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 This is the electronic reserve you have to use.Thanks 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 champions 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 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. 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 comprehensive 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 programs. Each program received approval from their institutional 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 learning 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 acceptance 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 outcomes 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 “ 0 ” 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 calculated 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 915 Mladenovic et al.: Variation in Residency Clinic Practices JGIM

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