-
[show abstract]
[hide abstract]
ABSTRACT: Changes in certification requirements and examinee characteristics are likely to influence the validity of the evidence associated with interpretations made based on test data. We examined whether changes in Educational Commission for Foreign Medical Graduates (ECFMG) certification requirements over time were associated with changes in internal medicine (IM) residency program director ratings and certification examination scores. Comparisons were made between physicians who were ECFMG-certified before and after the Clinical Skills Assessment (CSA) requirement. A multivariate analysis of covariance was conducted to examine the differences in program director ratings based on CSA cohort and whether the examinees emigrated for undergraduate medical education (national vs. international students). A univariate analysis of covariance was conducted to examine differences in scores from the American Board of Internal Medicine (ABIM) Internal Medicine Certification Examination. For both analyses, United States Medical Licensing Examination (USMLE) Step 1 and Step 2 scores were used as covariates. Results indicate that, of those certified by ECFMG between 1993 and 1997, 17 % (n = 1,775) left their country of citizenship for undergraduate medical education. In contrast, 38 % (n = 1,874) of those certified between 1999 and 2003 were international students. After adjustment by covariates, the main effect of cohort membership on the program director ratings was statistically significant (Wilks' λ = 0.99, F 5, 15391 = 19.9, P < 0.001). However, the strength of the relationship between cohort group and the ratings was weak (η = 0.01). The main effect of migration status was statistically significant and weak (Wilks' λ = 0.98, F 5,15391 = 45.3, P < 0.01; η = 0.02). Differences in ABIM Internal Medicine Certification Examination scores based on whether or not CSA were required was statistically significant, although the magnitude of the association between these variables was very small. The findings suggest that the implementation of an additional evaluation of skills (e.g., history-taking, physical examination) as a prerequisite to postgraduate medical education (residency) provides some additional, relevant data to those who select ECFMG-certified residents.
Advances in Health Sciences Education 04/2013; · 2.09 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Given the rising burden of healthcare costs, both patients and healthcare purchasers are interested in discerning which physicians deliver quality care. We proposed a methodology to assess physician clinical performance in preventive cardiology care, and determined a benchmark for minimally acceptable performance. We used data on eight evidence-based clinical measures from 811 physicians that completed the American Board of Internal Medicine's Preventive Cardiology Practice Improvement Module(SM) to form an overall composite score for preventive cardiology care. An expert panel of nine internists/cardiologists skilled in preventive care for cardiovascular disease used an adaptation of the Angoff standard-setting method and the Dunn-Rankin method to create the composite and establish a standard. Physician characteristics were used to examine the validity of the inferences made from the composite scores. The mean composite score was 73.88 % (SD = 11.88 %). Reliability of the composite was high at 0.87. Specialized cardiologists had significantly lower composite scores (P = 0.04), while physicians who reported spending more time in primary, longitudinal, and preventive consultative care had significantly higher scores (P = 0.01), providing some evidence of score validity. The panel established a standard of 47.38 % on the composite measure with high classification accuracy (0.98). Only 2.7 % of the physicians performed below the standard for minimally acceptable preventive cardiovascular disease care. Of those, 64 % (N = 14) were not general cardiologists. Our study presents a psychometrically defensible methodology for assessing physician performance in preventive cardiology while also providing relative feedback with the hope of heightening physician awareness about deficits and improving patient care.
Advances in Health Sciences Education 02/2013; · 2.09 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: PURPOSE: Educators in internal medicine are concerned that reducing clinical training from three years to two could negatively affect physicians' ability to provide good patient care. Physician-scientists already follow a short-track research pathway that shortens clinical training to two years. The authors examine whether this shortened training affects ability. METHOD: The authors use a national sample of 101,031 physicians who took their first internal medicine certification examination between 1993 and 2008 and trained in either a traditional or research pathway. They collected data, including demographics, exam information, and maintenance of certification (MOC) return rates. They used regression models to assess the relationship between training pathway and MOC exam scores and eventual certification status, adjusting for physician characteristics. RESULTS: In this study, research pathway training did not adversely impact internal medicine certification status. Although the scores of physicians who followed the research pathway were slightly lower, the effect size was small. In a subset of research pathway physicians, 63% remained in academic medicine and 37% continued to spend a substantial portion of time in medical research 10 years later. CONCLUSIONS: Different training pathways can lead to similar achievements in clinical judgment. The educational model, competency-based rather than time-dependent, that works for research pathway physicians could be extended to other talented trainees who would benefit by customizing training to meet career goals.
Academic medicine: journal of the Association of American Medical Colleges 09/2012; · 2.34 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: To ensure that medical residents will be prepared to deliver consistently high-quality care, they should be trained in settings that provide such care. Residents in internal medicine, particularly, need to learn good care habits in order to meet the needs of patients with diabetes and other common chronic and high-impact illnesses. To assess the strength of such training, we compared the quality of medical care provided in sixty-seven US internal medicine residency ambulatory clinics with the quality of care provided by 703 practicing general internists. We found significant quality gaps in process, intermediate outcome, and patient-experience measures. These inadequacies in ambulatory training for internal medicine residents must be addressed by policy makers and educators-for example, by accelerating the movement toward new residency curricula that emphasize competency-based training.
Health Affairs 01/2012; 31(1):150-8. · 4.31 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: To examine the association between physicians' cognitive skills and their performance on a composite measure of diabetes care that included process, outcome, and patient experience measures.
The sample was 676 physicians from the United States with time-limited certification in general internal medicine between 2005 and 2009. Scores from the American Board of Internal Medicine (ABIM) internal medicine maintenance of certification (MOC) examination were used to measure practicing physicians' cognitive skills (scores reflect fund of medical knowledge, diagnostic acumen, and clinical judgment). Practice performance was assessed using a diabetes composite measure aggregated from clinical and patient experience measures obtained from the ABIM Diabetes Practice Improvement Module.
Using multiple regression analyses and controlling for physician and patient characteristics, MOC examination scores were significantly associated with the diabetes composite scores (β = .22, P < .001). The association was particularly stronger with intermediate outcomes than with process and patient experience measures. Performance in the endocrine disease content domain of the examination was more strongly associated with the diabetes composite scores (β = .19, P < .001) than the performance in other medical content domains (β = .06-.14).
Physicians' cognitive skills significantly relate to their performance on a comprehensive composite measure for diabetes care. Although significant, the modest association suggests that there are unique aspects of physician competence captured by each assessment alone and that both must be considered when assessing a physician's ability to provide high-quality care.
Academic medicine: journal of the Association of American Medical Colleges 12/2011; 87(2):157-63. · 2.34 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Clinical protocols are associated with improved patient outcomes; however, they may negatively affect medical education by removing trainees from clinical decision making.
To study the relationship between critical care training with mechanical ventilation protocols and subsequent knowledge about ventilator management.
A retrospective cohort equivalence study, linking a national survey of mechanical ventilation protocol availability in accredited US pulmonary and critical care fellowship programs with knowledge about mechanical ventilation among first-time examinees of the American Board of Internal Medicine (ABIM) Critical Care Medicine Certification Examination in 2008 and 2009. Exposure to protocols was defined as high intensity if an examinee's training intensive care unit had 2 or more protocols for at least 3 years and as low intensity if 0 or 1 protocol.
Knowledge, measured by performance on examination questions specific to mechanical ventilation management, calculated as a mechanical ventilation score using item response theory. The score is standardized to a mean (SD) of 500 (100), and a clinically important difference is defined as 25. Variables included in adjusted analyses were birth country, residency training country, and overall first-attempt score on the ABIM Internal Medicine Certification Examination.
Ninety of 129 programs (70%) responded to the survey. Seventy-seven programs (86%) had protocols for ventilation liberation, 66 (73%) for sedation management, and 54 (60%) for lung-protective ventilation at the time of the survey. Eighty-eight (98%) of these programs had trainees who completed the ABIM Critical Care Medicine Certification Examination, totaling 553 examinees. Of these 88 programs, 27 (31%) had 0 protocols, 19 (22%) had 1 protocol, 24 (27%) had 2 protocols, and 18 (20%) had 3 protocols for at least 3 years. Forty-two programs (48%) were classified as high intensity and 46 (52%) as low intensity, with 304 trainees (55%) and 249 trainees (45%), respectively. In bivariable analysis, no difference in mean scores was observed in high-intensity (497; 95% CI, 486-507) vs low-intensity programs (497; 95% CI, 485-509). Mean difference was 0 (95% CI, -16 to 16), with a positive value indicating a higher score in the high-intensity group. In multivariable analyses, no association of training was observed in a high-intensity program with mechanical ventilation score (adjusted mean difference, -5.36; 95% CI, -20.7 to 10.0).
Among first-time ABIM Critical Care Medicine Certification Examination examinees, training in a high-intensity ventilator protocol environment compared with a low-intensity environment was not associated with worse performance on examination questions about mechanical ventilation management.
JAMA The Journal of the American Medical Association 09/2011; 306(9):935-41. · 30.03 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Little is known about the best approaches and format for measuring physicians' communication skills in an online environment. This study examines the reliability and validity of scores from two Web-based communication skill assessment formats.
We created two online communication skill assessment formats: (a) MCQ (multiple-choice questions) consisting of video-based multiple-choice questions; (b) multi-format including video-based multiple-choice questions with rationales, Likert-type scales, and free text responses of what physicians would say to a patient. We randomized 100 general internists to each test format. Peer and patient ratings collected via the American Board of Internal Medicine (ABIM) served as validity sources.
Seventy-seven internists completed the tests (MCQ: 38; multi-format: 39). The adjusted reliability was 0.74 for both formats. Excellent communicators, as based on their peer and patient ratings, performed slightly better on both tests than adequate communicators, though this difference was not statistically significant. Physicians in both groups rated test format innovative (4.2 out of 5.0).
The acceptable reliability and participants' overall positive experiences point to the value of ongoing research into rigorous Web-based communication skills assessment.
With efficient and reliable scoring, the Web offers an important way to measure and potentially enhance physicians' communication skills.
Patient Education and Counseling 05/2011; 84(3):359-67. · 2.31 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: To investigate the feasibility, reliability, and validity of comprehensively assessing physician-level performance in ambulatory practice.
Ambulatory-based general internists in 13 states participated in the assessment.
We assessed physician-level performance, adjusted for patient factors, on 46 individual measures, an overall composite measure, and composite measures for chronic, acute, and preventive care. Between- versus within-physician variation was quantified by intraclass correlation coefficients (ICC). External validity was assessed by correlating performance on a certification exam.
Medical records for 236 physicians were audited for seven chronic and four acute care conditions, and six age- and gender-appropriate preventive services.
Performance on the individual and composite measures varied substantially within (range 5-86 percent compliance on 46 measures) and between physicians (ICC range 0.12-0.88). Reliabilities for the composite measures were robust: 0.88 for chronic care and 0.87 for preventive services. Higher certification exam scores were associated with better performance on the overall (r = 0.19; p<.01), chronic care (r = 0.14, p = .04), and preventive services composites (r = 0.17, p = .01).
Our results suggest that reliable and valid comprehensive assessment of the quality of chronic and preventive care can be achieved by creating composite measures and by sampling feasible numbers of patients for each condition.
Health Services Research 12/2010; 45(6 Pt 2):1912-33. · 2.16 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Assessing physicians' clinical performance using statistically sound, evidence-based measures is challenging. Little research has focused on methodological approaches to setting performance standards to which physicians are being held accountable.
Determine if a rigorous approach for setting an objective, credible standard of minimally-acceptable performance could be used for practicing physicians caring for diabetic patients.
Retrospective cohort study.
Nine hundred and fifty-seven physicians from the United States with time-limited certification in internal medicine or a subspecialty.
The ABIM Diabetes Practice Improvement Module was used to collect data on ten clinical and two patient experience measures. A panel of eight internists/subspecialists representing essential perspectives of clinical practice applied an adaptation of the Angoff method to judge how physicians who provide minimally-acceptable care would perform on individual measures to establish performance thresholds. Panelists then rated each measure's relative importance and the Dunn-Rankin method was applied to establish scoring weights for the composite measure. Physician characteristics were used to support the standard-setting outcome.
Physicians abstracted 20,131 patient charts and 18,974 patient surveys were completed. The panel established reasonable performance thresholds and importance weights, yielding a standard of 48.51 (out of 100 possible points) on the composite measure with high classification accuracy (0.98). The 38 (4%) outlier physicians who did not meet the standard had lower ratings of overall clinical competence and professional behavior/attitude from former residency program directors (p = 0.01 and p = 0.006, respectively), lower Internal Medicine certification and maintenance of certification examination scores (p = 0.005 and p < 0.001, respectively), and primarily worked as solo practitioners (p = 0.02).
The standard-setting method yielded a credible, defensible performance standard for diabetes care based on informed judgment that resulted in a reasonable, reproducible outcome. Our method represents one approach to identifying outlier physicians for intervention to protect patients.
Journal of General Internal Medicine 11/2010; 26(5):467-73. · 2.83 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: A shortage of primary care physicians is expected, due in part to decreasing numbers of physicians entering general internal medicine (GIM). Practicing general internists may contribute to the shortage by leaving internal medicine (IM) for other careers in and out of medicine.
To better understand mid-career attrition in IM.
Mail survey to a national sample of internists originally certified by the American Board of Internal Medicine in GIM or an IM subspecialty during the years 1990 to 1995.
Self-reported current status as working in IM, working in another medical or non-medical field, not currently working but plan to return, or retired; and career satisfaction.
Nine percent of all internists in the 1990-1995 certification cohorts and a significantly larger proportion of general internists (17%) than IM subspecialists [(4%) P < 0.001] had left IM at mid career. A significantly lower proportion of general internists (70%) than IM subspecialists [(77%) (P < 0.008)] were satisfied with their career. The proportion of general internists who had left IM in 2006 (19%) was not significantly different from the 21% who left in 2004 (P = 0.45). The proportion of general internists who left IM was not significantly different in earlier (1990-92; 19%) versus later (1993-95; 15%) certification cohorts (P = 0.15).
About one in six general internists leave IM by mid-career compared to one in 25 IM subspecialists. Although research finds that doctors leave medicine because of dissatisfaction, this study was inconclusive about whether general internists left IM in greater proportion than IM subspecialists for this reason. A more likely explanation is that GIM serves as a stepping stone to careers outside of IM.
Journal of General Internal Medicine 10/2010; 25(10):1020-3. · 2.83 Impact Factor
-
JAMA The Journal of the American Medical Association 09/2010; 304(12):1379-80. · 30.03 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Much research has been devoted to addressing challenges in achieving reliable assessments of physicians' clinical performance but less work has focused on whether valid and accurate classification decisions are feasible. This study used 957 physicians certified in internal medicine (IM) or a subspecialty, who completed the American Board of Internal Medicine (ABIM) Diabetes Practice Improvement Module (PIM). Ten clinical and two patient-experience measures were aggregated into a composite measure. The composite measure score was highly reliable (r = .91) and classification accuracy was high across the entire score scale (>0.90), which indicated that it is possible to differentiate high-performing and low-performing physicians. Physicians certified in endocrinology and those who scored higher on their IM certification examination had higher composite scores, providing some validity evidence. In summary, it is feasible to create a psychometrically robust composite measure of physicians' clinical performance, specifically for the quality of care they provide to patients with diabetes.
Evaluation & the Health Professions 09/2010; 33(3):302-20. · 1.23 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Interventional cardiology, with large numbers of complex procedures and potentially serious complications, stands out as an obvious discipline in which to apply simulation to help prevent medical errors. The objective of the study was to determine whether it is feasible to develop a valid and reliable evaluation approach using medical simulation to assess technical and cognitive skills of physicians performing coronary interventions.
Clinical case scenarios were developed by a committee of subject matter experts, who defined key decision nodes, such as stent positioning, and introduced unanticipated complications, such as coronary perforation. Subjects were 115 physicians from 10 U.S. healthcare institutions at three levels of expertise: novice, skilled, or expert. Subjects completed a questionnaire, one practice case and six test cases on a SimSuite simulator (Medical Simulation Corporation, Denver, CO), and an opinion survey. Clinical specialists rated subjects' procedural skills.
A technical and cognitive skills evaluation of performance in interventional cardiology procedures using medical simulation yielded results that distinguished between a novice group and skilled or expert groups (P<0.001) and scores correlated moderately with clinical specialist ratings of subjects' procedural skills and with number and complexity of procedures performed in practice during the previous year. Approximately 90% of subjects generally thought that the cases were well simulated and presented situations encountered in practice.
This study suggests that an evaluation approach using high-fidelity medical simulation to assess technical and cognitive skills of physicians performing interventional cardiology procedures can be used to identify physicians who are extremely poor performers and not likely to be providing appropriate patient care. We believe that use of a high-fidelity simulator incorporating situations with multiple events, immediate feedback, and high sensory load would complement the results of traditional written examinations of medical knowledge to provide a more comprehensive assessment of physician ability in interventional cardiology.
Simulation in healthcare: journal of the Society for Simulation in Healthcare 04/2010; 5(2):65-74. · 1.83 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: The U.S. health care system is not prepared to meet the needs of the increasing population of older adults. Few physicians become geriatricians, but most will care for older adults. The authors assessed the quality of care for older adults in residency clinics and physician practices.
Using the American Board of Internal Medicine's Care of the Vulnerable Elderly practice improvement module, researchers studied the quality of care provided to older adults in 52 internal and family medicine residency clinic sites and by a motivated group of 144 practicing physicians from 2006 to 2008. They also studied the characteristics of the practice systems in the clinics and offices and the relationship between specific elements of practice systems and the quality of care.
Patients seen by residents were younger, had fewer chronic conditions, and were less likely to receive recommended care. Residency clinic systems were less likely to have elements designed to support care for older adults. Even when present, there was little correlation with care provided. Practicing physicians were more likely to provide recommended processes of care, and system elements in their practices were more likely to function well and correlate with delivery of key processes of care, but much room for improvement remains.
Practice system elements designed to support care for older adults perform differently in residency clinics than in practicing physicians' offices. Significant gaps in the quality of care for older adults exist and are much more pronounced in the residency clinic setting.
Academic medicine: journal of the Association of American Medical Colleges 12/2009; 84(12):1732-40. · 2.34 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Effective care coordination requires good physician-to-physician communication. The authors evaluated a new tool called the Communication with Referring Physicians Practice Improvement Module (CRP-PIM), which assesses and encourages improved communication among physician consultants and referring physicians.
Eight-hundred three consultants (internists and subspecialists) completed a practice system survey and were rated by 12,212 referring physicians on 13 communication processes using a six-point scale. Consultants received an interactive performance report and selected targets for improvement. Data were analyzed using descriptive statistics, correlations, t tests, and factor analysis.
Mean overall rating was high, at 5.53 (SD 0.23, range 2.46-5.95); consultants still identified areas for improvement. The generalizability coefficient for overall ratings was 0.78. Factor analysis supported two categories of ratings associated with consultants' gender, subspecialty, residency performance ratings, and specific practice system features.
The CRP-PIM provides a psychometrically viable measure and encourages consultants to improve communication with referring physicians.
Academic medicine: journal of the Association of American Medical Colleges 10/2009; 84(10 Suppl):S109-12. · 2.34 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: The relationship between physicians' cognitive skill and the delivery of evidence-based processes of care is not well characterized.Therefore, we set out to determine associations between general internists' performance on the American Board of Internal Medicine maintenance of certification examination and the receipt of important processes of care by Medicare patients.
Physicians were grouped into quartiles based on their performance on the American Board of Internal Medicine examination. Hierarchical generalized linear models examined associations between examination scores and the receipt of processes of care by Medicare patients. The main outcome measures were the associations between diabetes care, using a composite measure of hemoglobin A(1c), and lipid testing and retinal screening, mammography, and lipid testing in patients with cardiovascular disease and the physician's performance on the American Board of Internal Medicine examination, adjusted for the number of Medicare patients with diabetes and cardiovascular disease in a physician's practice panel; frequency of visits; patient comorbidity, age, and ethnicity; and physician training history and type of practice.
Physicians scoring in the top quartile were more likely to perform processes of care for diabetes (composite measure odds ratio [OR], 1.17; 95% confidence interval [CI], 1.07-1.27) and mammography screening (OR, 1.14; 95% CI, 1.08-1.21) than physicians in the lowest physician quartile, even after adjustment for multiple factors. There was no significant difference among the groups in lipid testing of patients with cardiovascular disease (OR, 1.00; 95% CI, 0.91-1.10).
Our findings suggest that physician cognitive skills, as measured by a maintenance of certification examination, are associated with higher rates of processes of care for Medicare patients.
Archives of internal medicine 08/2008; 168(13):1396-403. · 11.46 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Few studies have systematically and rigorously examined the quality of care provided in educational practice sites.
The objectives of this study were to (1) describe the patient population cared for by trainees in internal medicine residency clinics; (2) assess the quality of preventive cardiology care provided to these patients; (3) characterize the practice-based systems that currently exist in internal medicine residency clinics; and (4) examine the relationships between quality, practice-based systems, and features of the program: size, type of program, and presence of an electronic medical record.
This is a cross-sectional observational study.
This study was conducted in 15 Internal Medicine residency programs (23 sites) throughout the USA.
The participants included site champions at residency programs and 709 residents.
Abstracted charts provided data about patient demographics, coronary heart disease risk factors, processes of care, and clinical outcomes. Patients completed surveys regarding satisfaction. Site teams completed a practice systems survey.
Chart abstraction of 4,783 patients showed substantial variability across sites. On average, patients had between 3 and 4 of the 9 potential risk factors for coronary heart disease, and approximately 21% had at least 1 important barrier of care. Patients received an average of 57% (range, 30-77%) of the appropriate interventions. Reported satisfaction with care was high. Sites with an electronic medical record showed better overall information management (81% vs 27%) and better modes of communication (79% vs 43%).
This study has provided insight into the current state of practice in residency sites including aspects of the practice environment and quality of preventive cardiology care delivered. Substantial heterogeneity among the training sites exists. Continuous measurement of the quality of care provided and a better understanding of the training environment in which this care is delivered are important goals for delivering high quality patient care.
Journal of General Internal Medicine 08/2008; 23(7):914-20. · 2.83 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Physicians who are disciplined by state licensing boards are more likely to have demonstrated unprofessional behavior in medical school. Information is limited on whether similar performance measures taken during residency can predict performance as practicing physicians.
To determine whether performance measures during residency predict the likelihood of future disciplinary actions against practicing internists.
Retrospective cohort study.
State licensing board disciplinary actions against physicians from 1990 to 2006.
66,171 physicians who entered internal medicine residency training in the United States from 1990 to 2000 and became diplomates.
Predictor variables included components of the Residents' Annual Evaluation Summary ratings and American Board of Internal Medicine (ABIM) certification examination scores.
2 performance measures independently predicted disciplinary action. A low professionalism rating on the Residents' Annual Evaluation Summary predicted increased risk for disciplinary action (hazard ratio, 1.7 [95% CI, 1.3 to 2.2]), and high performance on the ABIM certification examination predicted decreased risk for disciplinary action (hazard ratio, 0.7 [CI, 0.60 to 0.70] for American or Canadian medical school graduates and 0.9 [CI, 0.80 to 1.0] for international medical school graduates). Progressively better professionalism ratings and ABIM certification examination scores were associated with less risk for subsequent disciplinary actions; the risk ranged from 4.0% for the lowest professionalism rating to 0.5% for the highest and from 2.5% for the lowest examination scores to 0.0% for the highest.
The study was retrospective. Some diplomates may have practiced outside of the United States. Nondiplomates were excluded.
Poor performance on behavioral and cognitive measures during residency are associated with greater risk for state licensing board actions against practicing physicians at every point on a performance continuum. These findings support the Accreditation Council for Graduate Medical Education standards for professionalism and cognitive performance and the development of best practices to remediate these deficiencies.
Annals of internal medicine 06/2008; 148(11):869-76. · 16.73 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: To assess the psychometric properties of the three components of the Diabetes Practice Improvement Module, to compare reliabilities of composites to individual measures, and to identify associations among practice-based and patient-based measures.
Data include practice systems surveys of 626 physicians, 13,965 chart audits, and 12,927 patient surveys. Quality composites were identified using factor analysis. Means with reliabilities (intraclass correlation coefficient [ICC] and Cronbach's alpha) are reported. Associations among patient-based quality measures and practice measures with case-mix adjustments were estimated via hierarchical models.
Composite ICCs range from 0.11 to 0.54, and single items range from 0.05 to 0.49. Staff communication, efficiency, care access, and patient knowledge correlate with patient satisfaction (P < .001). Clinical outcomes are associated with clinical processes (e.g., annual foot exam) and appropriate treatment (P < .001). Patient adjusters (e.g., overall health or factors limiting self-care) are important for the models; physician characteristics used (e.g., age, practice size) seem less important.
Composites require smaller patient sample sizes and result in more reliable measures than do individual items. Additionally, the data show meaningful relationships between composites; physician-directed components (i.e., clinical processes and treatments) are related to clinical outcomes, and patients are clearly more satisfied with care if it is easily accessible and if communication about care is good.
Academic Medicine 10/2007; 82(10 Suppl):S48-52. · 3.52 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: The American Board of Medical Specialties (ABMS) adopted a framework, called Maintenance of Certification (MOC), for all certifying boards to evaluate physicians' competence throughout their careers, with the goal of improving the quality of health care. The MOC participation rates of the American Board of Internal Medicine (ABIM) show that 23% of general internists and 14% of subspecialists choose not to renew their respective certificates.
To study U.S. internists' perceptions about the forces driving them to maintain certification.
Mail survey.
A nationally representative sample of certified internists in the United States.
Physicians originally certified in internal medicine, a subspecialty, or an area of added qualifications in 1990, 1991, or 1992.
The overall rate of response to the survey was 51%. Although 91% of all participants are still working in internal medicine or its subspecialties, this percentage is notably lower among general internists (79%). Of those still working in the field of internal medicine or its subspecialties, approximately half report being required to maintain their specialty certificate by at least 1 employer, but only approximately one third of those who completed or enrolled in MOC report this requirement as a reason for participating. Those who completed or enrolled in MOC do so more for positive professional reasons than for monetary benefits or professional advancement. The most common reasons for not participating are the perceptions that it takes too much time, is too expensive, and is not required for employment.
Respondents were volunteers from an early cohort of diplomates entering the program, and those with less positive attitudes may have responded at higher rates. Results are based on self-reported data, and misconceptions about program requirements may have led to some inaccurate responses.
The relatively large percentage of general internists who left internal medicine mostly to work in another medical field explains why rates of MOC participation for general internists seem lower than those for subspecialists (77% vs. 86%). Although positive professional reasons clearly have a compelling internal influence on program participation, it is less clear whether employers' requirements are an equally compelling external influence. Although half of all respondents report that MOC is required by 1 of their employers, only one third of those who participate in the program describe it as a reason for participating.
Annals of internal medicine 02/2006; 144(1):29-36. · 16.73 Impact Factor
