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Academia and the Profession |

Development of a High-Value Care Subscore on the Internal Medicine In-Training ExaminationAssessing Residents' Knowledge of HVC

Kira L. Ryskina, MD; Deborah Korenstein, MD; Arlene Weissman, PhD; Philip Masters, MD; Patrick Alguire, MD; and Cynthia D. Smith, MD
[+] Article, Author, and Disclosure Information

This article was published online first at www.annals.org on 14 October 2014.


From the Division of General Internal Medicine and Leonard Davis Institute of Health Economics, University of Pennsylvania, and American College of Physicians, Philadelphia, Pennsylvania.

Disclaimer: The content is solely the responsibility of the authors and does not necessarily represent the official views of the American College of Physicians.

Financial Support: Dr. Ryskina is supported by a National Research Service Award. Drs. Korenstein, Weissman, Masters, Alguire, and Smith are employees of the ACP.

Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M14-0444.

Requests for Single Reprints: Kira L. Ryskina, MD, Division of General Internal Medicine, University of Pennsylvania, 13-30B4, 13th Floor, Blockley Hall, 423 Guardian Drive, Philadelphia, PA 19104; e-mail, ryskina@mail.med.upenn.edu.

Current Author Addresses: Dr. Ryskina: Division of General Internal Medicine, University of Pennsylvania, 13-30B4, 13th Floor Blockley Hall, 423 Guardian Drive, Philadelphia, PA 19104.

Drs. Korenstein, Weissman, Masters, Alguire, and Smith: American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106-1572.

Author Contributions: Conception and design: K.L. Ryskina, D. Korenstein, P. Masters, P. Alguire, C.D. Smith.

Analysis and interpretation of the data: K.L. Ryskina, D. Korenstein, P. Masters, C.D. Smith.

Drafting of the article: K.L. Ryskina, D. Korenstein, A. Weissman, C.D. Smith.

Critical revision of the article for important intellectual content: K.L. Ryskina, D. Korenstein, P. Masters, P. Alguire, C.D. Smith.

Final approval of the article: K.L. Ryskina, D. Korenstein, A. Weissman, P. Masters, P. Alguire, C.D. Smith.

Provision of study materials or patients: A. Weissman, P. Masters, P. Alguire, C.D. Smith.

Statistical expertise: K.L. Ryskina, A. Weissman.

Administrative, technical, or logistic support: A. Weissman, P. Alguire, C.D. Smith.

Collection and assembly of data: A. Weissman, C.D. Smith.


Ann Intern Med. 2014;161(10):733-739. doi:10.7326/M14-0444
Text Size: A A A

Background: Although high-value care (HVC) that balances benefits of tests or treatments against potential harms and costs has been a recently emphasized competency for internal medicine (IM) residents, few tools to assess residents' knowledge of HVC are available.

Objective: To describe the development and initial results of an HVC subscore of the Internal Medicine In-Training Examination (IM-ITE).

Design: The HVC concepts were introduced to IM-ITE authors during question development. Three physicians independently reviewed each examination question for selection in the HVC subscore according to 6 HVC principles. The final subscore was determined by consensus. Data from the IM-ITE administered in October 2012 were analyzed at the program level.

Setting: U.S. IM residency programs.

Participants: 362 U.S. IM residency programs with IM-ITE data for at least 10 residents.

Measurements: Program-level performance on the HVC subscore was compared with performance on the overall IM-ITE, the Dartmouth Atlas hospital care intensity (HCI) index of the program's primary training hospital, and residents' attitudes about HVC assessed with a voluntary survey.

Results: The HVC subscore comprised 38 questions, including 21 (55%) on managing conservatively when appropriate and 14 (37%) on identifying low-value care. Of the 362 U.S. IM programs in the sample, 41% were in a different quartile when ranked based on the HVC subscore compared with overall IM-ITE performance. Rankings by HVC subscore and HCI index were modestly inversely associated, with 30% of programs ranked in the same quartile based on both measures.

Limitation: Knowledge of HVC assessed from examination vignettes may not reflect practice of HVC.

Conclusion: Although the HVC subscore has face validity and can contribute to evaluation of residents' HVC knowledge, additional tools are needed to accurately measure residents' proficiency in HVC.

Primary Funding Source: None.

Figures

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Figure 1.

Sample HVC examination question.

HVC = high-value care.

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Appendix Figure.

Program rankings based on overall IM-ITE score versus HVC subscore.

Programs were ranked from lowest (worst) to highest (best) score. Overall, 149 programs (41%) ranked in a different quartile based on the HVC subscore versus the overall IM-ITE, whereas 213 (59%) ranked in the same quartile. HVC = high-value care; IM-ITE = Internal Medicine In-Training Examination.

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Figure 2.

Program rankings based on HCI index versus HVC subscore.

Programs were ranked from lowest (worst) to highest (best) HVC subscore on the y-axis. Programs were ranked from most intensive (worst) to least intensive (best) HCI index score on the x-axis. Overall, 30% of programs ranked in the same quartile based on both measures. HCI = hospital care intensity; HVC = high-value care.

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