Lorna A. Lynn

Promoting physicians' self‐assessment and quality improvement: The ABIM diabetes practice improvement module

Introduction: The American Board of Internal Medicine (ABIM) recognized that certification and recertification must be based on an assessment of performance in practice as well as an examination of medical knowledge. Physician self‐assessment of practice performance is proposed as one method that certification boards may use to evaluate competence in practice‐based learning and improvement and systems‐based practice. Methods: Sixteen practicing general internists and endocrinologists with 10‐year time‐limited certification participated in a beta test of the ABIMs diabetes practice improvement module (PIM) as part of their recertification program. A PIM consists of a self‐directed medical record audit, practice system survey, and patient survey. A quality improvement education specialist from the Connecticut Quality Improvement Organization provided on‐site and distance consultation on quality improvement methods and tools. An independent audit assessed the reliability of physician self‐audit. Qualitative interviews were conducted at 2 time points to assess for physician satisfaction and behavioral change in quality improvement. Results: Fourteen physicians completed the diabetes PIM. All but 1 physician found the medical record audit to provide important information about the practice. Of the 11 physicians who completed a follow‐up interview, 10 stated that the quality improvement education specialist helped improve their practice. Discussion: Self‐assessment using the ABIM diabetes PIM as part of recertification provides valuable practice information and can lead to meaningful behavioral change by physicians. Collaboration with an educator in quality improvement appears to facilitate the effects of the practice improvement module. Future work should investigate the effect on patient outcomes.

Association Between Imposition of a Maintenance of Certification Requirement and Ambulatory Care–Sensitive Hospitalizations and Health Care Costs

IMPORTANCE In 1990, the American Board of Internal Medicine (ABIM) ended lifelong certification by initiating a 10-year Maintenance of Certification (MOC) program that first took effect in 2000. Despite the importance of this change, there has been limited research examining associations between the MOC requirement and patient outcomes. OBJECTIVE To measure associations between the original ABIM MOC requirement and outcomes of care. DESIGN, SETTING, AND PARTICIPANTS Quasi-experimental comparison between outcomes for Medicare beneficiaries treated in 2001 by 2 groups of ABIM-certified internal medicine physicians (general internists). One group (n = 956), initially certified in 1991, was required to fulfill the MOC program in 2001 (MOC-required) and treated 84 215 beneficiaries in the sample; the other group (n = 974), initially certified in 1989, was grandfathered out of the MOC requirement (MOC-grandfathered) and treated 69 830 similar beneficiaries in the sample. We compared differences in outcomes for the beneficiary cohort treated by the MOC-required general internists before (1999-2000) and after (2002-2005) they were required to complete MOC, using the beneficiary cohort treated by the MOC-grandfathered general internists as the control. MAIN OUTCOMES AND MEASURES Quality measures were ambulatory care-sensitive hospitalizations (ACSHs), measured using prevention quality indicators. Ambulatory care-sensitive hospitalizations are hospitalizations triggered by conditions thought to be potentially preventable through better access to and quality of outpatient care. Other outcomes included health care cost measures (adjusted to 2013 dollars). RESULTS Annual incidence of ACSHs (per 1000 beneficiaries) increased from the pre-MOC period (37.9 for MOC-required beneficiaries vs 37.0 for MOC-grandfathered beneficiaries) to the post-MOC period (61.8 for MOC-required beneficiaries vs 61.4 for MOC-grandfathered beneficiaries) for both cohorts, as did annual per-beneficiary health care costs (pre-MOC period,

Setting a Fair Performance Standard for Physicians’ Quality of Patient Care

5157 for MOC-required beneficiaries vs

Variation in Internal Medicine Residency Clinic Practices: Assessing Practice Environments and Quality of Care

5133 for MOC-grandfathered beneficiaries; post-MOC period,

A three-part model for measuring diabetes care in physician practice.

7633 for MOC-required beneficiaries vs

Measuring physicians' performance in clinical practice: reliability, classification accuracy, and validity.

7793 for MOC-grandfathered beneficiaries). The MOC requirement was not statistically associated with cohort differences in the growth of the annual ACSH rate (per 1000 beneficiaries, 0.1 [95% CI, -1.7 to 1.9]; P = .92), but was associated with a cohort difference in the annual, per-beneficiary cost growth of -

Improving the Quality of Care via Maintenance of Certification and the Web: An Early Status Report

167 (95% CI, -

Toward better care coordination through improved communication with referring physicians.

270.5 to -

Gaps In Quality Of Diabetes Care In Internal Medicine Residency Clinics Suggest The Need For Better Ambulatory Care Training

63.5; P = .002; 2.5% of overall mean cost). CONCLUSION AND RELEVANCE Imposition of the MOC requirement was not associated with a difference in the increase in ACSHs but was associated with a small reduction in the growth differences of costs for a cohort of Medicare beneficiaries.

Comparative trial of a web-based tool to improve the quality of care provided to older adults in residency clinics: modest success and a tough road ahead.

BackgroundAssessing 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.ObjectiveDetermine if a rigorous approach for setting an objective, credible standard of minimally-acceptable performance could be used for practicing physicians caring for diabetic patients.DesignRetrospective cohort study.ParticipantsNine hundred and fifty-seven physicians from the United States with time-limited certification in internal medicine or a subspecialty.Main MeasuresThe 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.Key ResultsPhysicians 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).ConclusionsThe 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.