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.
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)].
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