Development of a high-value care subscore on the internal medicine in-training examination

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.

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

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.

U.S. IM residency programs.

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

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.

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.

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

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.

None.