committee was created (Dr. Brunisholz is a member of that group) to develop a strategic plan for SDM, with an accompanying organizational response to reimplement SDM in a targeted manner. Learning from this program is being leveraged to support a subproject analysis on a large scale using data from the High Value Healthcare Collaborative as part of an AHRQ-funded Center of Excellence award. (See https://www.ahrq.gov/news/newsroom/press-releases/2015/pcorawards.html. For more information on the High Value Healthcare Collaborative, please visit: https://www.highvaluehealthcare.org.)

Moving forward, the DSSF will continue working with progressive delivery systems. Partnerships between organizations that are interested in integrating rigorous research practice to drive continuous system improvement and maximize the value of care will have substantial need for technical skills and analytic capacity. They will also need to ensure that researchers working in their systems have sufficient understanding of cultural and political context within the organization to be effective leaders who can manage change.

AcademyHealth created the DSSF in response to the field’s request to build a research workforce that reflects the vision for a 21st Century Health System, as laid out by the NAM.¹⁶ We anticipate that as the US Department of Health & Human Services’ goals for payment reform and new measures to promote quality and high-value care are implemented, the DSSF trainees’ skill set will be increasingly valuable and will provide needed thought leadership on strategies to generate and apply evidence in practice.

Disclosure

Ms. Kanani received funding from Intermountain Healthcare, Kaiser Permanente Southern California for support for the Delivery System Science Fellowship. Drs. Hahn, Gould, and Brunisholz have no conflicts to disclose. Dr. Savitz has received funding from HRQ COE, PCORI LHSNet; received funding for lectures from the Institute from Healthcare Improvement, Department of Epidemiology, University of Utah; received funding for travel, accommodations, and meeting expenses from AHRQ NAC, EDM Forum, AH CAPP, AARP NPC, and PROM TEP; and received additional funding from Dartmouth University. Dr. Holve received funding from Intermountain Healthcare, Kaiser Permanente Southern California for support for the Delivery System Science Fellowship, provided by our delivery system partners, several of whom are coauthors on this manuscript.

For over 3 decades, AcademyHealth and its predecessor organizations and members have been studying how the healthcare system works and ways to improve health outcomes. The value of health services research (HSR) training programs that emphasize learning opportunities in delivery system settings was initially articulated at the 2009 AcademyHealth Summit on the Future of HSR Data and Methods.¹ Two years later, the need for such programs was reiterated as a priority for AcademyHealth’s HSR Learning Consortium in their strategic plan.² While HSR methods have become increasingly sophisticated, historical approaches largely relied on extant (usually academic-based) researchers.

To realize the goal of building learning health systems (considered here to be entities where applied, operationally relevant research is systematically designed, generated, and translated into high-quality care delivery), many healthcare organizations have begun to use researchers as an internal resource to inform and support higher quality and more efficient care delivery operations. However, there is a current dearth of scientists trained in research disciplines (eg, comparative effectiveness research, patient-centered outcomes research, implementation science) more directly applicable to operational settings.^3,4 Conducting research within these “real-world” environments is challenging for a variety of well-documented reasons,^5,6 and many important questions cannot be answered using traditional study designs and/or methodologies. Until more researchers are trained in research approaches that align better with care delivery needs, the field will continue to fall short of addressing topics identified by the National Academy of Medicine (NAM; formerly the Institute of Medicine) as priorities for real system improvement.

While researchers in academic and consulting settings play critical roles in knowledge generation, a substantial area for expansion is support for “embedded researchers” who work more directly with operational leaders and understand local context, data, and organizational-level goals of delivery systems. AcademyHealth’s Delivery System Science Fellowship (DSSF) was developed to forge a stronger link between rigorous research practice and pragmatic aspects of care delivery.

Since inception of the DSSF, national attention has further emphasized the need for specialized, experiential learning with specific competencies that extend formal HSR training. The Agency for Healthcare Research and Quality (AHRQ) is currently convening a Technical Expert Panel to guide Training the Next Generation of Learning Health System Researchers as part of its larger effort to provide support for evidence generation and uptake in these applied settings (see http://www.ahrq.gov/news/blog/ahrqviews/supporting-learning-health-systems.html for more information). This work is reinforced by an ongoing project at AcademyHealth focused on Understanding the Current Health Services Research Workforce and Maximizing Its Future,⁷ partially sponsored by AHRQ. These efforts aim to inform AHRQ-funded career and training program requirements in order to build a workforce in partnership with academia and delivery organizations in support of developing high-functioning researchers directly positioned to drive progress toward learning healthcare systems.

The AcademyHealth DSSF Program is a pioneering effort designed to meet the needs of learning healthcare systems for a human capital resource capable of generating insights from operational data and deploying this knowledge effectively. Established in 2012 in partnership with 3 initial host sites, the DSSF provides a paid, postdoctoral training opportunity to help highly qualified, early-career researchers gain applied experience in delivery system settings.⁸ The goal is to provide hands-on experience and professional leadership opportunities to enhance the array of skills needed to generate and apply evidence in delivery systems. The long-term program objective is for graduates to employ the methods and training garnered during the DSSF to produce new, practical insights required to transform healthcare delivery and achieve the “Triple Aim.”⁹

Sixteen delivery systems have participated in the DSSF program over the course of 5 years. These organizations represent a diverse group of innovative, high-performing systems that serve populations across the rural-urban continuum. Host site preceptors are nationally recognized experts in areas such as health economics, comparative effectiveness, pragmatic trials, clinical decision support, and implementation science. The fellowship is guided by an advisory committee that provides strategic direction and plays a key role in selecting fellows. AcademyHealth partners with 8 to 10 health systems annually, accepting new partnerships as interest and availability allows. The Figure summarizes program inputs, elements, antecedents, outputs, and intended outcomes. As a relatively new and evolving program, the DSSF is using a disciplined approach to assess both mid- and long-term outcomes. The Table is a comparative matrix that depicts the range in areas of investment offered by a sample of host sites during the fellowship program. Complementing development of the common core competencies and exposures presented in the Table, specific project choice at a host site is mutually determined according to system needs and the fellow’s interests.

To apply for DSSF, researchers must hold a doctoral degree in any relevant aspect of clinical medicine, HSR, or a related field. The review committee evaluates applicants based on their qualifications, a clear statement of professional goals, appropriateness for placement, the quality of a writing sample, and letters of recommendation. Host sites select a fellow based on their individual preferences and recommendations from the review committee. The minimum duration of the fellowship is 1 year, during which the fellow works full time at the host site. Host sites provide the fellows’ salary and benefits, financial support to attend AcademyHealth’s Annual Research Meeting, and mentorship and/or training. To ensure general continuity across sites, each fellow’s work focuses on “delivery system science (DSS),” with a significant part of the work intended for public dissemination (eg, a conference presentation) or publication in a peer-reviewed journal.

Host sites additionally provide AcademyHealth financial support to manage the process of recruiting promising candidates. AcademyHealth manages and convenes the advisory committee proceedings, facilitates the application cycle (including peer review of applicants), markets the fellowship, guides the interview and match process, and promotes placement of fellows upon program completion. AcademyHealth also convenes active and graduate fellows to foster engagement and professional development.

Program Level

AcademyHealth administers an annual evaluation to assess the program, understand impact on the fellow’s professional development and growth, track publications, and inform programmatic goals. To date, we have identified over 50 peer-reviewed publications resulting from work conducted through the fellowship (visit http://www.academyhealth.org/dssfpublications for a full listing of publications stemming from the DSSF program). As an example of continuous program improvement, this year staff implemented a fellow-led monthly call in response to requests to connect fellows. This has proven to be a useful response for fellows to understand how to enhance their own experience by learning from fellows in other systems to incorporate focused areas of development via cross-system sharing. As an indicator of continued value, of the 16 sites that have participated to date, 10 have participated in the DSSF for more than 1 cycle; 3 are new host sites currently participating in their first year of the program; and 3 host sites participated for 1 year. The 3 inaugural host sites that helped launch the DSSF continue to serve as host sites to date.

As a marker of longitudinal success, staff will continue to follow up with preceptors and fellows to understand fellows’ contributions to the host site and the field, as well as impact on the fellow career trajectory. Of the 19 fellow alumni to date, 8 have moved on to academic or research positions, and 11 have remained in care delivery systems to provide local expertise in study design, execution, and evidence uptake.

The program has also made some general contributions to advance the discipline of delivery system science, including:

1. Defining DSS and clarifying training needs for “embedded researchers” and health system analysts. To characterize the fellowship, AcademyHealth and the program advisory committee jointly developed the following definition for delivery system science (DSS):

“DSS includes research that seeks to understand how delivery systems operate, influence, change, and respond to external stimulus, among other topics. DSS may include efforts to examine how and under what circumstances interventions work and how delivery systems effectively implement evidence-based innovations. For the DSSF, DSS is conducted by researchers who are ‘embedded’ in delivery systems and respond to the decision-making needs of those systems.”

Additionally, closer connections with DSS leaders have led to a better understanding of challenges, opportunities, and needs of delivery systems.^10,11

2. Cultivating a network of delivery systems and system leaders interested in expanding the cadre of embedded researchers, and trainees who intend to build careers in DSS. The DSSF also aims to enhance fellows’ skills and knowledge base, career opportunities, and professional network. To extend these relationships and support delivery system analytics, AcademyHealth worked with preceptors and fellows to inform creation of a new Community of Practice supported by AcademyHealth’s EDM Forum and guide planning for AcademyHealth’s Concordium conference to provide a national meeting to showcase DSS.

3. Strategic planning to ensure sustainable support for embedded research within delivery systems. Substantial interest in the program developed quickly, with rapid learning over the first few cycles to refine the program to meet host sites’ and fellows’ needs. Both efforts were critical to demonstrate that the DSSF fulfills an important need for our health system partners and members. As indicated previously, strong, sustained interest from prospective host sites and applicants demonstrates the program has created a win-win to jointly assess fit while building skills and supporting continuous learning.

Likewise, Lisa Simpson, President and CEO of AcademyHealth, and Lucy Savitz, DSSF host site preceptor at Intermountain Healthcare, participated in the Canadian Institutes of Health Research (CIHR) Invitational Workshop, “Modernizing Health Services and Policy Research Training in Canada” in March 2016. Shared learning largely informed by the DSSF led to CIHR creating a similar fellowship program with initial awards to be made in 2017 (see https://www.researchnet-recherchenet.ca/rnr16/vwOpprtntyDtls.do?prog=2540&view=browseActive&sponsor=CIHR-8&type=EXACT&resultCount=25 for more information). We are working to thread these efforts together in a way to leverage our learning community of government agencies, academia, and employers as a long-term funding stream for training in delivery science.

Participant Host Site Level

Two selected examples of how DSSF researchers have engaged high-priority topics that contributed to health system operations are provided here.

Kaiser Permanente Southern California: Assessing adherence with “Choosing Wisely” recommendations in oncology. In partnership with preceptor Dr. Michael Gould, 2013-2014 DSSF fellow Dr. Erin Hahn worked with the Kaiser Permanente Southern California (KPSC) Care Improvement Research Team to lead a project addressing several KPSC priority areas. Focusing on “Choosing Wisely” recommendations from the American Society of Clinical Oncology,¹² the project evaluated appropriateness of imaging and laboratory services for early-stage cancer patients and survivors between and within 2 integrated health systems, Kaiser Permanente (KP) and Intermountain Healthcare.^13,14 Results were presented to KP national leaders, including an external health policy advisory board. In close collaboration with clinical and operational leaders in medical oncology, this multiregional, multisystem project is contributing to targeted quality improvement efforts and improved healthcare value, including audit and feedback of nonrecommended labs.

Dr. Hahn subsequently received a KPSC Incubator Award, a competitive internal grant, to further study factors associated with use of nonrecommended surveillance lab tests for early-stage breast cancer patients. The study focused on medical oncologists within KPSC, categorizing them as high or low utilizers of the tests.¹⁵ Results indicate that high utilizers perceive that the tests help manage patient anxiety about recurrence, while acknowledging that the tests do not provide clinical utility. These findings are contributing to the development of targeted survivorship services across the organization.

Intermountain Healthcare: Formative evaluation of large-scale implementation of shared decision-making. Preceptor Dr. Lucy Savitz assembled a team to conduct a formative evaluation of Intermountain Healthcare’s efforts to implement shared decision-making (SDM) as part of its Center for Medicare and Medicaid Innovation Challenge Award. The 2015-2017 DSSF fellow at Intermountain Healthcare, Dr. Kim Brunisholz, served as a core member of the project team, focusing primarily on a mixed-methods evaluation of the SDM program.

Dr. Brunisholz engaged operational leads, clinical teams, patient and family advisory councils, and senior executives to conduct the program assessment. Results demonstrated significant variation in invited participation in SDM among eligible patient populations: preference sensitive conditions (1 in 30 patients), oncology-related diagnosis (1 in 3 patients), and chronic conditions (1 in 74 patients). Provisional analysis of patient-level clinical outcomes demonstrated that among those invited to the SDM program compared to those that were not, total joint replacement was decreased (10.1% vs 17.3%; P < 0.001) and a trend towards breast conservation emerged (61.8% vs 56.4%; P = 0.10). No difference in treatment choice for lower back pain was observed. Qualitative program analysis suggested need for improvements in the areas of (1) routine and continuous staff training, (2) workflow standardization, and (3) active data monitoring with meaningful, actionable feedback to caregivers. In response to these results, a chartered SDM Steering Committee was created (Dr. Brunisholz is a member of that group) to develop a strategic plan for SDM, with an accompanying organizational response to reimplement SDM in a targeted manner. Learning from this program is being leveraged to support a subproject analysis on a large scale using data from the High Value Healthcare Collaborative as part of an AHRQ-funded Center of Excellence award. (See https://www.ahrq.gov/news/newsroom/press-releases/2015/pcorawards.html. For more information on the High Value Healthcare Collaborative, please visit: https://www.highvaluehealthcare.org.)

Moving forward, the DSSF will continue working with progressive delivery systems. Partnerships between organizations that are interested in integrating rigorous research practice to drive continuous system improvement and maximize the value of care will have substantial need for technical skills and analytic capacity. They will also need to ensure that researchers working in their systems have sufficient understanding of cultural and political context within the organization to be effective leaders who can manage change.

AcademyHealth created the DSSF in response to the field’s request to build a research workforce that reflects the vision for a 21st Century Health System, as laid out by the NAM.¹⁶ We anticipate that as the US Department of Health & Human Services’ goals for payment reform and new measures to promote quality and high-value care are implemented, the DSSF trainees’ skill set will be increasingly valuable and will provide needed thought leadership on strategies to generate and apply evidence in practice.

Disclosure

Ms. Kanani received funding from Intermountain Healthcare, Kaiser Permanente Southern California for support for the Delivery System Science Fellowship. Drs. Hahn, Gould, and Brunisholz have no conflicts to disclose. Dr. Savitz has received funding from HRQ COE, PCORI LHSNet; received funding for lectures from the Institute from Healthcare Improvement, Department of Epidemiology, University of Utah; received funding for travel, accommodations, and meeting expenses from AHRQ NAC, EDM Forum, AH CAPP, AARP NPC, and PROM TEP; and received additional funding from Dartmouth University. Dr. Holve received funding from Intermountain Healthcare, Kaiser Permanente Southern California for support for the Delivery System Science Fellowship, provided by our delivery system partners, several of whom are coauthors on this manuscript.

Medical services overuse is the provision of healthcare services for which there is no medical basis or for which harms equal or exceed benefits.¹ This overuse drives poor-quality care and unnecessary cost.^2,3 The high prevalence of overuse is recognized by patients,⁴ clinicians,⁵ and policymakers.⁶ Initiatives to reduce overuse have targeted physicians,⁷ the public,⁸ and medical educators^9,10 but have had limited impact.^11,12 Few studies have addressed methods for reducing overuse, and de-implementation of nonbeneficial practices has proved challenging.^1,13,14 Models for reducing overuse are only theoretical¹⁵ or are focused on administrative decisions.^16,17 We think a practical framework is needed. We used an iterative process, informed by expert opinion and discussion, to design such a framework.

The authors, who have expertise in overuse, value, medical education, evidence-based medicine, and implementation science, reviewed related conceptual frameworks¹⁸ and evidence regarding drivers of overuse. We organized these drivers into domains to create a draft framework, which we presented at Preventing Overdiagnosis 2015, a meeting of clinicians, patients, and policymakers interested in overuse. We incorporated feedback from meeting attendees to modify framework domains, and we performed structured searches (using key words in Pubmed) to explore, and estimate the strength of, evidence supporting items within each domain. We rated supporting evidence as strong (studies found a clear correlation between a factor and overuse), moderate (evidence suggests such a correlation or demonstrates a correlation between a particular factor and utilization but not overuse per se), weak (only indirect evidence exists), or absent (no studies identified evaluating a particular factor). All authors reached consensus on ratings.

Framework Principles and Evidence

Patient-centered definition of overuse. During framework development, defining clinical appropriateness emerged as the primary challenge to identifying and reducing overuse. Although some care generally is appropriate based on strong evidence of benefit, and some is inappropriate given a clear lack of benefit or harm, much care is of unclear or variable benefit. Practice guidelines can help identify overuse, but their utility may be limited by lack of evidence in specific clinical situations,¹⁹ and their recommendations may apply poorly to an individual patient. This presents challenges to using guidelines to identify and reduce overuse.

Despite limitations, the scope of overuse has been estimated by applying broad, often guideline-based, criteria for care appropriateness to administrative data.²⁰ Unfortunately, these estimates provide little direction to clinicians and patients partnering to make usage decisions. During framework development, we identified the importance of a patient-level, patient-specific definition of overuse. This approach reinforces the importance of meeting patient needs while standardizing treatments to reduce overuse. A patient-centered approach may also assist professional societies and advocacy groups in developing actionable campaigns and may uncover evidence gaps.

Centrality of patient-clinician interaction. During framework development, the patient–clinician interaction emerged as the nexus through which drivers of overuse exert influence. The centrality of this interaction has been demonstrated in studies of the relationship between care continuity and overuse²¹ or utilization,^22,23 by evidence that communication and patient–clinician relationships affect utilization,²⁴ and by the observation that clinician training in shared decision-making reduces overuse.²⁵ A patient-centered framework assumes that, at least in the weighing of clinically reasonable options, a patient-centered approach optimizes outcomes for that patient.

Incorporating drivers of overuse. We incorporated drivers of overuse into domains and related them to the patient–clinician interaction.²⁶ Domains included the culture of healthcare consumption, patient factors and experiences, the practice environment, the culture of professional medicine, and clinician attitudes and beliefs.

We characterized the evidence illustrating how drivers within each domain influence healthcare use. The evidence for each domain is listed in Table 1.

The final framework is shown in the Figure. Within the healthcare system, patients are influenced by the culture of healthcare consumption, which varies within and among countries.²⁷ Clinicians are influenced by the culture of medical care, which varies by practice setting,²⁸ and by their training environment.²⁹ Both clinicians and patients are influenced by the practice environment and by personal experiences. Ultimately, clinical decisions occur within the specific patient–clinician interaction.²⁴ Table 1 lists each domain’s components, likely impact on overuse, and estimated strength of supporting evidence. Interventions can be conceptualized within appropriate domains or through the interaction between patient and clinician.

We developed a novel and practical conceptual framework for characterizing drivers of overuse and potential intervention points. To our knowledge, this is the first framework incorporating a patient-specific approach to overuse and emphasizing the patient–clinician interaction. Key strengths of framework development are inclusion of a range of perspectives and characterization of the evidence within each domain. Limitations include lack of a formal systematic review and broad, qualitative assessments of evidence strength. However, we believe this framework provides an important conceptual foundation for the study of overuse and interventions to reduce overuse.

Framework Applications

This framework, which highlights the many drivers of overuse, can facilitate understanding of overuse and help conceptualize change, prioritize research goals, and inform specific interventions. For policymakers, the framework can inform efforts to reduce overuse by emphasizing the need for complex interventions and by clarifying the likely impact of interventions targeting specific domains. Similarly, for clinicians and quality improvement professionals, the framework can ground root cause analyses of overuse-related problems and inform allocation of limited resources. Finally, the relatively weak evidence on the role of most acknowledged drivers of overuse suggests an important research agenda. Specifically, several pressing needs have been identified: defining relevant physician and patient cultural factors, investigating interventions to impact culture, defining practice environment features that optimize care appropriateness, and describing specific patient–clinician interaction practices that minimize overuse while providing needed care.

Targeting Interventions

Domains within the framework are influenced by different types of interventions, and different stakeholders may target different domains. For example:
 

• The culture of healthcare consumption may be influenced through public education (eg, Choosing Wisely^® patient resources)^30-32 and public health campaigns.
• The practice environment may be influenced by initiatives to align clinician incentives,³³ team care,³⁴ electronic health record interventions,³⁵ and improved access.³⁶
• Clinician attitudes and beliefs may be influenced by audit and feedback,^37-40 reflection,⁴¹ role modeling,⁴² and education.^43-45
• Patient attitudes and beliefs may be influenced by education, access to price and quality information, and increased engagement in care.^46,47
• For clinicians, the patient–clinician interaction can be improved through training in communication and shared decision-making,25 through access to information (eg, costs) that can be easily shared with patients,^48,49 and through novel visit structures (eg, scribes).⁵⁰
• On the patient side, this interaction can be optimized with improved access (eg, through telemedicine)^51,52 or with patient empowerment during hospitalization.
• The culture of medicine is difficult to influence. Change likely will occur through:

○ Regulatory interventions (eg, Transforming Clinical Practice Initiative of Center for Medicare & Medicaid Innovation).

○ Educational initiatives (eg, high-value care curricula of Alliance for Academic Internal Medicine/American College of Physicians⁵³).

○ Medical journal features (eg, “Less Is More” in JAMA Internal Medicine⁵⁴ and “Things We Do for No Reason” in Journal of Hospital Medicine).

○ Professional organizations (eg, Choosing Wisely^®).

As organizations implement quality improvement initiatives to reduce overuse of services, the framework can be used to target interventions to relevant domains. For example, a hospital leader who wants to reduce opioid prescribing may use the framework to identify the factors that encourage prescribing in each domain—poor understanding of pain treatment (a clinician factor), desire for early discharge encouraging overly aggressive pain management (an environmental factor), patient demand for opioids combined with poor understanding of harms (patient factors), and poor communication regarding pain (a patient–clinician interaction factor). Although not all relevant factors can be addressed, their classification by domain facilitates intervention, in this case perhaps leading to a focus on clinician and patient education on opioids and development of a practical communication tool that targets 3 domains. Table 2 lists ways in which the framework informs approaches to this and other overused services in the hospital setting. Note that some drivers can be acknowledged without identifying targeted interventions.

Moving Forward

Through a multi-stakeholder iterative process, we developed a practical framework for understanding medical overuse and interventions to reduce it. Centered on the patient–clinician interaction, this framework explains overuse as the product of medical and patient culture, the practice environment and incentives, and other clinician and patient factors. Ultimately, care is implemented during the patient–clinician interaction, though few interventions to reduce overuse have focused on that domain.

Conceptualizing overuse through the patient–clinician interaction maintains focus on patients while promoting population health that is both better and lower in cost. This framework can guide interventions to reduce overuse in important parts of the healthcare system while ensuring the final goal of high-quality individualized patient care.

Acknowledgments

The authors thank Valerie Pocus for helping with the artistic design of Framework. An early version of Framework was presented at the 2015 Preventing Overdiagnosis meeting in Bethesda, Maryland.

Disclosures

Dr. Morgan received research support from the VA Health Services Research (CRE 12-307), Agency for Healthcare Research and Quality (AHRQ) (K08- HS18111). Dr. Leppin’s work was supported by CTSA Grant Number UL1 TR000135 from the National Center for Advancing Translational Sciences, a component of the National Institutes of Health (NIH). Dr. Korenstein’s work on this paper was supported by a Cancer Center Support Grant from the National Cancer Institute to Memorial Sloan Kettering Cancer Center (award number P30 CA008748). Dr. Morgan provided a self-developed lecture in a 3M-sponsored series on hospital epidemiology and has received honoraria for serving as a book and journal editor for Springer Publishing. Dr. Smith is employed by the American College of Physicians and owns stock in Merck, where her husband is employed. The other authors report no potential conflicts of interest.

Medical services overuse is the provision of healthcare services for which there is no medical basis or for which harms equal or exceed benefits.¹ This overuse drives poor-quality care and unnecessary cost.^2,3 The high prevalence of overuse is recognized by patients,⁴ clinicians,⁵ and policymakers.⁶ Initiatives to reduce overuse have targeted physicians,⁷ the public,⁸ and medical educators^9,10 but have had limited impact.^11,12 Few studies have addressed methods for reducing overuse, and de-implementation of nonbeneficial practices has proved challenging.^1,13,14 Models for reducing overuse are only theoretical¹⁵ or are focused on administrative decisions.^16,17 We think a practical framework is needed. We used an iterative process, informed by expert opinion and discussion, to design such a framework.

The authors, who have expertise in overuse, value, medical education, evidence-based medicine, and implementation science, reviewed related conceptual frameworks¹⁸ and evidence regarding drivers of overuse. We organized these drivers into domains to create a draft framework, which we presented at Preventing Overdiagnosis 2015, a meeting of clinicians, patients, and policymakers interested in overuse. We incorporated feedback from meeting attendees to modify framework domains, and we performed structured searches (using key words in Pubmed) to explore, and estimate the strength of, evidence supporting items within each domain. We rated supporting evidence as strong (studies found a clear correlation between a factor and overuse), moderate (evidence suggests such a correlation or demonstrates a correlation between a particular factor and utilization but not overuse per se), weak (only indirect evidence exists), or absent (no studies identified evaluating a particular factor). All authors reached consensus on ratings.

Framework Principles and Evidence

Patient-centered definition of overuse. During framework development, defining clinical appropriateness emerged as the primary challenge to identifying and reducing overuse. Although some care generally is appropriate based on strong evidence of benefit, and some is inappropriate given a clear lack of benefit or harm, much care is of unclear or variable benefit. Practice guidelines can help identify overuse, but their utility may be limited by lack of evidence in specific clinical situations,¹⁹ and their recommendations may apply poorly to an individual patient. This presents challenges to using guidelines to identify and reduce overuse.

Despite limitations, the scope of overuse has been estimated by applying broad, often guideline-based, criteria for care appropriateness to administrative data.²⁰ Unfortunately, these estimates provide little direction to clinicians and patients partnering to make usage decisions. During framework development, we identified the importance of a patient-level, patient-specific definition of overuse. This approach reinforces the importance of meeting patient needs while standardizing treatments to reduce overuse. A patient-centered approach may also assist professional societies and advocacy groups in developing actionable campaigns and may uncover evidence gaps.

Centrality of patient-clinician interaction. During framework development, the patient–clinician interaction emerged as the nexus through which drivers of overuse exert influence. The centrality of this interaction has been demonstrated in studies of the relationship between care continuity and overuse²¹ or utilization,^22,23 by evidence that communication and patient–clinician relationships affect utilization,²⁴ and by the observation that clinician training in shared decision-making reduces overuse.²⁵ A patient-centered framework assumes that, at least in the weighing of clinically reasonable options, a patient-centered approach optimizes outcomes for that patient.

Incorporating drivers of overuse. We incorporated drivers of overuse into domains and related them to the patient–clinician interaction.²⁶ Domains included the culture of healthcare consumption, patient factors and experiences, the practice environment, the culture of professional medicine, and clinician attitudes and beliefs.

We characterized the evidence illustrating how drivers within each domain influence healthcare use. The evidence for each domain is listed in Table 1.

The final framework is shown in the Figure. Within the healthcare system, patients are influenced by the culture of healthcare consumption, which varies within and among countries.²⁷ Clinicians are influenced by the culture of medical care, which varies by practice setting,²⁸ and by their training environment.²⁹ Both clinicians and patients are influenced by the practice environment and by personal experiences. Ultimately, clinical decisions occur within the specific patient–clinician interaction.²⁴ Table 1 lists each domain’s components, likely impact on overuse, and estimated strength of supporting evidence. Interventions can be conceptualized within appropriate domains or through the interaction between patient and clinician.

We developed a novel and practical conceptual framework for characterizing drivers of overuse and potential intervention points. To our knowledge, this is the first framework incorporating a patient-specific approach to overuse and emphasizing the patient–clinician interaction. Key strengths of framework development are inclusion of a range of perspectives and characterization of the evidence within each domain. Limitations include lack of a formal systematic review and broad, qualitative assessments of evidence strength. However, we believe this framework provides an important conceptual foundation for the study of overuse and interventions to reduce overuse.

Framework Applications

This framework, which highlights the many drivers of overuse, can facilitate understanding of overuse and help conceptualize change, prioritize research goals, and inform specific interventions. For policymakers, the framework can inform efforts to reduce overuse by emphasizing the need for complex interventions and by clarifying the likely impact of interventions targeting specific domains. Similarly, for clinicians and quality improvement professionals, the framework can ground root cause analyses of overuse-related problems and inform allocation of limited resources. Finally, the relatively weak evidence on the role of most acknowledged drivers of overuse suggests an important research agenda. Specifically, several pressing needs have been identified: defining relevant physician and patient cultural factors, investigating interventions to impact culture, defining practice environment features that optimize care appropriateness, and describing specific patient–clinician interaction practices that minimize overuse while providing needed care.

Targeting Interventions

Domains within the framework are influenced by different types of interventions, and different stakeholders may target different domains. For example:
 

• The culture of healthcare consumption may be influenced through public education (eg, Choosing Wisely^® patient resources)^30-32 and public health campaigns.
• The practice environment may be influenced by initiatives to align clinician incentives,³³ team care,³⁴ electronic health record interventions,³⁵ and improved access.³⁶
• Clinician attitudes and beliefs may be influenced by audit and feedback,^37-40 reflection,⁴¹ role modeling,⁴² and education.^43-45
• Patient attitudes and beliefs may be influenced by education, access to price and quality information, and increased engagement in care.^46,47
• For clinicians, the patient–clinician interaction can be improved through training in communication and shared decision-making,25 through access to information (eg, costs) that can be easily shared with patients,^48,49 and through novel visit structures (eg, scribes).⁵⁰
• On the patient side, this interaction can be optimized with improved access (eg, through telemedicine)^51,52 or with patient empowerment during hospitalization.
• The culture of medicine is difficult to influence. Change likely will occur through:

○ Regulatory interventions (eg, Transforming Clinical Practice Initiative of Center for Medicare & Medicaid Innovation).

○ Educational initiatives (eg, high-value care curricula of Alliance for Academic Internal Medicine/American College of Physicians⁵³).

○ Medical journal features (eg, “Less Is More” in JAMA Internal Medicine⁵⁴ and “Things We Do for No Reason” in Journal of Hospital Medicine).

○ Professional organizations (eg, Choosing Wisely^®).

As organizations implement quality improvement initiatives to reduce overuse of services, the framework can be used to target interventions to relevant domains. For example, a hospital leader who wants to reduce opioid prescribing may use the framework to identify the factors that encourage prescribing in each domain—poor understanding of pain treatment (a clinician factor), desire for early discharge encouraging overly aggressive pain management (an environmental factor), patient demand for opioids combined with poor understanding of harms (patient factors), and poor communication regarding pain (a patient–clinician interaction factor). Although not all relevant factors can be addressed, their classification by domain facilitates intervention, in this case perhaps leading to a focus on clinician and patient education on opioids and development of a practical communication tool that targets 3 domains. Table 2 lists ways in which the framework informs approaches to this and other overused services in the hospital setting. Note that some drivers can be acknowledged without identifying targeted interventions.

Moving Forward

Through a multi-stakeholder iterative process, we developed a practical framework for understanding medical overuse and interventions to reduce it. Centered on the patient–clinician interaction, this framework explains overuse as the product of medical and patient culture, the practice environment and incentives, and other clinician and patient factors. Ultimately, care is implemented during the patient–clinician interaction, though few interventions to reduce overuse have focused on that domain.

Conceptualizing overuse through the patient–clinician interaction maintains focus on patients while promoting population health that is both better and lower in cost. This framework can guide interventions to reduce overuse in important parts of the healthcare system while ensuring the final goal of high-quality individualized patient care.

Acknowledgments

The authors thank Valerie Pocus for helping with the artistic design of Framework. An early version of Framework was presented at the 2015 Preventing Overdiagnosis meeting in Bethesda, Maryland.

Disclosures

Dr. Morgan received research support from the VA Health Services Research (CRE 12-307), Agency for Healthcare Research and Quality (AHRQ) (K08- HS18111). Dr. Leppin’s work was supported by CTSA Grant Number UL1 TR000135 from the National Center for Advancing Translational Sciences, a component of the National Institutes of Health (NIH). Dr. Korenstein’s work on this paper was supported by a Cancer Center Support Grant from the National Cancer Institute to Memorial Sloan Kettering Cancer Center (award number P30 CA008748). Dr. Morgan provided a self-developed lecture in a 3M-sponsored series on hospital epidemiology and has received honoraria for serving as a book and journal editor for Springer Publishing. Dr. Smith is employed by the American College of Physicians and owns stock in Merck, where her husband is employed. The other authors report no potential conflicts of interest.

Medical services overuse is the provision of healthcare services for which there is no medical basis or for which harms equal or exceed benefits.¹ This overuse drives poor-quality care and unnecessary cost.^2,3 The high prevalence of overuse is recognized by patients,⁴ clinicians,⁵ and policymakers.⁶ Initiatives to reduce overuse have targeted physicians,⁷ the public,⁸ and medical educators^9,10 but have had limited impact.^11,12 Few studies have addressed methods for reducing overuse, and de-implementation of nonbeneficial practices has proved challenging.^1,13,14 Models for reducing overuse are only theoretical¹⁵ or are focused on administrative decisions.^16,17 We think a practical framework is needed. We used an iterative process, informed by expert opinion and discussion, to design such a framework.

The authors, who have expertise in overuse, value, medical education, evidence-based medicine, and implementation science, reviewed related conceptual frameworks¹⁸ and evidence regarding drivers of overuse. We organized these drivers into domains to create a draft framework, which we presented at Preventing Overdiagnosis 2015, a meeting of clinicians, patients, and policymakers interested in overuse. We incorporated feedback from meeting attendees to modify framework domains, and we performed structured searches (using key words in Pubmed) to explore, and estimate the strength of, evidence supporting items within each domain. We rated supporting evidence as strong (studies found a clear correlation between a factor and overuse), moderate (evidence suggests such a correlation or demonstrates a correlation between a particular factor and utilization but not overuse per se), weak (only indirect evidence exists), or absent (no studies identified evaluating a particular factor). All authors reached consensus on ratings.

Framework Principles and Evidence

Patient-centered definition of overuse. During framework development, defining clinical appropriateness emerged as the primary challenge to identifying and reducing overuse. Although some care generally is appropriate based on strong evidence of benefit, and some is inappropriate given a clear lack of benefit or harm, much care is of unclear or variable benefit. Practice guidelines can help identify overuse, but their utility may be limited by lack of evidence in specific clinical situations,¹⁹ and their recommendations may apply poorly to an individual patient. This presents challenges to using guidelines to identify and reduce overuse.

Despite limitations, the scope of overuse has been estimated by applying broad, often guideline-based, criteria for care appropriateness to administrative data.²⁰ Unfortunately, these estimates provide little direction to clinicians and patients partnering to make usage decisions. During framework development, we identified the importance of a patient-level, patient-specific definition of overuse. This approach reinforces the importance of meeting patient needs while standardizing treatments to reduce overuse. A patient-centered approach may also assist professional societies and advocacy groups in developing actionable campaigns and may uncover evidence gaps.

Centrality of patient-clinician interaction. During framework development, the patient–clinician interaction emerged as the nexus through which drivers of overuse exert influence. The centrality of this interaction has been demonstrated in studies of the relationship between care continuity and overuse²¹ or utilization,^22,23 by evidence that communication and patient–clinician relationships affect utilization,²⁴ and by the observation that clinician training in shared decision-making reduces overuse.²⁵ A patient-centered framework assumes that, at least in the weighing of clinically reasonable options, a patient-centered approach optimizes outcomes for that patient.

Incorporating drivers of overuse. We incorporated drivers of overuse into domains and related them to the patient–clinician interaction.²⁶ Domains included the culture of healthcare consumption, patient factors and experiences, the practice environment, the culture of professional medicine, and clinician attitudes and beliefs.

We characterized the evidence illustrating how drivers within each domain influence healthcare use. The evidence for each domain is listed in Table 1.

The final framework is shown in the Figure. Within the healthcare system, patients are influenced by the culture of healthcare consumption, which varies within and among countries.²⁷ Clinicians are influenced by the culture of medical care, which varies by practice setting,²⁸ and by their training environment.²⁹ Both clinicians and patients are influenced by the practice environment and by personal experiences. Ultimately, clinical decisions occur within the specific patient–clinician interaction.²⁴ Table 1 lists each domain’s components, likely impact on overuse, and estimated strength of supporting evidence. Interventions can be conceptualized within appropriate domains or through the interaction between patient and clinician.

We developed a novel and practical conceptual framework for characterizing drivers of overuse and potential intervention points. To our knowledge, this is the first framework incorporating a patient-specific approach to overuse and emphasizing the patient–clinician interaction. Key strengths of framework development are inclusion of a range of perspectives and characterization of the evidence within each domain. Limitations include lack of a formal systematic review and broad, qualitative assessments of evidence strength. However, we believe this framework provides an important conceptual foundation for the study of overuse and interventions to reduce overuse.

Framework Applications

This framework, which highlights the many drivers of overuse, can facilitate understanding of overuse and help conceptualize change, prioritize research goals, and inform specific interventions. For policymakers, the framework can inform efforts to reduce overuse by emphasizing the need for complex interventions and by clarifying the likely impact of interventions targeting specific domains. Similarly, for clinicians and quality improvement professionals, the framework can ground root cause analyses of overuse-related problems and inform allocation of limited resources. Finally, the relatively weak evidence on the role of most acknowledged drivers of overuse suggests an important research agenda. Specifically, several pressing needs have been identified: defining relevant physician and patient cultural factors, investigating interventions to impact culture, defining practice environment features that optimize care appropriateness, and describing specific patient–clinician interaction practices that minimize overuse while providing needed care.

Targeting Interventions

Domains within the framework are influenced by different types of interventions, and different stakeholders may target different domains. For example:
 

• The culture of healthcare consumption may be influenced through public education (eg, Choosing Wisely^® patient resources)^30-32 and public health campaigns.
• The practice environment may be influenced by initiatives to align clinician incentives,³³ team care,³⁴ electronic health record interventions,³⁵ and improved access.³⁶
• Clinician attitudes and beliefs may be influenced by audit and feedback,^37-40 reflection,⁴¹ role modeling,⁴² and education.^43-45
• Patient attitudes and beliefs may be influenced by education, access to price and quality information, and increased engagement in care.^46,47
• For clinicians, the patient–clinician interaction can be improved through training in communication and shared decision-making,25 through access to information (eg, costs) that can be easily shared with patients,^48,49 and through novel visit structures (eg, scribes).⁵⁰
• On the patient side, this interaction can be optimized with improved access (eg, through telemedicine)^51,52 or with patient empowerment during hospitalization.
• The culture of medicine is difficult to influence. Change likely will occur through:

○ Regulatory interventions (eg, Transforming Clinical Practice Initiative of Center for Medicare & Medicaid Innovation).

○ Educational initiatives (eg, high-value care curricula of Alliance for Academic Internal Medicine/American College of Physicians⁵³).

○ Medical journal features (eg, “Less Is More” in JAMA Internal Medicine⁵⁴ and “Things We Do for No Reason” in Journal of Hospital Medicine).

○ Professional organizations (eg, Choosing Wisely^®).

As organizations implement quality improvement initiatives to reduce overuse of services, the framework can be used to target interventions to relevant domains. For example, a hospital leader who wants to reduce opioid prescribing may use the framework to identify the factors that encourage prescribing in each domain—poor understanding of pain treatment (a clinician factor), desire for early discharge encouraging overly aggressive pain management (an environmental factor), patient demand for opioids combined with poor understanding of harms (patient factors), and poor communication regarding pain (a patient–clinician interaction factor). Although not all relevant factors can be addressed, their classification by domain facilitates intervention, in this case perhaps leading to a focus on clinician and patient education on opioids and development of a practical communication tool that targets 3 domains. Table 2 lists ways in which the framework informs approaches to this and other overused services in the hospital setting. Note that some drivers can be acknowledged without identifying targeted interventions.

Moving Forward

Through a multi-stakeholder iterative process, we developed a practical framework for understanding medical overuse and interventions to reduce it. Centered on the patient–clinician interaction, this framework explains overuse as the product of medical and patient culture, the practice environment and incentives, and other clinician and patient factors. Ultimately, care is implemented during the patient–clinician interaction, though few interventions to reduce overuse have focused on that domain.

Conceptualizing overuse through the patient–clinician interaction maintains focus on patients while promoting population health that is both better and lower in cost. This framework can guide interventions to reduce overuse in important parts of the healthcare system while ensuring the final goal of high-quality individualized patient care.

Acknowledgments

The authors thank Valerie Pocus for helping with the artistic design of Framework. An early version of Framework was presented at the 2015 Preventing Overdiagnosis meeting in Bethesda, Maryland.

Disclosures

Dr. Morgan received research support from the VA Health Services Research (CRE 12-307), Agency for Healthcare Research and Quality (AHRQ) (K08- HS18111). Dr. Leppin’s work was supported by CTSA Grant Number UL1 TR000135 from the National Center for Advancing Translational Sciences, a component of the National Institutes of Health (NIH). Dr. Korenstein’s work on this paper was supported by a Cancer Center Support Grant from the National Cancer Institute to Memorial Sloan Kettering Cancer Center (award number P30 CA008748). Dr. Morgan provided a self-developed lecture in a 3M-sponsored series on hospital epidemiology and has received honoraria for serving as a book and journal editor for Springer Publishing. Dr. Smith is employed by the American College of Physicians and owns stock in Merck, where her husband is employed. The other authors report no potential conflicts of interest.