• Lorette A Stammen, Renée E Stalmeijer, Emma Paternotte, Andrea Oudkerk Pool, Erik W Driessen, Fedde Scheele, and Laurents P S Stassen.
• Department of Educational Development and Research, Faculty of Health, Medicine, and Life Sciences, Maastricht University, Maastricht, the Netherlands.
• JAMA. 2015 Dec 8;314(22):2384-400.

ImportanceIncreasing health care expenditures are taxing the sustainability of the health care system. Physicians should be prepared to deliver high-value, cost-conscious care.ObjectiveTo understand the circumstances in which the delivery of high-value, cost-conscious care is learned, with a goal of informing development of effective educational interventions.Data SourcesPubMed, EMBASE, ERIC, and Cochrane databases were searched from inception until September 5, 2015, to identify learners and cost-related topics.Study SelectionStudies were included on the basis of topic relevance, implementation of intervention, evaluation of intervention, educational components in intervention, and appropriate target group. There was no restriction on study design.Data Extraction And SynthesisData extraction was guided by a merged and modified version of a Best Evidence in Medical Education abstraction form and a Cochrane data coding sheet. Articles were analyzed using the realist review method, a narrative review technique that focuses on understanding the underlying mechanisms in interventions. Recurrent patterns were identified in the data through thematic analyses. Resulting themes were discussed within the research team until consensus was reached.Main Outcomes And MeasuresMain outcomes were factors that promote education in delivering high-value, cost-conscious care.FindingsThe initial search identified 2650 articles; 79 met the inclusion criteria, of which 14 were randomized clinical trials. The majority of the studies were conducted in North America (78.5%) using a pre-post interventional design (58.2%; at least 1619 participants); they focused on practicing physicians (36.7%; at least 3448 participants), resident physicians (6.3%; n = 516), and medical students (15.2%; n = 275). Among the 14 randomized clinical trials, 12 addressed knowledge transmission, 7 reflective practice, and 1 supportive environment; 10 (71%) concluded that the intervention was effective. The data analysis suggested that 3 factors aid successful learning: (1) effective transmission of knowledge, related, for example, to general health economics and prices of health services, to scientific evidence regarding guidelines and the benefits and harms of health care, and to patient preferences and personal values (67 articles); (2) facilitation of reflective practice, such as providing feedback or asking reflective questions regarding decisions related to laboratory ordering or prescribing to give trainees insight into their past and current behavior (56 articles); and (3) creation of a supportive environment in which the organization of the health care system, the presence of role models of delivering high-value, cost-conscious care, and a culture of high-value, cost-conscious care reinforce the desired training goals (27 articles).Conclusions And RelevanceResearch on educating physicians to deliver high-value, cost-conscious care suggests that learning by practicing physicians, resident physicians, and medical students is promoted by combining specific knowledge transmission, reflective practice, and a supportive environment. These factors should be considered when educational interventions are being developed.

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