Internal Residency Clinic Practice
Mladenovic, J., Shea, J. A., Duffy, F. D., Lynn, L. A., Holmboe, E. S., & Lipner, R. S. (2008). Variation in internal medicine residency clinic practices: assessing practice environments and quality of care. Journal Of General Internal Medicine, 23(7), 914-920. doi:10.1007/s11606-008-051
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LINKING EDUCATION AND QUALITY OF CARE
Variation in Internal Medicine Residency Clinic Practices:
Assessing Practice Environments and Quality of Care
Jeanette Mladenovic, MD
1
, Judy A. Shea, PhD
2
, F. Daniel Duffy, MD
3
, Lorna A. Lynn, MD
3
,
Eric S. Holmboe, MD
3
, and Rebecca S. Lipner, PhD
3
1
University of Miami, Coral Gables, FL, USA;
2
University of Pennsylvania, Philadelphia, PA, USA;
3
American Board of Internal Medicine,
Philadelphia, PA, USA.
BACKGROUND:
Few studies have systematically and
rigorously examined the quality of care provided in
educational practice sites.
OBJECTIVE:
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.
DESIGN:
This is a cross-sectional observational study.
SETTING:
This study was conducted in 15 Internal
Medicine residency programs (23 sites) throughout the
USA.
PARTICIPANTS:
The participants included site cham-
pions at residency programs and 709 residents.
MEASUREMENTS:
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.
RESULTS:
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%).
CONCLUSIONS:
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 het-
erogeneity 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.
KEY WORDS:
practice-based learning; systems-based practice;
quality of care; preventive cardiology; Internal Medicine residency.
J Gen Intern Med 23(7):914
–
20
DOI: 10.1007/s11606-008-0511-6
© Society of General Internal Medicine 2008
T
hroughout the course of an academic year, over 21,000
residents in Internal Medicine provide ongoing compre-
hensive care to a panel of ambulatory patients.
1
,
2
Residents
provide most of this care during 1 half-day weekly continuity
clinic in sites that include community, hospital-based or
Veterans Health Affairs clinics, faculty group practices, and
private physician offices. Yet, reports from the last 15 years
note how most Internal Medicine residents feel unprepared to
provide outpatient care at the completion of training. Recently,
4 important reports call for urgent reform to the ambulatory
education of residents, express concern that residents too
often train in
“
dysfunctional
”
ambulatory clinics, and argue
that residents should train in high functioning outpatient
settings in order to learn how to deliver care effectively and
efficiently.
3
–
6
However, little systematic and methodologically rigorous
information has been gathered on the quality of care provided
by residents in ambulatory training sites.
7
A few studies have
examined some aspects of the quality of care delivered in
residency clinics but were limited to single institutions and
small numbers of patients.
7
–
10
Less is known about the
characteristics of the clinical microsystems, i.e., the working
front-line units in which residents provide patient care.
To this end, this study uses a web-based tool developed by
the American Board of Internal Medicine (ABIM) for its
Maintenance of Certification
™
(MOC) program and adapted
for residency practices. The ABIM, in collaboration with the
Alliance for Academic Internal Medicine (AAIM), implemented
this pilot study using the Preventive Cardiology Practice
Improvement Module (PC-PIM) to learn more about the
practice environment and quality of care provided in 23
ambulatory training sites of 15 diverse Internal Medicine
training programs.
The goals of this paper are as follows: (1) to describe the
patient population cared for by trainees in internal medicine
residency clinics; (2) to assess the quality of preventive
JGIM
914
cardiology care provided to these patients; (3) to characterize
the practice systems that currently exist in Internal Medicine
residency clinics; and (4) to examine the relationships between
quality, practice systems, and features of the program [size,
type of program, and presence of an electronic medical record
(EMR)].
METHODS
In February 2004, a request for applications was issued for a
joint ABIMF/AAIM project, titled the Resident and Faculty
Practicum in Practice-Based Learning and Improvement. From
24 applicants, 15 residency programs (comprising 23 unique
ambulatory training sites) were funded for an 18-month
feasibility project to implement the PC-PIM in training pro-
grams. Each program received approval from their institution-
al review board. Designated program champions participated
in a 2-day orientation and quality improvement training
session in June 2004. This paper reports results of clinical,
patient survey, and practice system data collected during the
initial phase in fall 2004.
Study Participants
The 15 residency programs were selected based on size and
type of program, geographic location, qualifications of project
champion, strength of support letter, and assessment of
potential for completion. Seven programs utilized more than
1 training site; therefore, the unit of analysis is the 23 clinic
sites.
Instrument
The PC-PIM is a web-based tool whose purpose is to help
physicians better understand and make routine use of the
patient and systems data collected from their practice in an
effort to improve the quality of care delivered to patients and is
closely linked to the Accreditation Council for Graduate
Medical Education
’
s competency goals of practice-based learn-
ing and improvement and systems-based practice.
1
The tool
identifies relevant process and outcome measures based on
evidence-based national guidelines of care with broad accep-
tance from most constituencies.
11
–
14
Participating residents
performed chart reviews of a subset of their patients to provide
data for calculating measures of preventive cardiology care; the
program obtained surveys from patients to assess the presence
of and satisfaction with preventive services in the resident-staff
clinics, and residents completed one site-level survey that
described the practice systems. Power analysis for estimating
required sample size to detect differences among the sites for
type and size of site and type of medical record determined that
7 chart reviews and 5 patients
’
surveys per resident would be
sufficient. Patients included were required to have been in the
practice for at least 1 year, seen in the last 12 months, and
management decisions about their preventive cardiology care
made by providers in the practice. The PC-PIM can be viewed
in its entirety at
www.abim.org/online/pim/demo.aspx
.
Patient Survey
Residents, assisted by a research assistant, recruited 5 of their
patients to complete a survey.
15
–
16
Questions addressed
patients
’
perspective on care, self-perceived health status,
and two subscales: (1) satisfaction with the practice including
overall satisfaction with delivery of preventive cardiology care,
specific information about prevention, or side effects of
prescription medication; (2) access to practice including ease
of obtaining appointments, referrals, and prescription refills.
Chart Review
Residents were expected to abstract charts for 7 of their
patients. These were not necessarily the same patients who
were surveyed. The abstraction form contained the following:
(1) patient demographics; (2) the presence or absence of
cardiovascular disease (CVD); (3) the presence or absence of
risk factors for coronary heart disease (CHD); 4) whether
patient barriers to self-care were present, absent, or not
known; (5) the presence or absence of processes of care
performed (e.g., lipid testing according to guidelines, blood
pressure recording, prescribing aspirin); and (6) clinical out-
comes such as the result of most recent lipid profile. Although
residents were instructed to abstract information from charts,
they were not required to strictly report what was recorded
and, therefore, could supply answers from knowledge of the
patient or by inferences made from other chart information.
For instance, a resident could have answered that he/she
advised a patient to stop smoking without it being formally
recorded in the chart.
Individual measures such as hypertension were scored
dichotomously for each patient; a
“
1
”
was equivalent to
“
yes
”
and signifies its presence, and a
“
”
was equivalent to
“
no
”
and
signifies its absence. For each site, the percent of patients with
hypertension was calculated by summing the
“
1s
”
and dividing
by the total number of patients with recorded data for the
variable (0s or 1s) and converting the fraction to a percent [e.g.,
(5/20)×100=25%].
Summary measures consider the individual measures in a
particular category together. The average percent of measures
present in a category was calculated and used as an overall
assessment of patient health. Summary measures were calcu-
lated first at the patient level, then the site level. For example,
the summary measure
“
prevalence of risk factors for CHD
”
consisted of 9 individual measures. For each patient, it was
scored by summing the number of risk factors present (1) and
then dividing by the total number of risk factors with recorded
data (0s or 1s) and converting the fraction to a percent. For
example, 33.3% represents that 3 of the 9 risk factors were
present for the patient. For each site, the average overall
patient percents represent the site mean, i.e., the average
percent of risk factors for the site.
Practice System Survey
The site practice champion and the residents completed a
survey assessing key structural elements of the clinic
’
s
practice systems. The Practice System Survey was developed
by two of the authors (FDD and LAL) [AU1]based on the
principles of the Wagner Chronic Care Model, the Institute for
Healthcare Improvement Idealized Office Design project, and
Putting Prevention into Practice monograph from the Task
Force On Clinical Preventive Services.
17
–
19
Six broad categories of practice system elements were
included: care management (26 questions), patient-activation
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Mladenovic et al.: Variation in Residency Clinic Practices
JGIM