A new instrument to measure high value, cost-conscious care attitudes among healthcare stakeholders: Development of the MHAQ

Background: Residents have to learn to provide high value, cost-conscious care (HVCCC) to counter the trend of excessive healthcare costs. Their learning is impacted by individuals from different stakeholder groups within the workplace environment. These individuals' attitudes toward HVCCC may influence how and what residents learn. This study was carried out to develop an instrument to reliably measure HVCCC attitudes among residents, staff physicians, administrators, and patients. The instrument can be used to assess the residency-training environment. Method: The Maastricht HVCCC Attitude Questionnaire (MHAQ) was developed in four phases. First, we conducted exploratory factor analyses using original data from a previously published survey. Next, we added nine items to strengthen subscales and tested the new questionnaire among the four stakeholder groups. We used exploratory factor analysis and Cronbach's alphas to define subscales, after which the final version of the MHAQ was constructed. Finally, we used generalizability theory to determine the number of respondents (residents or staff physicians) needed to reliably measure a specialty attitude score. Results: Initial factor analysis identified three subscales. Thereafter, 301 residents, 297 staff physicians, 53 administrators and 792 patients completed the new questionnaire between June 2017 and July 2018. The best fitting subscale composition was a three-factor model. Subscales were defined as high-value care, cost incorporation, and perceived drawbacks. Cronbach's alphas were between 0.61 and 0.82 for all stakeholders on all subscales. Sufficient reliability for assessing national specialty attitude (G-coefficient > 0.6) could be achieved from 14 respondents. Conclusions: The MHAQ reliably measures individual attitudes toward HVCCC in different stakeholders in health care contexts. It addresses key dimensions of HVCCC, providing content validity evidence. The MHAQ can be used to identify frontrunners of HVCCC, pinpoint aspects of residency training that need improvement, and benchmark and compare across specialties, hospitals and regions

Attitudes toward cost-conscious care among U.S. physicians and medical students: analysis of national cross-sectional survey data by age and stage of training

Abstract Background The success of initiatives intended to increase the value of health care depends, in part, on the degree to which cost-conscious care is endorsed by current and future physicians. This study aimed to first analyze attitudes of U.S. physicians by age and then compare the attitudes of physicians and medical students. Methods A paper survey was mailed in mid-2012 to 3897 practicing physicians randomly selected from the American Medical Association Masterfile. An electronic survey was sent in early 2015 to all 5,992 students at 10 U.S. medical schools. Survey items measured attitudes toward cost-conscious care and perceived responsibility for reducing healthcare costs. Physician responses were first compared across age groups (30–40 years, 41–50 years, 51–60 years, and > 60 years) and then compared to student responses using Chi square tests and logistic regression analyses (controlling for sex). Results A total of 2,556 physicians (65%) and 3395 students (57%) responded. Physician attitudes generally did not differ by age, but differed significantly from those of students. Specifically, students were more likely than physicians to agree that cost to society should be important in treatment decisions (p < 0.001) and that physicians should sometimes deny beneficial but costly services (p < 0.001). Students were less likely to agree that it is unfair to ask physicians to be cost-conscious while prioritizing patient welfare (p < 0.001). Compared to physicians, students assigned more responsibility for reducing healthcare costs to hospitals and health systems (p < 0.001) and less responsibility to lawyers (p < 0.001) and patients (p < 0.001). Nearly all significant differences persisted after controlling for sex and when only the youngest physicians were compared to students. Conclusions Physician attitudes toward cost-conscious care are similar across age groups. However, physician attitudes differ significantly from medical students, even among the youngest physicians most proximate to students in age. Medical student responses suggest they are more accepting of cost-conscious care than physicians and attribute more responsibility for reducing costs to organizations and systems rather than individuals. This may be due to the combined effects of generational differences, new medical school curricula, students’ relative inexperience providing cost-conscious care within complex healthcare systems, and the rapidly evolving U.S. healthcare system.https://deepblue.lib.umich.edu/bitstream/2027.42/146517/1/12909_2018_Article_1388.pd

Validity and Feasibility of the Electromyography Direct Observation Tool (EMG-DOT)

Objective – To develop a new workplace-based electromyography direct observation tool (the EMG-DOT) and gather validity evidence supporting its use for assessing electrodiagnostic skills among post-graduate medical trainees. Methods – The EMG-DOT was developed by experts using an iterative process. Validity evidence from content, response process, internal structure, relations to other variables, and consequences of testing was prospectively collected during the 2013-2014 academic year. Both supervising physicians and nerve conduction study technicians served as raters. Results – The 14-item EMG-DOT had a high content validity index (0.94) and excellent internal-consistency reliability (Cronbach alpha 0.94). Mean (SD) performance ratings assigned by physician and technician raters were 3.89 (0.79) and 3.57 (0.85) respectively using a five-point, competency-based rating scale (p<0.001). Correlations between individual items and global ratings of trainee performance ranged from 0.36 to 0.76 (p<0.001). Mean scores increased from 70 to 81% over the course of the EMG rotation (p<0.001) despite a corresponding increase in case complexity. Trainees reported that the observational assessment exercise was useful for improving their knowledge or skills in 82% of encounters (188/230) and that feedback generated by the EMG-DOT improved the quality of care provided to patients in 58% (133/230). Trainees were “satisfied” or “very satisfied” with the observational assessment exercise in 96% of encounters (234/243). Conclusions – This study provides validity evidence supporting the use of EMG-DOT scores to assess electrodiagnostic skills of residents and fellows. The EMG-DOT can be used to inform milestone-based assessments of trainee performance in Neurology, Child Neurology, Physical Medicine and Rehabilitation, Neuromuscular, and Clinical Neurophysiology training programs

The Basic Four Approach to Clinical Neuroscience Instruction: Using Cognitive Load Theory to Enhance Case-based Learning

Among medical students, neurosceince is considered a notoriously difficult subject. This challenges faculty to teach preclinical neurology in more engaging, efficient, and prioritized ways. Traditional approaches to neuroscience instruction typically begin with neuroanatomy and advance to clinical problem solving after this foundation of knowledge is in place. Over the past 45 years, neurology faculty at Mayo Clinic Alix School of Medicine have developed and iteratively refined an inverted approach called The Basic Four. The Basic Four uses authentic clinical scenarios as the basis for neuroscience instruction and incorporates principles from cognitive load theory to calibrate load on students’ working memory. This perspective describes The Basic Four and illustrates how cognitive load theory can be used to enhance case-based learning