title: Development of a high-value care subscore on the internal medicine in-training examination.
abstract: 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).
  
  
  METHODS
  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.
  
  
  METHODS
  U.S. IM residency programs.
  
  
  METHODS
  362 U.S. IM residency programs with IM-ITE data for at least 10 residents.
  
  
  METHODS
  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.
  
  
  CONCLUSIONS
  Knowledge of HVC assessed from examination vignettes may not reflect practice of HVC.
  
  
  CONCLUSIONS
  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.
  
  
  BACKGROUND
  None.
authors.forename: Kira L
authors.initials: KL
authors.lastname: Ryskina
authors.forename: Deborah
authors.initials: D
authors.lastname: Korenstein
authors.forename: Arlene
authors.initials: A
authors.lastname: Weissman
authors.forename: Philip
authors.initials: P
authors.lastname: Masters
authors.forename: Patrick
authors.initials: P
authors.lastname: Alguire
authors.forename: Cynthia D
authors.initials: CD
authors.lastname: Smith
mesh_terms: D002983:Clinical Competence; D003362:Cost-Benefit Analysis; D004521:Educational Measurement; D006801:Humans; D007388:Internal Medicine / Q000193:education*; D007396:Internship and Residency; D005791:Patient Care / Q000191:economics*; D014481:United States