BACKGROUND: Because physician practices contribute to national healthcare expenditures, initiatives aimed at educating physicians about high-value cost-conscious care (HVCCC) are important. Prior studies suggest that the training environment influences physician attitudes and behaviors towards HVCCC.
OBJECTIVE: To explore the relationship between medical student experiences and HVCCC attitudes.
METHODS: Quantitative and qualitative analysis of a multi-institutional survey.
METHODS: Medical students from nine US medical schools.
METHODS: A 44-item survey that included the Maastricht HVCCC Attitudes Questionnaire, a validated tool for assessing HVCCC attitudes, was administered electronically. Attitudinal domains of high-value care (HVC), cost incorporation (CI), and perceived drawbacks (PD) were compared using one-way ANOVA among students with a range of exposures. Open text responses inviting participants to reflect on their attitudes were analyzed using classical content analysis.
RESULTS: A total of 740 students completed the survey (response rate 15%). Students pursuing a \"continuity-oriented\" specialty held more favorable attitudes towards HVCCC than those pursuing \"technique-oriented\" specialties (HVC sub-score = 3.20 vs. 3.06; p = 0.005, CI sub-score = 2.83 vs. 2.74; p < 0.001). Qualitative analyses revealed personal, educational, and professional experiences shape students\' HVCCC attitudes, with similar experiences interpreted differently leading to both more and less favorable attitudes.
CONCLUSIONS: Students pursuing specialties with longitudinal patient contact may be more enthusiastic about practicing high-value care. Life experiences before and during medical school shape these attitudes, and complex interactions between these forces drive student perceptions of HVCCC.

Although cancer care is often contextualized in terms of survival, there are other important cancer care outcomes, such as quality of life and cost of care. The ASCO Value Framework assesses the value of cancer therapies not only in terms of survival but also with consideration of quality of life and financial cost. Early palliative care for patients with advanced cancer is associated with improved quality of life, mood, symptoms, and overall survival for patients, as well as cost savings. While palliative care has been shown to have numerous benefits, the impact of real-world implementation of outpatient embedded palliative care on value-based metrics is not fully understood. We sought to describe the association between outpatient embedded palliative care in a multidisciplinary thoracic oncology clinic and inpatient value-based metrics. We performed a retrospective cohort study of 215 patients being treated for advanced thoracic malignancies with non-curative intent. We evaluated the association between outpatient embedded palliative care and inpatient clinical outcomes including emergency room visits, hospitalizations, intensive care unit admissions, hospital charges, as well as hospital quality metrics including 30-day readmissions, admissions within 30 days of death, inpatient mortality, and inpatient hospital charges. Outpatient embedded palliative care was associated with lower hospital charges per day (USD 3807 vs. USD 4695, p = 0.024). Furthermore, patients who received outpatient embedded palliative care had lower hospital admissions within 30 days of death (O.R. 0.45; 95% CI 0.29, 0.68; p < 0.001) and a lower inpatient mortality rate (IRR 0.67; 95% CI 0.48, 0.95; p = 0.024). Our study further supports that outpatient palliative care is a high-value intervention and alternative models of palliative care, including one embedded into a multidisciplinary thoracic oncology clinic, is associated with improved value-based metrics.

BACKGROUND: Healthcare spending represents a large portion of the GDP of the United States. Value-based care (VBC) seeks to decrease waste in health care spending, yet this concept is insufficiently taught to medical students. The Choosing Wisely Students and Trainees Advocating for Resource Stewardship (STARS) campaign promotes initiatives that integrate knowledge of VBC into undergraduate medical education (UME). This study sought to determine the most effective strategy to educate medical students on key principles of VBC as taught by the STARS campaign.
METHODS: Choosing Wisely principles were incorporated into the UME curriculum of an academic medical institution via the creation of eight new learning objectives (LOs) for case-based learning (CBL) sessions and lectures. Medical students completed an annual 10-question survey from 2019 to 2022 and 10 formal examination questions during the preclinical (years 1 and 2) curriculum after exposure to varying quantities of LOs. Pearson correlation, chi-square, and logistic regression were employed to determine the association between increased LOs in the curriculum and (1) campaign awareness and (2) knowledge of VBC principles.
RESULTS: A total of 700 survey responses over a four-year period (2019 to 2022) were analyzed. Student awareness of the campaign and knowledge of VBC principles increased year over year during the survey period (39% to 92% and 64% to 74%, respectively). There were significant associations between increased LOs in the curriculum and (1) campaign awareness (0.828, p<0.0001) and (2) knowledge of VBC principles (0.934, p<0.001). Students also performed well on formal examination questions related to VBC principles (mean: 81.5% and mean discrimination index: 0.18).
CONCLUSIONS: Integration of VBC-focused LOs is significantly associated with awareness of the Choosing Wisely STARS campaign and knowledge of VBC principles taught by the campaign. Collaborative initiatives to increase exposure to VBC education may improve students\' knowledge of these principles during medical school.

BACKGROUND: The growing number of melanoma patients who need long-term surveillance increasingly exceeds the capacity of the dermatology workforce, particularly outside of metropolitan areas. Digital technologies that enable patients to perform skin self-examination and send dermoscopic images of lesions of concern to a dermatologist (mobile teledermoscopy) are a potential solution. If these technologies and the remote delivery of melanoma surveillance are to be incorporated into routine clinical practice, they need to be accepted by clinicians providing melanoma care, such as dermatologists and general practitioners (GPs).
OBJECTIVE: This study aimed to explore perceptions of potential benefits and harms of mobile teledermoscopy, as well as experiences with this technology, among clinicians participating in a pilot randomized controlled trial (RCT) of patient-led melanoma surveillance.
METHODS: This qualitative study was nested within a pilot RCT conducted at dermatologist and skin specialist GP-led melanoma clinics in New South Wales, Australia. We conducted semistructured interviews with 8 of the total 11 clinicians who were involved in the trial, including 4 dermatologists (3 provided teledermatology, 2 were treating clinicians), 1 surgical oncologist, and 3 GPs with qualifications in skin cancer screening (the remaining 3 GPs declined an interview). Thematic analysis was used to analyze the data with reference to the concepts of \"medical overuse\" and \"high-value care.\"
RESULTS: Clinicians identified several potential benefits, including increased access to dermatology services, earlier detection of melanomas, reassurance for patients between scheduled visits, and a reduction in unnecessary clinic visits. However, they also identified some potential concerns regarding the use of the technology and remote monitoring that could result in diagnostic uncertainty. These included poor image quality, difficulty making assessments from a 2D digital image (even if good quality), insufficient clinical history provided, and concern that suspicious lesions may have been missed by the patient. Clinicians thought that uncertainty arising from these concerns, together with perceived potential medicolegal consequences from missing a diagnosis, might lead to increases in unnecessary clinic visits and procedures. Strategies suggested for achieving high-value care included managing clinical uncertainty to decrease the potential for medical overuse and ensuring optimal placement of patient-led teledermoscopy within existing clinical care pathways to increase the potential for benefits.
CONCLUSIONS: Clinicians were enthusiastic about the potential and experienced benefits of mobile teledermoscopy; however, managing clinical uncertainty will be necessary to achieve these benefits in clinical care outside of trial contexts and minimize potential harms from medical overuse.
BACKGROUND: Australian and New Zealand Clinical Trials Registry ACTRN12616001716459; https://anzctr.org.au/Trial/Registration/TrialReview.aspx?id=371865.

BACKGROUND: Non-specific low back pain is a common musculoskeletal condition that often requires the involvement of physiotherapists for effective management. However, there is limited understanding of the factors influencing physiotherapists\' implementation of high-value care in the management of non-specific low back pain (NSLBP), particularly in Indian healthcare settings.
OBJECTIVE: The aim of this study was to explore the barriers and facilitators of implementation of high-value care in managing NSLBP from the perspective of physiotherapists practicing in Indian healthcare settings.
METHODS: Descriptive qualitative design.
METHODS: We adopted a descriptive phenomenological approach and purposefully selected physiotherapists (N = 15) from diverse healthcare settings, encompassing varying years of clinical experience, to capture a broad range of perspectives. Semi-structured face-to-face interviews were conducted via the Zoom video conferencing platform. Each interview lasted on average for 30-45 min, and no follow-up interviews were conducted. Data were analyzed using thematic analysis with an inductive approach.
RESULTS: Our analysis revealed three major themes and seven sub-themes uncovering barriers and facilitators of implementation of high-value care. These themes include misconceptions about low back pain and its management among physiotherapists, their perceived lack of autonomy in clinical decision-making due to external influences, and the significance of aligning treatment plans with patient goals while considering evidence-based care.
CONCLUSIONS: The study results provide insights into the unique challenges associated with implementation of high-value care for non-specific low back pain in Indian healthcare settings.

UNASSIGNED: Patients with syncope often undergo costly testing, despite current guidelines and data supporting the contrary.
UNASSIGNED: To determine the diagnostic value through positivity rate of electrocardiogram (EKG), computed tomography (CT) of the brain, magnetic resonance imaging (MRI) of the brain, transthoracic echocardiogram, nuclear and pharmacologic cardiac stress test, tilt table test and carotid ultrasound in patients diagnosed with syncope.
UNASSIGNED: This is a retrospective study of 10,036 adults presenting to the emergency department or hospitalized with a primary diagnosis of syncope at 8 acute care facilities in the southwest United States from January 1, 2019, to December 31, 2019. A chi-square analysis was performed for each testing modality to evaluate for a statistically significant difference. The cost of each test was estimated based on published national averages per Medicare.
UNASSIGNED: Of our sample, 903 patients (9%) received a test that yielded any positive finding. The results in the order of highest percent positivity rate to lowest were EKG (5.7%), carotid ultrasound (4.84%), transthoracic echocardiogram (2.56%), tilt table test (1%), MRI brain (0.99%), CT brain (0.82%) and cardiac stress test (0.09%). The total sum spent on testing was estimated at $43,347,332. Only $489,170 of this total was spent on a positive test. If this data is expanded to the 6,146 hospitals across the United States, a yearly $33 billion are wasted on syncope workups.
UNASSIGNED: Costly testing continues to be performed on syncope patients despite guidelines discouraging testing. The necessity of these tests should be carefully evaluated for each patient based on diagnostic value.

Despite the importance of patient satisfaction in ensuring high-quality care, studies investigating patient satisfaction in Mohs micrographic surgery (MMS) are limited.
We investigated the factors associated with patient satisfaction in MMS for nonmelanoma skin cancer and how patient satisfaction changes in the postoperative period.
In this prospective cohort study including 100 patients, patient satisfaction surveys were administered at the time of surgery and at 3 months postsurgery. Sociodemographic characteristics, medical history, and surgical parameters were collected by chart review. Univariate linear and logistic regression models were created to examine these relationships.
Decreased satisfaction was observed in patients requiring 3 or more MMS stages both at the time of surgery (P = .047) and at 3 months post-surgery (P = .0244). Patients with morning procedures ending after 1:00 pm had decreased satisfaction at the time of surgery (P = .019). A decrease in patient satisfaction between the time of surgery and 3 months postsurgery was observed in patients with surgical sites on the extremities (P = .036), larger preoperative lesion sizes (P = .012), and larger defect sizes (P = .033).
Single-institution data, self-selection bias, and recall bias.
Patient satisfaction with MMS is impacted by numerous factors and remains dynamic over time.

BACKGROUND: In the context of rising healthcare costs, formal education on treatment-related financial hardship is lacking in many medical schools, leaving future physicians undereducated and unprepared to engage in high-value care.
METHODS: We performed a prospective cohort study to characterize medical student knowledge regarding treatment-related financial hardship from 2019 to 2020 and 2020-2021, with the latter cohort receiving a targeted educational intervention to increase cost awareness. Using Kirkpatrick\'s four-level training evaluation model, survey data was analyzed to characterize the acceptability of the intervention and the impact of the intervention on student knowledge, attitudes, and self-reported preparedness to engage in cost-conscious care.
RESULTS: Overall, N = 142 medical students completed the study survey; 61 (47.3%) in the non-intervention arm and 81 (66.4%) in the intervention arm. Of the 81 who completed the baseline survey in the intervention arm, 65 (80.2%) completed the immediate post-intervention survey and 39 (48.1%) completed the two-month post-intervention survey. Following the educational intervention, students reported a significantly increased understanding of common financial terms, access to cost-related resources, and level of comfort and preparedness in engaging in discussions around cost compared to their pre-intervention responses. The majority of participants (97.4%) reported that they would recommend the intervention to future students. A greater proportion of financially stressed students reported considering patient costs when making treatment decisions compared to their non-financially stressed peers.
CONCLUSIONS: Targeted educational interventions to increase cost awareness have the potential to improve both medical student knowledge and preparedness to engage in cost-conscious care. Student financial stress may impact high-value care practices. Robust curricula on high-value care, including treatment-related financial hardship, should be formalized and universal within medical school training.

Currently, there is no consensus on the best rehabilitation program to perform for nonspecific chronic low back pain (NSCLBP). However, multimodal exercises, education, and group-based sessions seem to be beneficial. We, therefore, launched such a treatment program and aimed to evaluate its effectiveness in improving patient health status. We retrospectively analyzed the records of 23 NSCLB patients who followed the MyBack program at La Tour hospital from 2020 to 2022 (25 sessions, 8 weeks). Patients were evaluated before and after intervention using pain on a visual analog scale (pVAS), Roland−Morris Disability Questionnaire (RMDQ), Pain Catastrophizing Scale (PCS), Tampa Scale of Kinesiophobia (TSK), and the EuroQol-5D-3L (EQ-5D-3L). Responder rates were calculated using minimal clinically important differences. Patients reported a significant reduction (p < 0.05) in the pVAS (5.3 ± 1.2 vs. 3.1 ± 1.6), RMDQ (8.8 ± 3.3 vs. 4.0 ± 3.7), PCS (24.5 ± 9.4 vs. 11.7 ± 7.9) and TSK (41.5 ± 9.2 vs. 32.7 ± 7.0). The EQ-5D-3L also statistically improved (score: 0.59 ± 0.14 vs. 0.73 ± 0.07; and VAS: 54.8 ± 16.8 vs. 67.0 ± 15.2). The responder rates were 78% for the pVAS and PCS, 74% for the RMDQ and TSK, and only 26% for the EQ-5D-3L. The MyBack program combining education with multimodal group exercises led to satisfactory clinical, functional, and psychosocial outcomes.

Sarcoidosis is a granulomatous disorder with an elusive etiology and pathogenesis. Classically, sarcoidosis is associated with non-caseating granulomas composed of mononuclear phagocytes, lymphocytes, and multinucleated giant cells. Necrotizing granulomas can also be associated with sarcoidosis but is scarcely reported in the medical literature. Necrotizing sarcoid granulomatosis is challenging to diagnose due to its rarity and similarity with other necrotizing disorders. Therefore, it is mainly considered a diagnosis of exclusion. We report one such case study, which could prompt further research to lay the course of treatment strategies for this disease. Moreover, our patient had a family history of sarcoidosis, which raises questions regarding possible genetic predisposition, and future work might help solve this medical mystery.