"Never doubt that a small group of thoughtful, committed citizens can change the world. Indeed, it is the only thing that ever has."

Technical report
peer-reviewed

## Gamification of Hospital Utilization: Incorporating Cost-consciousness in Daily Practices

### Abstract

#### Results

Quantitative evaluation of the educational intervention was obtained through a 22-item questionnaire using a five-point Likert scale from 19 of the 22 enrolled residents (86% response rate). Responses were generally positive, with an overall course rating score of 4.16 (SD +/- 0.90) (Figure 7). Nearly all learners reported increased knowledge of hospital costs (4.58 +/- 0.61); understanding of cost concepts (4.42 +/- 0.69); and insight into increased spending (4.21 +/- 0.71). Learners reported that the session was structured in a sequence that was logical and easy to follow (4.05 +/- 0.90), and that the interactive nature of the game complemented their existing knowledge on cost practices (4.47 +/- 0.68). Qualitative feedback identified learners’ predilection for gamified delivery of nonclinical content during the conference. The majority of residents (89%) recommend the activity be used in subsequent offerings for other learners. During the phase 1 debriefing, learners consistently expressed surprise at the high costs of testing and medications. This led to more questions from learners regarding additional items not included in phase 1. Ultimately it provided a great transition to phase 2 where the additional costs of items were revealed.

### Discussion

The design of our activity allowed us to first educate residents about the costs of individual tests, medications, and healthcare supplies. The repetition of prices, the surprise many residents felt regarding the cost of commonly ordered tests, and the points awarded for correct responses employed a behaviorist model for the most basic level of understanding. As we progressed to Phase 2, a constructivist approach was utilized, with residents synthesizing both the knowledge gained in Phase 1 with their prior medical knowledge and direct clinical experience to formulate responsible, cost-efficient plans. These learning objectives are in line with the ACGME objectives for diagnostic studies (PC3) and systems-based management (SBP2), with strong scores in increased knowledge of hospital cost and clearer understanding of cost concepts.

Over the course of this activity, the authors noted that the residents who were highly interactive during the game appreciated the educational session the most. This was contingent on learners suspending their preconceived notions about healthcare costs and fully immersing themselves in the activity.

The learner to faculty ratio was approximately seven to eight students per faculty. We felt this ratio was crucial for the overall success of this didactic as it allowed multiple residents from each training level to provide their own perspectives and receive faculty input within the allotted time. Allocating the correct amount of time can be challenging with these types of lectures. Insufficient or overabundant time allotted per lecture can result in the failure to cover all necessary materials or failure to capture the learners' attention, respectively. While 60 minutes were allocated for this lecture, we believe that future iterations should allow for at least 70 minutes to allow for smoother transitions between each phase as well as time to field additional questions. The medical cost handout provided to learners during Phase 2 was very well received as it decreased the cognitive load when calculating the total cost of the workup and served as a convenient take-home handout due to its convenient formatting that reflected the existing order panels for the most commonly ordered ED items.

The study was limited in power, as it was conducted at a single center with a small sample size of EM learners, with cost and charges only applicable to the authors' home institution. Furthermore, the authors were only able to provide paired cost and charges of limited items in the ED. While the authors would have liked to demonstrate how hospital charges varied with insurance companies and individualized plans, the overarching goal was to determine if utilizing a game to reflect on healthcare costs was feasible in EM resident learners. The authors posit that the proposed structure described in this educational technical report can be easily generalized to other institutions with their respective costs and charges.

### Conclusions

With healthcare costs on the rise, our feasibility study demonstrated that gamification is an effective way to teach mindful, cost-conscious care to EM residents. Gamification offers a fun and engaging alternative that should be further utilized in EM educational formats. Future studies are needed to longitudinally assess learner retention and cost-containment practices.

### References

1. Hartman M, Martin AB, Espinosa N, Catlin A; The National Health Expenditure Accounts Team: National Health Care spending in 2016: spending and enrollment growth slow after initial coverage expansions. Health Affairs. 2018, 37:150-160. 10.1377/hlthaff.2017.1299
2. Levitt L: Single-payer health care: opportunities and vulnerabilities. J Am Med Assoc. 2018, 319:1646-1647. 10.1001/jama.2018.3997
3. Yu H, Greenberg M, Haviland A: The impact of state medical malpractice reform on individual-level health care expenditures. Health Services Res. 2017, 52:2018-2037. 10.1111/1475-6773.12789
4. Gaffney A, Lexchin J, US; Canadian Pharmaceutical Policy Reform Working Group: Healing an ailing pharmaceutical system: prescription for reform for United States and Canada. Br Med J. 2018, 361:k1039. 10.1136/bmj.k1039
5. Ryskina KL, Smith CD, Weissman A, et al.: U.S. Internal Medicine Residents' knowledge and practice of high-value care: a national survey. Acad Med. 2015, 90:1373-1379. 10.1097/acm.0000000000000791
6. Vijayasarathi A, Duszak R Jr, Gelbard RB, Mullins ME: Knowledge of the costs of diagnostic imaging: a survey of physician trainees at a large academic medical center. J Am Coll Radiol. 2016, 13:1304-1310. 10.1016/j.jacr.2016.05.009
7. Hoffman KA, Mancini M: Emergency health care professionals' understanding of the costs of care in the emergency department. J Am Osteopathic Assoc. 2017, 117:359-364. 10.7556/jaoa.2017.073
8. Stammen LA, Stalmeijer RE, Paternotte E, et al.: Training physicians to provide high-value, cost-conscious care: a systematic review. J Am Med Assoc. 2015, 314:2384-2400. 10.1001/jama.2015.16353
9. Hing E, Rui P, Ashman J: Expected source of payment at emergency department visits for adults aged 18-64 for the United States and in the five most populous states, 2012. Natl Center Health Stat Data Brief. 2016, 253:1-8.
10. Varkey P, Murad MH, Braun C, Grall KJ, Saoji V: A review of cost-effectiveness, cost-containment and economics curricula in graduate medical education. J Eval Clin Pract. 2010, 16:1055-1062. 10.1111/j.1365-2753.2009.01249.x
11. Liteplo AS, Carmody K, Fields MJ, Liu RB, Lewiss RE: SonoGames: effect of an innovative competitive game on the education, perception, and use of point-of-care ultrasound. J Ultrasound Med. 2018, 10.1002/jum.14606

### Appendices

Appendix 1: Post Medical Cost Game Evaluation Survey. Questions 1-22 were evaluated based on a 5-point Likert scale (1=strongly disagree, 5=strongly agree) or (1=extremely poor, 5=excellent).

1.    The course presented skills in a helpful sequence

2.    The course provided an appropriate balance between instruction and practice

3.    The course was appropriate for the stated level of the class

4.    The course was organized in a way that helped me learn

5.    The course provided a mixture of explanation and practice

6.    The course was effectively organized

7.    The course lectures complemented the EM curriculum

8.    The course instructions (including Powerpoint directions and verbal instructions) were clear

9.    The course helped me understand concepts (i.e. cost-conscious care) more clearly

10.   Instructions for the game content were clear

11.   The interactive game complemented my understanding of the lectures

12.   The section helped to complement the residency training

13.   Increased knowledge in hospital cost

14.    The course provided guidance on how to become a competent professional

15.    The course developed my ability to order hospital tests critically

16.   The course  helped me improve the way I order tests for workup

17.    The course developed my ability to provide constructive critiques to others

18.    The course gave me a deeper insight into the topic

19.    In this course, I learned a great deal

20.    The course improved my problem-solving skills

21.    The course developed my ability to think critically about the subject

22.    Overall, I would rate this presentation/instruction as:

Technical report
peer-reviewed

### Author Information

###### Ethics Statement and Conflict of Interest Disclosures

Human subjects: Consent was obtained by all participants in this study. Thomas Jefferson University issued approval 45 CFR 46.101. This study was determined to be EXEMPT from IRB review on 04/03/2018 pursuant to Title 45 Code of Federal Regulations Part 46.101(b) governing exempted protocol declarations. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.

###### Acknowledgements

The authors would like to acknowledge Frederick Randolph Jr., MD, Vice Chair of the Thomas Jefferson University Department of Emergency Medicine for his support in obtaining data for the study.

Technical report
peer-reviewed