Multifaceted but Invisible: Perceptions of the Value of a Pediatric Cognitive Specialty
Abstract
BACKGROUND: Systems for standardizing physician payment have been shown to undervalue cognitive clinical encounters. Because health care reform emphasizes value-based approaches, we need an understanding of the way pediatric cognitive specialties are used to contribute to the provision of high-value care. We sought to investigate how clinical and administrative stakeholders perceive the value of pediatric infectious disease (PID) specialists.
METHODS: We conducted qualitative interviews with a purposive sample of physicians and administrators from 5 hospitals across the United States in which children are cared for. All interviews were transcribed and systematically analyzed for common themes.
RESULTS: We interviewed 97 stakeholders. Analysis revealed the following 3 domains of value: clinical, organizational, and communicative. Clinically, PID specialists were perceived to be highly valuable in treating patients with unusual infections that respond poorly to therapy, in optimizing the use of antimicrobial agents and in serving as outpatient homes for complex patients. Respondents perceived that PID specialists facilitate communication with patients and their families, the health care team and the media. PID specialists were perceived to generate value by participating in systemwide activities, including antimicrobial stewardship and infection prevention. Despite this, much of the valuable work PID specialists perform is difficult to measure causing some administrative stakeholders to question how many PID specialists are necessary to achieve high-quality care.
CONCLUSIONS: With our findings, we suggest that pediatric cognitive specialties contribute value in multiple ways to the health care delivery system. Many of these domains are difficult to capture by using current metrics, which may lead administrators to overlook valuable work and to under-allocate resources.
Recent developments in American health care policy have emphasized a shift from fee-for-service systems to a value-based approach that seeks to reward improved patient outcomes achieved at a lower cost.1 How to best compensate physicians for the work they perform is at the core of these changes. Efforts to standardize payment for physician services perpetuate inequities in compensation for different types of physician labor, with procedural specialties (eg, ophthalmology, gastroenterology, and anesthesiology) being compensated at a higher rate than cognitive specialties (eg, infectious diseases, psychiatry, and endocrinology).2 The resource-based relative value scale has been criticized for its substantial misvaluing of physician work and failure to capture the range and intensity of nonprocedural physician activities.3,4 As policymakers move forward on devising strategies to appropriately compensate a diverse array of medical specialties in a way that fosters improved outcomes at a lower cost, there is a need to identify the range of physician activities that are valuable.5,6
As the provision of pediatric medical care becomes more complicated, with sicker children hospitalized and increasingly complex therapies administered, the contribution that various specialists and subspecialists bring is evolving. A close examination of the possible mechanisms by which pediatric cognitive medical specialties contribute to the delivery of high-quality medical care for children is needed. Pediatric infectious disease (PID) specialists are a good case study to use to investigate this issue because they specialize in a problem that remains a major cause of hospitalization in children and a complication of invasive therapeutic interventions.7,8 Understanding the ways in which PID specialists are perceived to contribute value to the delivery of health care to children in a rapidly changing clinical, financial, and regulatory environment can inform broader discussions about measuring the value of pediatric cognitive specialties.
Methods
Design, Sample, and Recruitment
From April 2014 to March 2015, we conducted in-depth, semistructured interviews with a purposive sample of physicians and administrators from 5 US hospitals in which children are cared for. Study sites were selected to maximize variation in our sample by geographic location, size, number of PID specialists, and type of hospital (Table 1). We interviewed physicians in core pediatric subspecialties that frequently care for patients with infectious diseases, such as pediatric hospital medicine, neonatology, hematology-oncology, critical care, and surgery. We also interviewed hospital administrators, which included individuals with roles such as chief medical officer, chief financial officer, and director of patient safety and quality. The design of the study, creation of the interview guide, recruitment of participants, and conduct of the interviews were all performed by a medical sociologist with extensive experience gathering qualitative data on physician perceptions.9,10
Characteristics of Sites From Which Interview Respondents Were Sampled
To recruit respondents, we identified a key contact in the PID division at each hospital to identify eligible respondents and provide us with their contact information. In each case, the key contact provided us with the list of entire divisions and did not filter the list beyond identifying full-time staff. Once this list was generated, our study team recruited respondents via e-mail. We did not include our PID key contact in this process and made every effort to ensure that they were unaware of who participated. We assured respondents that their specific comments would not be shared with the PID key contact beyond a report of aggregated themes across hospital sites. Our protocol was approved by the Children’s Hospital of Philadelphia Institutional Review Board.
Data Collection
Our interview guides were developed in a 2-stage process. First, we conducted 2 in-person focus groups with PID specialists at the IDWeek 2013 annual meeting to generate question prompts. Second, we pilot tested our guides over the telephone with 10 clinical and administrative stakeholders from across the United States. Guides were modified on the basis of feedback about question clarity and length. Questions were explicitly designed to be open-ended and to ensure that the prompts were not leading (Table 2). Interviews were conducted in person at each hospital during a 1-week site visit. All interviews were, with permission, recorded. Respondents were recruited until thematic saturation, the state in which increasing sample size would not produce new insights, was achieved.11
Sample Questions From the Interview Guide
Data Analysis
All audio files were transcribed and uploaded to NVivo 11 qualitative data analysis software.12 Data were independently analyzed by using a modified grounded theory approach by the medical sociologist and a trained research assistant. Themes and patterns in the text were systematically identified in a 2-stage process. First, all transcripts were read in a process of open coding, capturing, and defining salient themes that emerged inductively from the data. All codes were discussed by the 2 coders in consultation with the other investigators on the study and clearly defined to ensure consistent application throughout the data set. Disagreements and discrepancies were resolved by consensus. Second, after the preliminary code list was developed, we reviewed all transcripts line by line to manually assign codes to passages of text. Intercoder reliability was assessed every fifth transcript throughout analysis. Modifications were made to the coding procedure until reliability consistently exceeded 95%.
Results
Characteristics of Study Subjects
Of the 163 physicians and administrators recruited to participate in the study, 97 were interviewed, for an overall response rate of 59.5%. In Table 3, we describe the characteristics of participating respondents.
Characteristics of Interview Sample (n = 97)
Domains of Value: Clinical, Organizational, and Communicative
Our analysis revealed that clinical and administrative stakeholders identified numerous multifaceted ways in which they perceived PID specialists to bring value. We identified the following 3 major domains of value: clinical, organizational, and communicative. Within those domains, we identified subdomains that we used to further specify what activities were deemed valuable. In Table 4, we summarize each domain and subdomain and provide an illustrative quotation. The subdomains of value reported here were mentioned by at least 50 respondents. We report on repeated themes and not isolated perceptions.
Domains and Subdomains of Value and Illustrative Quotations
Clinical value includes 7 subdomains that were explicitly associated with the care of individual patients or medical decision-making. First, all respondents perceived that PID specialists are vitally important in caring for complex patients, such as those with infections caused by unusual pathogens or cases in which the first attempts at treating an infection are unsuccessful. Second, all respondents perceived that PID specialists brought value by helping to optimize antimicrobial therapy. Within this domain, a number of administrative stakeholders said that they perceived PID specialists’ expertise surrounding the optimal use of antimicrobial agents to contribute greatly to important organizational metrics, including reducing length of stay, overall antimicrobial expenditures, and rates of health care–associated infections attributed to drug-resistant organisms.
Third, numerous respondents said that PID specialists brought value to the overall interdisciplinary care of patients because of their diagnostic acumen. Many stories were told of “good catches” or obscure diagnoses made by PID specialists, even for noninfectious disease cases. Fourth, a number of respondents across sites described that they thought of PID specialists, in general, as an “ideal” consultant service. When probed to clarify what they meant by ideal, respondents suggested that they perceived PID specialists to be extremely thorough (in physical exams, history taking, and note writing), prompt, accessible, affable, engaged, and receptive to being consulted.
Fifth, both clinical and administrative stakeholders perceived that the PID division served a valuable role as an outpatient home for patients whom general pediatricians did not have time to manage, such as children on long-term intravenous antimicrobial therapy, children with recurrent fevers, and patients with complex, chronic illness that may have a psychological component (eg, “chronic” Lyme disease). Many administrative respondents perceived that the outpatient setting will grow as a place for PID specialists to bring value in a changing health care environment, in which keeping patients out of the hospital and reducing length of stay will be central foci. Sixth, many respondents perceived that PID specialists brought value by guiding decision-making around laboratory testing as technologies and standards change over time. Finally, numerous respondents perceived PID specialists to be helpful in reducing unnecessary invasive interventions such as blood draws or surgery; however, respondents at 2 sites perceived that PID specialists actually increased unnecessary diagnostic testing.
Organizational value includes subdomains of value that were thought to be hospital- or systemwide. We identified 5 distinct subdomains in this category. First, the majority of respondents mentioned that they perceived PID specialists to play a crucial role in overseeing formal hospital programs in antimicrobial stewardship and infection prevention. These system-level roles were perceived to be highly valuable by administrators, who described these programs as “mission critical,” especially in a regulatory climate with increasing attention to patient safety and quality improvement. Numerous clinical stakeholders said that they particularly appreciated having PID specialists’ expertise reflected in antimicrobial stewardship and infection prevention activities in addition to pharmacists and nurses, because it bolstered the credibility of guidelines. A small number of clinical stakeholders at 2 sites (primarily in neonatology and hematology-oncology) were frustrated with the restrictive antimicrobial stewardship efforts at their institutions and reported that they perceived these programs to have eroded the quality of their relationship with PID specialists.
Second, the contribution that PID specialists make to education, both formally via residency programs or continuing medical education and informally, via conversations held during the care of patients, was mentioned by the majority of respondents. Many respondents expressed the perception that PID specialists are skilled teachers. Third, administrative stakeholders said they perceived PID specialists to be valuable because they enhance the prestige of the organization. This prestige was understood to be generated by research breakthroughs at sites with robust research infrastructures, successful treatment of particularly sick patients who generated media attention, or generalized clinical excellence that was recognized regionally. Finally, all administrative stakeholders in our sample said they perceived PID specialists to be crucial for the supportive role they play in allowing other highly valued pediatric subspecialties, like critical care, neonatology, hematology-oncology, and transplant surgery to be offered at their institution.
Communicative value includes subdomains that contain the perception that PID specialists facilitate communication between different parties. Many respondents across hospital sites, with a few exceptions due to individual personalities, perceived PID specialists to be skilled at communicating with patients and parents. A number of respondents suggested that they sometimes consult PID specialists to help communicate with a family or provide reassurance even in the absence of a clinical question. Many respondents stated that PID specialists are good at communicating with other disciplines. Some respondents suggested that they rely on PID specialists in a strategic way to communicate with other, difficult to interact with, subspecialists. Finally, administrative stakeholders suggested that they perceived PID specialists to be good at communicating with the news media and with pediatricians in the community. Communication with community pediatricians was perceived as valuable because it drove business to their institution and increased the hospital’s regional profile.
Invisible Value and Its Consequences
We found that, despite the multiple and multifaceted domains in which our respondents perceived that PID specialists bring value, much of this valuable labor escapes capture and is difficult to demonstrate (Table 5). This “invisible” value manifests in work or skills that are not reimbursed or otherwise accounted for in the metrics that administrators use to capture physician labor (like phone calls to pediatricians in the community, curbside consultations, thorough notes, diagnostic acumen, and good communication skills). Many of the domains of value mentioned by respondents are the absence of something and are typically not dramatic (eg, fewer antimicrobial agents used, outbreaks prevented, misdiagnoses averted, or costly workups avoided). Most of the administrators in our sample recognized the existence of this invisible labor, but said they struggled to make sense of it, especially in a “widget-counting” and “fiscal restraint” culture.
Invisible Value and the Amount of PID Specialists
The consequence of this invisible value is that it led to uncertainty among clinical and administrative stakeholders regarding how many PID specialists are “really” needed to improve quality and reduce cost. Some clinical subspecialists, particularly those in neonatology, hematology-oncology, and hospitalist medicine expressed the perception that PID specialists are only needed for the outlier, particularly complicated, or puzzling patients. Administrative stakeholders expressed a variety of perceptions about the number of PID specialists that are needed in a particular institution and in what configuration. A number of these respondents expressed the perception that they could probably “muddle through” with a small number of PID specialists but that this might not be optimal for patients or the hospital. Administrative stakeholders at the nonfreestanding children’s hospitals (sites A and E) reported that they needed to be “creative” to justify adding more full-time equivalents for PID specialists. They described looking for pockets of unmet clinical need (especially in the outpatient setting), such as considering hybrid hospitalist-PID specialist positions, appropriately maximizing billing and coding, and assigning PID specialists to systemwide patient safety leadership roles.
Discussion
We sought to identify the perceptions that clinical and administrative stakeholders working in hospitals that provide pediatric care hold about the value of PID specialists. Through our analysis, we identified 3 domains of value (clinical, organizational, and communicative), in which the perceptions of stakeholders could be discretely classified. Subdomains in each category were used to illustrate the specific, multifaceted ways that PID specialists were perceived to improve care. Although we identified multiple domains of value, our analysis also revealed that much of the valuable work that PID specialists are perceived to perform escapes capture by current measures of physician work, causing some stakeholders to question how many PID specialists are necessary to achieve cost reduction while simultaneously improving safety and quality. In this study, we purposefully used an open-ended research design, in which we did not define for our respondents what “value” meant, to elicit a full range of perceptions (including the discovery of unanticipated concepts, a well-known strength of qualitative methodology).13 Systematically gathering data on stakeholder perceptions is important, because it can be used to generate a more nuanced understanding of the roles that a cognitive specialty can play in an evolving health care environment subject to many countervailing powers.14
From a public health perspective, with this case study, we reveal the limitations of physician reimbursement in recognizing the valuable labor that cognitive specialists play in providing services that impact the larger epidemiologic environment that a hospital operates in, what Outterson and Yevtukova15 call a “germ shed.” Infectious diseases do not respect organizational or legal boundaries, and their control depends on actions that happen in a clinical region where institutions such as hospitals, ambulatory care centers, long-term care facilities, schools, and rehabilitation facilities are epidemiologically interdependent. Cognitive medical specialists in other disciplines such as developmental-behavioral pediatrics, genetics, adolescent medicine, and hospice-palliative medicine may perform similar labor that positively impacts the health of a local or regional population but is not recognized or compensated.
Previous researchers investigating the value of other cognitive specialties have largely focused on clinical outcomes such as mortality, readmissions, length of stay, and cost.16,17 With our findings, we point to some of the mechanisms by which a cognitive medical specialty may contribute to these outcomes (the “clinical” domain of value). Our work expands on this literature by identifying “softer” domains of value that are harder to quantify but play a crucial role in the provision of health care in complex organizations, such as communication skills, collegiality, and diagnostic acumen. Communication skills are of particular importance to understanding the value of a specialist, given that communication failures are estimated to cause >70% of serious adverse outcomes in hospitals18 and commonly lead to malpractice claims.19
Although the term “value” can have different meanings to different people,20 consensus is growing in discussions of health care reform that it be defined by the relationship between patient-centered outcomes and cost.1 Forrest and Silber21 have further specified that in pediatrics, because of the dependency of children on their parents, value be expanded to include family- and parent-centered outcomes. Two clinicians may achieve the same patient outcome at the same cost, but the one who does a better job managing parent outcomes (eg, anxiety, social isolation, family stress, missed work) can be said to have provided higher-value care. More research needs to be done to better understand the range of soft skills exhibited by cognitive medical specialties and how these skills might impact patient outcomes.
In our findings is suggested a troubling paradox. PID specialists were perceived to bring value in a variety of domains that are congruent with key drivers known to optimize health system performance, including improving the patient experience of care, improving the health of populations, and reducing the per capita cost of care.22 At the same time, widespread uncertainty was expressed in the number of PID specialists needed to achieve these aims. Because current productivity metrics operationalize value in ways unrelated to the achievement of these aims, hospital administrators may overlook valuable work and under-allocate resources to support PID specialists. More research is needed to better understand how many cognitive specialists in different fields are needed and in what configuration depending upon type of organization, to achieve improved outcomes. Research using a similar conceptual framework and methodological approach could prove fruitful in better understanding the value of other pediatric cognitive specialties like nephrology, endocrinology, and rheumatology.
Our study has several limitations. First, because we adopted a qualitative approach, our findings may not be generalizable to the entire population of pediatrics clinical and administrative stakeholders in the United States. Second, despite explicit efforts to minimize their effects, our sample may be biased. It is possible that the clinical and administrative stakeholders who agreed to participate to an interview possessed systematically different characteristics that influenced their willingness to participate and shaped their perceptions compared with those not interviewed. We were unable to assess the characteristics of respondents versus nonrespondents. It is also possible that interview respondents did not honestly share their perceptions about PID specialists to please the interviewer. Given that a number of respondents shared perceptions that were critical of PID specialists, we believe the impact of social desirability bias is minimal.
Despite these limitations, we are confident that the insights shared by the stakeholders in our study provide a nuanced framework to understand value that has heretofore been neglected. With our findings, we point to important next steps in defining a research agenda that can be used to establish value and address gaps in knowledge about how pediatric cognitive medical specialists can best contribute to high-quality, cost-effective health care.
Footnotes
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: Funded by the Pediatric Infectious Diseases Society.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
References
- Copyright © 2018 by the American Academy of Pediatrics
