Researchers found that residency clinics didn’t deliver as much high-quality diabetes care as was found in private-practice physician offices.…
Lorna Lynn, PhD, of the American Board of Internal Medicine in Philadelphia, and colleagues, reported that, even when controlling for patient characteristics, residency clinics performed significantly lower on composite measures of quality compared with clinicians already in practice (P<0.001).
“Our results clearly signal a problem: residency clinics are not providing high-quality care for one of the most common chronic conditions in the United States,” they wrote.
Recent work has revealed “troubling indications” that internal medicine residents aren’t being adequately trained to meet the needs of the growing population of patients living with diabetes and other chronic diseases.
Indeed, experts in graduate medical education have acknowledged the need to reform internal medicine residency training — especially in the ambulatory setting. Currently, there’s a lack of training in ambulatory settings outside of the hospital, they said.
To assess the disparity in quality between residency training and practice, Lynn and colleagues compared care delivered at 67 U.S. internal medicine residency ambulatory clinics with that provided by 703 practicing general internists.
Quality was measured via the Diabetes Practice Improvement Modules of the American Board of Internal Medicine, which involves chart reviews, patient surveys, and feedback reports.
About 40% of the residency clinics were affiliated with a university and the rest were community-based, with a mean of 10.1 residents per site. Among practicing clinicians, the average age was 44.5, and 43% worked in private group practices, 22% in solo practice, 13% in hospital-affiliated practices, and 22% in other settings such as community health centers and military treatment facilities.
The final analysis included data from 2,493 charts and 2,429 patient surveys submitted by the residency clinics, and from 13,777 charts and 14,167 patient surveys from clinicians.
Patients seen in residency clinics were younger, had lower ratings of self-reported health, were more likely to be current smokers, and had more long-term complications of diabetes such as vision loss, end-stage renal disease, macro- or microalbuminuria, and peripheral neuropathy. They also were more likely to have barriers to self-care such as psychiatric illness, cognitive impairment, or substance abuse.
In multivariate analyses, Lynn and colleagues found significant quality gaps in the examination process, intermediate outcomes such as blood sugar control, and patient experience measures.
“Even when we controlled for patient characteristics, the residency clinics performed substantially lower on the composite measure [of these three factors] than did the practicing physicians,” the researchers wrote (mean 61.8 for residency clinics versus 71.4 for practicing physicians, P<0.001).
Clinicians in practice performed three of four exams or processes more frequently: the retinal exam, the foot exam, and smoking cessation. Their patients had better blood pressure and blood glucose control, though there were no differences in LDL cholesterol, the researchers found.
Residency clinics had lower ratings on patient-experience measures, but Lynn and colleagues noted that practicing physician ratings still “show room for improvement on multiple measures.”
The disparities could be due to the fact that few programs require residents to collect or review data on their own patients, and because clinics are large and don’t practice tenets of the patient-centered medical home model.
“Residency clinics, by their very nature, are unable to foster long-term doctor-patient relationships,” the researchers wrote.
Lynn and colleagues called for new residency training programs that emphasize competency-based training and give residents more exposure to ambulatory care settings.
“The movement away from process- and time-based residency curricula toward competency-based training has the potential to greatly alter expectations about what residents will do during training and to change the results of that training,” they concluded.
- Patients cared for in the residents’ clinics were younger, more likely to be current smokers, more likely to have barriers to self-care such as psychiatric illness, cognitive impairment, and substance abuse, and more likely to suffer from complications of diabetes.
- The study found that care for patients with diabetes fell short in multiple measures in clinics staffed by internal medicine residents compared with patients cared for by practicing physicians.
Lynn L, et al “Gaps in quality of diabetes care in internal medicine residency clinics suggest the need for better ambulatory care training” Health Affairs 2012; DOI: 10.1377/hlthaff.2011.0907.