New score assesses residents’ knowledge of high value care

1. Using questions from the Internal Medicine In-Training Exam, the authors developed a score to measure residents’ knowledge of high value care (HVC).

2. There was no association between residents’ self-reported HVC behaviors and HVC subscore, but there was a weak, inverse relationship between hospital care intensity and the HVC subscore.

Evidence Rating Level: 2 (Good)       

Study Rundown: Residency programs have begun to emphasize high value care (HVC), which balances benefits with costs and harms, in training physicians. The authors of this study developed a tool to measure internal medicine residents’ knowledge of HVC using the Internal Medicine In-Training Exam (IM-ITE), where the authors selected questions pertaining to HVC to create a standardized system. The authors calculated HVC subscores for the residents’ training programs and compared the programs’ scores with residents’ self-reported HVC behaviors and with a national index reflecting intensity of care at training hospitals. There was no association between self-reported HVC practices and HVC subscore. There was a small, inverse relationship between HVC subscore and the intensity of care at residents’ training hospitals, but this was only observed among residents at hospitals at the extremes of care intensity. This study is limited in that the HVC scores were based on multiple-choice questions and not on clinical practice, and questions were not specifically designed to assess HVC. Furthermore, exam questions change from exam to exam, so ensuring consistent application of the subscore likely would require development of further questions and validation of their reliability as measures of HVC. Overall, the HVC subscore has potential to serve as part of the HVC evaluation for residents.

Click to read the study in Annals of Internal Medicine

Relevant Reading: High-Value, Cost-Conscious Health Care: Concepts for Clinicians to Evaluate the Benefits, Harms, and Costs of Medical Interventions

In-Depth [cross-sectional]: This score represents the first attempt to develop a comprehensive measure of HVC knowledge among internal medicine residents. Three authors, all experienced clinician-educators, selected IM-ITE questions by consensus for inclusion in the subscore. Each question related to one or more of six HVC competencies: 1) low-value, high-cost or harmful diagnostic tests, 2) recognizing a diagnosis without further testing, 3) conservative management, 4) selecting the best-value test or therapy among equally-effective options, 5) considering cost and risk for screening recommendations, and 6) understanding statistics for tests or therapies. The authors used the hospital care intensity (HCI) index to assess training hospitals’ intensity of care, and a standardized questionnaire to measure residents’ HVC behaviors. Among programs, 30% ranked in the same quartile according to HVC subscore and HCI index. The authors recommend addition of tools like observed structured clinical examinations to continue to refine HVC knowledge assessment.

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