A comparison of clinical performance of primary care and traditional internal medicine residents

Performance on preventive cancer screening tests in the ambulatory setting by internal medicine resident physicians

BACKGROUND

Limited information exists about the quality and determinants of ambulatory care by resident physicians.

DESCRIPTION

This study investigated whether year of training and primary care versus traditional categorical status for internal medicine residents influenced preventive cancer screening rates. Ambulatory patients cared for by 143 internal medicine residents in one program over a 1-year period were assessed. Patients eligible for breast, cervical, and colorectal cancer screening were identified and test completion status was assessed. Patients who had not yet completed screening and had a visit with the resident physician were prospectively followed for subsequent test completion. Cancer screening rates, overall and among those overdue, were compared controlling for baseline patient characteristics.

EVALUATION

Among 3, 729 patients, overall test completion rates for breast (72%), cervical (75%), and colorectal cancer screening (56%) did not differ by year of training or type of training (primary care vs. categorical). Among patients overdue for a screening test, no association was found by resident year of training or primary care versus categorical status: 22% vs. 12% for colorectal (p = .08), 46% versus 28% for breast (p = .69), and 24% versus 19% for cervical cancer (p = .61), respectively.

CONCLUSIONS

Neither resident physician type of training nor year of training were found to be associated with cancer screening rates in the ambulatory setting. Future research should seek to identify physician factors and educational strategies to augment system-based efforts to improve the quality of outpatient care by resident physicians.

Addressing the unit of analysis in medical care studies: a systematic review

OBJECTIVE

We assessed the frequency that patients are incorrectly used as the unit of analysis among studies of physicians' patient care behavior in articles published in high impact journals.

METHODS

We surveyed 30 high-impact journals across 6 medical fields for articles susceptible to unit of analysis errors published from 1994 to 2005. Three reviewers independently abstracted articles using previously published criteria to determine the presence of analytic errors.

RESULTS

One hundred fourteen susceptible articles were found published in 15 journals, 4 journals published the majority (71 of 114 or 62.3%) of studies, 40 were intervention studies, and 74 were noninterventional studies. The unit of analysis error was present in 19 (48%) of the intervention studies and 31 (42%) of the noninterventional studies (overall error rate 44%). The frequency of the error decreased between 1994-1999 (N = 38; 65% error) and 2000-2005 (N = 76; 33% error) (P = 0.001).

CONCLUSIONS

Although the frequency of the error in published studies is decreasing, further improvement remains desirable.

The Charlson comorbidity index is adapted to predict costs of chronic disease in primary care patients

OBJECTIVE

(1) To determine chronic illness costs for large cohort of primary care patients, (2) to develop prospective model predicting total costs over one year, using demographic and clinical information including widely used comorbidity index.

STUDY DESIGN AND SETTING

Data including diagnostic, medication, and resource utilization were obtained for 5,861 patients from practice-based computer system over a 1-year period beginning December 1, 1993, for retrospective analysis. Hospital cost data were obtained from hospital cost accounting system.

RESULTS

Average annual per patient cost was $2,655. Older patients and those with Medicare or Medicaid had higher costs. Hospital costs were $1,558, accounting for 58.7% of total costs. In the predictive model, individuals with higher comorbidity incurred exponentially higher annual costs, from $4,317 with comorbidity score of two, to $5,986 with score of three, to $13,326 with scores greater than seven. To use an adapted comorbidity index to predict total yearly costs, four conditions should be added to the index: hypertension, depression, and use of warfarin with a weight of one, skin ulcers/cellulitis, a weight of two.

CONCLUSION

The adapted comorbidity index can be used to predict resource utilization. Predictive models may help to identify targets for reducing high costs, by prospectively identifying those at high risk.

Can disease management target patients most likely to generate high costs? The impact of comorbidity

CONTEXT

Disease management programs are increasingly used to manage costs of patients with chronic disease.

OBJECTIVE

We sought to examine the clinical characteristics and measure the health care expenditures of patients most likely to be targeted by disease management programs.

DESIGN

Retrospective analysis of prospectively obtained data.

SETTING

A general medicine practice with both faculty and residents at an urban academic medical center.

PARTICIPANTS

Five thousand eight hundred sixty-one patients enrolled in the practice for at least 1 year.

MAIN OUTCOMES

Annual cost of diseases targeted by disease management.

MEASUREMENTS

Patients' clinical and demographic information were collected from a computer system used to manage patients. Data included diagnostic information, medications, and resource usage over 1 year. We looked at 10 common diseases targeted by disease management programs.

RESULTS

Unadjusted annual median costs for chronic diseases ranged between $1,100 and $1,500. Congestive heart failure ($1,500), stroke ($1,500), diabetes ($1,500), and cancer ($1,400) were the most expensive. As comorbidity increased, annual adjusted costs increased exponentially. Those with comorbidity scores of 2 or more accounted for 26% of the population but 50% of the overall costs.

CONCLUSIONS

Costs for individual chronic conditions vary within a relatively narrow range. However, the costs for patients with multiple coexisting medical conditions increase rapidly. Reducing health care costs will require focusing on patients with multiple comorbid diseases, not just single diseases. The overwhelming impact of comorbidity on costs raises significant concerns about the potential ability of disease management programs to limit the costs of care.

Differences in preventive health quality by residency year. Is seniority better?

BACKGROUND

It is assumed that the performance of more senior residents is superior to that of interns, but this has not been assessed objectively.

OBJECTIVE

To determine whether adherence to national guidelines for outpatient preventive health services differs by year of residency training.

DESIGN

Cross-sectional study.

PARTICIPANTS

One hundred twenty Internal Medicine residents, postgraduate year (PGY)- 1 and PGY -2, attending a University Internal Medicine teaching clinic between June 2000 and May 2003.

MEASUREMENTS

We studied 6 preventive health care services offered or received by patients by abstracting data from 1,017 patient records. We examined the differences in performance between PGY-1 and PGY-2 residents.

RESULTS

Postgraduate year-2 residents did not statistically outperform PGY-1 residents on any measure. The overall proportion of patients receiving appropriate preventive health services for pneumococcal vaccination, advising tobacco cessation, breast and colon cancer screening, and lipid screening was similar across levels of training. PGY-1s outperformed PGY-2s for tobacco use screening (58%, 51%, P = .03). These results were consistent after accounting for clustering of patients within provider and adjusting for patient age, gender, race and insurance, resident gender, and number of visits during the measurement year.

CONCLUSIONS

Overall, patients cared for by PGY-2 residents did not receive more outpatient preventive health services than those cared for by PGY-1 residents. Efforts should be made to ensure quality patient care in the outpatient setting for all levels of training.

Does experience matter? A comparison of the practice of attendings and residents

OBJECTIVE

To compare the utilization of health care resources and patterns of chronic disease care by patients of medical residents and patients of their attending physicians.

MATERIALS AND METHODS

This study involved a longitudinal cohort of 14,554 patients seen over a 1-year period by 149 residents and 36 attendings located in an urban academic medical center. Data were acquired prospectively through a practice management system used to order tests, write prescriptions, and code ambulatory visits. We assessed resource utilization by measuring the total direct costs of care over a 1-year period, including ambulatory and inpatient costs, and the numbers and types of resources used.

RESULTS

Residents' patients were similar to attendings' patients in age and gender, but residents' patients were more likely to have Medicaid or Medicare and to have a higher burden of comorbidity. Total annual ambulatory care costs were almost 60% higher for residents' patients than for attendings' patients in unadjusted analyses, and 30% higher in analyses adjusted for differences in case mix (adjusted mean 888 dollars vs 750 dollars; P=.0001). The primary cost drivers on the outpatient side were consultations and radiological procedures. Total inpatient costs were almost twice as high for residents' patients compared to attendings' patients in unadjusted analyses, but virtually identical in analyses adjusted for case mix differences (adjusted mean of 849 dollars vs 860 dollars). Admission rates were almost double for residents' patients. Total adjusted costs for residents' patients were slightly, but not significantly, higher than for attendings' patients (adjusted mean 1,651 dollars vs 1,540 dollars; P>.05). Residents' and attendings' patients generally did not differ in the patterns of care for diabetes, asthma/chronic obstructive pulmonary disease (COPD), congestive heart failure, ischemic heart disease, and depression, except that residents' patients with asthma/COPD, ischemic heart disease, and diabetes were admitted more frequently than attendings' patients.

CONCLUSIONS

Our results indicate that residents' patients had higher costs than attendings' patients, but the differences would have been seriously overestimated without adjustment. We conclude that it costs about 7% more for residents to manage patients than for attendings. On the ambulatory side, the larger number of procedures and consults ordered for residents' patients appears to drive the higher costs.

Assessing quality and costs of education in the ambulatory setting: a review of the literature

PURPOSE

Time-pressured interactions with little direct observation or feedback characterize teaching in ambulatory settings. The authors report findings from the literature on teaching and learning in the ambulatory setting and propose opportunities for further research that addresses these barriers.

METHOD

The authors searched 1995-1999 databases for all empirical studies that focused on research conducted in ambulatory settings. Publications were reviewed for evidence of inclusion criteria. Findings were sorted into categories previously described for defining and evaluating quality of ambulatory care educational programs.

RESULTS

Most studies were conducted in departments of internal medicine (40%), focused on medical students (43%), and took place in a single program (77%), making generalizations difficult. Students and residents are learning in ambulatory environments, and the types of patients they encounter are likely to prepare them for practice. Patient care outcomes have emerged as a measure of learning. Teachers may be the single most important factor, yet they lack self-confidence as teachers. Community-based preceptors teach because of enjoyment of teaching and the opportunity to stay current. However, none of the studies addressed the impact of the Medicare documentation requirements on satisfaction with teaching. Teaching settings cost about one third more than non-teaching settings to operate.

CONCLUSION

This review identifies many gaps in our knowledge of effective clinical teaching practices, and of learning environments in which that teaching takes place. The predominance of single-institution studies limits generalizability of current findings. A prioritized research agenda should be established and funded, focusing on improving the efficiency and effectiveness of teaching and learning in ambulatory settings.

Comparison of knowledge on asthma: doctors completing internal medicine residency and doctors completing medical school

CONTEXT

Asthma has been reported as a disease of increasing prevalence.

OBJECTIVE

To assess the level of information and knowledge about asthma by means of a questionnaire among recent graduate physicians applying for medical residency at the Clinical Hospital of the University of São Paulo Medical School, Brazil.

DESIGN

14 multiple-choice questions for asthma diagnosis and management.

SETTING

University of São Paulo Medical School (FMUSP).

PARTICIPANTS

Recent graduate physicians applying for the medical residency program at FMUSP in 1999 (n = 448) and physicians that had completed 2 year of internal medicine residency (n = 92).

MAIN MEASUREMENTS

We applied a questionnaire with 14 multiple-choice questions about the management of asthma based upon the Expert Panel Report 2 - Guidelines for the Diagnosis and Management of Asthma, NIH/NHLBI, 1997 (EPR-2).

RESULTS

The medical residency program in Internal Medicine improved treatment skills (the ability to propose adequate therapy) when compared to medical education (a score of 57.2% versus 46.9%, P < 0.001) but not diagnosis knowledge (understanding of asthma symptoms related to medicine intake) (33.5% versus 33.3%, P = 0.94). Treatment skills were higher among physicians who received their Medical Degree (MD) from public-sponsored medical schools in comparison with those from private schools [49.7 (SE 1.17)] versus [41.8 (SE 1.63)], P < 0.001.

CONCLUSION

Medical schools might consider reevaluating their programs regarding asthma in order to improve medical assistance, especially when considering the general results for residents, as they were supposed to have achieved performance after completing this in-service training.

Diagnosis, treatment, comorbidity, and resource utilization of depressed patients in a general medical practice

OBJECTIVE

The objective of the study was to determine the effect of depression on the utilization of health care resources, after adjusting for age and comorbidity from data obtained on routine clinical practice.

METHOD

The study is an observational cohort of 15,186 patients followed over a one-year period beginning December 1993. Comprehensive demographic, clinical, and utilization data were available from the computerized medical information system generated database of a general internal medicine practice in an urban academic medical center.

RESULTS

Four point seven percent of patients carried a provider-coded diagnosis of depression. With regards to utilization of health care resources, even after controlling for age and comorbidity, depressed patients had more primary care visits (5.3 vs. 2.9 visits, p < .001), higher rates of referral to specialists (1.1 vs. 0.5, p < .002), and radiologic tests (0.9 vs. 0.4 tests, p < .001). They had higher total outpatient charges ($1,324 vs. $701, p < .001) and total charges ($2,808 vs. $1,891, p < .001). Depressed patients also had longer length of stay when hospitalized (14.1 vs. 9.5 days, p < .002).

CONCLUSIONS

Patients diagnosed as depressed had significantly higher resource utilization of all types, even after controlling for the higher burden of comorbid medical illness associated with depression.