Value in health care is the measured improvement in a person’s health outcomes for the cost of achieving that improvement. While some descriptions conflate value-based health care and cost reduction, quality improvement, or patient satisfaction, those efforts—while important—are not the same as value, which focuses primarily on improving patient health outcomes. A decade of research into organizations that have achieved better outcomes while often lowering costs suggests a strategic framework for value-based health care implementation that starts with identifying and understanding a segment of patients whose health and related circumstances create a consistent set of needs. An interdisciplinary team of caregivers then comes together to design and deliver comprehensive solutions to address those needs. The team measures the health outcomes and costs of its care for each patient and uses that information to drive ongoing improvements. Care provided in this way aligns delivery with how patients experience their health and reconnects clinicians to their purpose as healers. It also asks physicians to think differently about their role within the larger care team and about the services that team provides. The authors suggest medical schools should incorporate education on the principles and implementation of value-based health care throughout the undergraduate medical curriculum to prepare their graduates to lead the transformation to value-based health care as they enter the physician workforce.

Abstract:The mean trophic level (TL) of fish landed in fisheries on the east and west coasts of Canada is declining by 0.03-0.10·decade -1 , similar to global trends. This finding is based on data from United Nations Food and Agriculture Organization and the Canadian Department of Fisheries and Oceans and other Canadian sources for the period 1873-1997. Significant rates of decline in mean TL were obtained even when key species -Atlantic cod (Gadus morhua) on the east coast and Pacific herring (Clupea pallasi) and Pacific hake (Merluccius productus) on the west coast -were omitted from the analysis. Fish taken in inland water fisheries did not exhibit a decline in mean TL. Two models were developed, based on length and age, respectively, for correcting TL estimates of individual species for the effects of changes in body size due to changes in fishing mortality. Both produced corrections that were small relative to changes in mean TL that resulted from changes in species composition of the catch over time. Overall, these results suggest that the mean TL of fish landed can be used as an index of sustainability in multispecies fisheries and that its reliability will depend on the quality of the data and length of the time series available for analysis.Résumé : Le niveau trophique (NT) moyen des poissons débarqués dans les pêches des côtes est et ouest du Canada baisse de 0,03 à 0,10 par décennie, comme c'est le cas dans les tendances mondiales. Ce constat se fonde sur des données de l'Organisation des Nations Unies pour l'alimentation et l'agriculture (FAO), du ministère des Pêches et des Océans du Canada et d'autres sources canadiennes, pour la période allant de 1873 à 1997. Des taux significatifs de dé-clin du NT moyen ont été obtenus même lorsque des espèces clés -morue franche sur la côte atlantique, hareng et merlu sur la côte pacifique -étaient omises dans l'analyse. Les poissons capturés dans les eaux intérieures ne présen-taient pas de baisse du NT moyen. Deux modèles ont été construits, basés respectivement sur la longueur et sur l'âge, pour corriger les estimations du NT de chaque espèce de façon à tenir compte des effets des changements de la taille corporelle dus à des changements dans la mortalité par pêche. Les deux modèles ont produit des corrections qui étaient petites par rapport aux changements dans le NT moyen dus à des modifications de la composition spécifique des captures au fil du temps. Globalement, ces résultats permettent de penser que le NT moyen des poissons débarqués peut être utilisé comme un indice de durabilité dans les pêches plurispécifiques, et que sa fiabilité dépendra de la qualité des données et de la longueur des séries chronologiques disponibles pour les analyses.[Traduit par la Rédaction] Invited perspectives and article 62

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Marine reserves have been suggested as tools for assisting the management of fisheries by protecting vulnerable marine species from overexploitation. Although there is a theoretical basis for believing that marine reserves may serve as management tools, there are few marine reserves in the world in which to test their effectiveness. My research evaluated three forms of marine reserve on the south coast of Vancouver Island, British Columbia, Canada. I used northern abalone (Haliotis kamtschatkana), a severely depleted shellfish in this region, as an indicator of the effectiveness of the reserves. Abalone populations in eight sites receiving different degrees of spatial protection were counted and measured in situ during the spring of 1996 and 1997. In all sites with enforced harvest closures, populations of abalone were greater, and one site with nearly 40 years of protection had on average much larger (older) abalone. Reproductive output, as a function of abundance and size, was also greater in the enforced reserve areas. Larval dispersal from reserves, and hence the benefit to exploited areas, was not formally surveyed. Nevertheless, the results of my study, combined with knowledge of present abalone populations, life history, and regional hydrodynamics, suggest that establishment of reserves is justified in the absence of perfect knowledge of larval dispersal.