Brenna Blackburn

Family Physicians’ Quality Interventions and Performance Improvement Through the ABFM Diabetes Performance in Practice Module

PURPOSE Practice performance assessment is the fourth requirement of Maintenance of Certification for Family Physicians (MC-FP). American Board of Family Medicine (ABFM) diplomates have many options for completing Part 4 requirements, including Web-based Performance in Practice Modules (PPMs) developed by the ABFM. Our objective was to describe the actions and outcomes of family physicians who completed the ABFM diabetes PPM. METHODS We undertook a descriptive study of all diabetes PPMs completed by physicians in the 50 United States and Washington, DC, from 2005 to October 2012. Successful completion required quality measure abstraction from 10 patient charts before and after a plan-do-study-act cycle improvement effort. We used descriptive statistics to assess physician demographics and quality outcomes. RESULTS Family physicians completed 7,924 diabetes qualitative improvement modules. Their mean age was 48.2 years, they had practiced a mean of 13.8 years, and three-fourths lived in urban areas (76.9%). Nearly one-half selected diabetic foot examination or eye examination as their quality improvement measure. Performance on all quality measures improved. Significant improvement was seen in rates of hemoglobin A1c control (<7.0%; 57.4% to 61.3%), blood pressure control (<130/90 mm Hg; 53.3% to 56.3%), foot examinations (68.0% to 85.8%); and retina examinations (55.5% to 71.1%). The most common interventions were standing orders (51.6%) and patient education (37.1%). CONCLUSIONS Family physicians participating in MC-FP implemented improvement projects and showed quality improvements in caring for patients with diabetes. Emphasis on quality of care by payers will increasingly require physicians to embrace quality measurement and improvement.

Improving quality of care for diabetes through a maintenance of certification activity: family physicians' use of the chronic care model.

Introduction: Improving the care of patients with diabetes is a health care priority. Through Part 4 of Maintenance of Certification for Family Physicians (MC‐FP), American Board of Family Medicine (ABFM) diplomates participate in quality improvement (QI) modules for diabetes. Our objective was to determine associations between physician characteristics and actions taken during Part 4 diabetes modules with quality of care outcomes. Methods: The study sample was all Part 4 modules completed by family physicians from 2005 to 2012. Descriptive statistics were used to characterize the physicians and their behavior in the module. We used linear regression to test for associations between choice of intervention, mode of intervention, and chronic care model domain with improvement in quality measures. Results: There were 7924 modules completed by family physicians, whose mean age was 48.2 years; 61.9% were male, and 76.9% lived in urban areas. All physician and patient quality measures improved over the course of the Part 4 module. Regression models found that only baseline performance was consistently associated with quality outcomes. No other consistent association was seen between intervention type, mode, or chronic care model domain and greater likelihood of improvements; however, every quality measure improved. Discussion: Through MC‐FP, family physicians improved the quality of care they delivered to diabetic patients. Improvement of care across nearly all measures, despite no consistent associations between processes of care or physician characteristics with improvement, suggests that participation in QI itself may lead to higher quality health care and this may be achieved through MC‐FP.

Family Physicians’ Quality Interventions and Performance Improvement for Hypertension through Maintenance of Certification

Purpose:Hypertension is a cause of considerable morbidity and mortality. Our objective was to describe the quality outcomes associated with physicians’ completion of hypertension Performance in Practice Modules (PPMs) as part of Maintenance of Certification (MOC). Methods:Descriptive study of all hypertension PPMs completed by family physicians from July 2006 to 2013. Descriptive statistics characterized physician demographics and quality outcomes; linear regression determined characteristics associated with improvement. Results:In total, 7,319 hypertension PPMs were completed by family physicians that had a mean age of 47.9 years and 14.2 years of practice experience. Most (52.4%) chose lipid control as their quality improvement (QI) focus. Performance on all quality measures improved except mean low-density lipoprotein (LDL) and high-density lipoprotein (HDL) cholesterol values; however, percentage of patients with LDL < 130 mg/dl improved. Improvement was seen in blood pressure control (87.4% to 92.6%, p < .05), low sodium diet counseling (74.1% to 92.7%, p < .05), and exercise counseling (82.4% to 94.4%, p < .05). In regression models, no variable was consistently associated with improvement. Discussion:Family physicians improved the quality of care for patients with hypertension through MOC. Leveraging MOC across all specialties may become an important support for improving management of conditions that cause considerable morbidity and mortality.

Do family physicians choose self-assessment activities based on what they know or don't know?

Introduction: Maintenance of Certification (MOC) for Family Physicians (MC‐FP) includes clinical Self‐Assessment Modules (SAMs). Whether family physicians choose SAMs that reflect their aptitudes or knowledge gaps has not been studied. Method: Secondary analysis of demographic data, 2009 certification examination scores, and 2009–2012 SAM participation data. We computed disease‐specific scores for asthma, diabetes, and hypertension from the examination. We ran unadjusted logistic and adjusted conditional logistic regression models of score quintiles, matched on the number of SAMs completed and controlling for physician demographics and area‐level social deprivation. Results: In 2009, 9 610 physicians passed the exam. Mean scores were 591.4 (SD ± 308.5) for asthma, 558.6 (SD ± 216.1) for diabetes, and 533.3 (± 226.7) for hypertension. Average scores on hypertension and diabetes were higher for physicians who subsequently completed related SAMs but not for those who completed the asthma SAM. The percentage of physicians in each quintile of scaled score who completed each SAM increased for diabetes (32.3%‐40.9%) and hypertension (33.0%‐36.9%). For asthma, logistic regression analyses found no statistically significant associations. For diabetes, there was a consistent association in both models between higher score quintile and likelihood of taking the SAM. For hypertension, an association of higher score and higher likelihood of taking the SAM was significant only in the third quintile (OR = 1.20 (1.03, 1.39)). Discussion: We found inconsistent relationships between physician knowledge and SAM selection. For MOC to better impact quality, boards should consider directing physicians toward MOC activities that fill knowledge gaps rather than areas of strength.

Family Physicians' Scope of Practice and American Board of Family Medicine Recertification Examination Performance

Purpose: Previous research indicated that rural family physicians were more likely to pass the American Board of Family Medicine (ABFM) Maintenance of Certification for Family Physicians (MC-FP) examination. One possible explanation is that rural family physicians may have a broader scope of practice. Method: This was a cross-sectional study of family physicians taking the ABFM MC-FP examination in 2013. Examination results were linked with the Scope of Practice for Primary Care (SP4PC) scale. Linear and logistic regression models, with and without SP4PC score, determined associations between scope of practice and examination results. Results: Among 10,978 examinees, rural physicians had a higher passing rate (90.7% vs 86.8%, P < .05) and higher SP4PC score (16.1 vs 14.3 P < .05) compared with urban physicians. Regression models without SP4PC score confirmed that urban physicians were less likely to pass (OR = 0.73; 95% CI, 0.62–0.87) and scored lower, −15.6 points, compared with rural physicians. Including SP4PC score completely attenuated the relationship between practice location and passing (OR = 0.86; 95% CI, 0.73–1.02) and decreased the relationship between score and practice location (−5.8 points). Each point increase on the SP4PC score was associated with 9% higher odds of passing (OR = 1.09; 95% CI, 1.07–1.11) and 4.9 more points. Conclusion: A broader scope of practice rather than rural or urban practice location, was associated with increased likelihood of passing the MC-FP examination. If higher board scores are associated with providing higher quality of care, then maintaining a broad scope of practice may enable the delivery of higher quality primary care.

Which Family Physicians Work Routinely With Nurse Practitioners, Physician Assistants or Certified Nurse Midwives

PURPOSE Facing rising numbers of insured with implementation of the Affordable Care Act, policy makers are interested in building teams of providers that can accommodate a growing demand for primary care services. Nurse Practitioners (NPs), Physician Assistants (PAs), and Certified Nurse Midwives (CNMs) already augment the physician workforce, particularly in rural areas. Our objective was to determine what physician and areal-level characteristics were associated with working with NPs, PAs or CNMs. METHODS The sample consisted of a convenience sample of physicians through the American Board of Family Medicine (ABFM) website in the fall of 2011. We linked these data to demographic and practice information collected by the ABFM and with provider information supplied from the National Provider Identifier file aggregated at the Primary Care Service Area level. Hierarchical logistic regression models were used to determine variables associated with working with NPs, PAs, or CNMs. FINDINGS Of the 3,855 family physicians in our sample, 60% reported routinely working with NPs, PAs, or CNMs. In regression analysis, characteristics positively associated with working with NPs, PAs, or CNMs were providing gynecological care (Odds Ratio = 1.23 [95% confidence interval, 1.06-1.42]), multispecialty group practice (OR = 1.72 [1.36-2.18]), any rural setting, and higher availability of PAs (OR = 1.40 [1.10-1.79]). Restrictive NP scope of practice laws failed to reach significance (OR = 0.86 [0.71-1.05]). CONCLUSIONS This study suggests that the number of family physicians routinely working with NPs, PAs, and CNMs continues to increase, which may allow for improved access to health care, particularly in rural areas.

Do family physicians electronic health records support meaningful use

BACKGROUND Spurred by government incentives, the use of electronic health records (EHRs) in the United States has increased; however, whether these EHRs have the functionality necessary to meet meaningful use (MU) criteria remains unknown. Our objective was to characterize family physician access to MU functionality when using a MU-certified EHR. METHODS Data were obtained from a convenience survey of family physicians accessing their American Board of Family Medicine online portfolio in 2011. A brief survey queried MU functionality. We used descriptive statistics to characterize the responses and bivariate statistics to test associations between MU and patient communication functions by presence of a MU-certified EHR. RESULTS Out of 3855 respondents, 60% reported having an EHR that supports MU. Physicians with MU-certified EHRs were more likely than physicians without MU-certified EHRs to report patient registry activities (49.7% vs. 32.3%, p-value<0.01), tracking quality measures (74.1% vs. 56.4%, p-value<0.01), access to labs or consultation notes, and electronic prescribing; but electronic communication abilities were low regardless of EHR capabilities. CONCLUSIONS Family physicians with MU-certified EHRs are more likely to report MU functionality; however, a sizeable minority does not report MU functions. IMPLICATIONS Many family physicians with MU-certified EHRs may not successfully meet the successively stringent MU criteria and may face significant upgrade costs to do so. LEVEL OF EVIDENCE Cross sectional survey.

A Majority of Family Physicians Use a Hospitalist Service When Their Patients Require Inpatient Care

Background:The hospitalist movement in the United States has risen in prominence over the past 2 decades with more physicians practicing as hospitalists. Our objective was to examine different strategies used by family physicians when their patients require inpatient care. Methods: Secondary analysis of a cross-sectional survey of physicians accessing the American Board of Family Medicine Web site in 2011 and the 2011 Area Resource File. Logistic regression assessed for associations between using hospitalists, managing inpatients personally, or with a group partner, and then comparing and contrasting these physicians with health care market characteristics. Results: A total of 3857 physicians had data on practice characteristics and could be geocoded to their county of residence. Compared with other physicians meeting inclusion criteria in the American Board of Family Medicine database, our sample was slightly older and more likely to be female. In all, 54% of respondents reported using hospitalist services while 18% reported managing hospitalized patients themselves. Respondents more likely to use hospitalist services were female and resided in urban areas. However, one third of these physicians living in isolated rural areas reported using hospitalist services. Respondents more likely to personally manage their patients in the hospital were more likely to be male and an international medical graduate. The likelihood of using hospitalist services increased with higher availability of hospitalist services. Conclusions: Overall, a majority of family physicians are using hospitalist services. Family physicians seem more likely to use hospitalist services when they are available which may lead to fragmentation of care.