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High-value care programmes from the bottom-up… and the top-down
  1. Christopher Moriates1,2,3,
  2. Brian M Wong4,5,6
  1. 1Department of Medicine, University of California at San Francisco, San Francisco, California, USA
  2. 2Center for Healthcare Value, University of California at San Francisco, San Francisco, California, USA
  3. 3Costs of Care, Boston, Massachusetts, USA
  4. 4Division of General Internal Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
  5. 5Department of Medicine, University of Toronto, Toronto, Ontario, Canada
  6. 6Department of Medicine, Centre for Quality Improvement and Patient Safety, University of Toronto, Toronto, Ontario, Canada
  1. Correspondence to Dr Christopher Moriates, 505 Parnassus Ave, M1287, San Francisco, CA 94143, USA; CMoriates{at}

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The introduction of high-value care into medical education is emerging as a global imperative.1 While delivering on the promise of ‘best care at lower cost’ will require major shifts at every level of the healthcare system,2 training the new pipeline of health professionals in both the ideals and the execution of high-value care remains a critical target for creating future change.3 ,4

Stinnett-Donnelly and colleagues describe a programme at their academic institution aimed at simultaneously reducing unnecessary or harmful care, improving patient experience and educating resident trainees about high-value care.5 Over the first two years of this comprehensive programme, this US academic medical centre (the University of Vermont) realised impressive reductions across dual-energy X-ray absorptiometry scans in non-elderly women, daily chest X-rays in the intensive care unit and routine serum creatinine measurements in patients undergoing chronic dialysis. These interventions improved quality of care by eliminating wasteful tests and also resulted in measurable cost savings for the institution, estimated conservatively to be $326 974 thus far.

The resident physicians in this programme contributed insights on areas of waste, served as peer educators, and co-led projects—a strategy that the authors highlight as an effective ‘bottom-up’ approach. There is no doubt that this type of front-line engagement of learners is necessary to move high-value care initiatives forward, and likely was largely responsible for some of the early successes seen in this study. However, we note that, unlike some of our experiences with quality improvement (QI) and patient safety initiatives, garnering enthusiasm from residents for high-value care tends not to be challenging: talk to resident physicians about something like hand hygiene and it is difficult …

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