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Does physician cognitive ability matter when considering the relationship between practice infrastructure and ambulatory quality of care?

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Vandergrift JL, Gray BM, Weng W. — American Board of Internal Medicine

Presented: AcademyHealth Annual Research Meeting, June 2016

Objective: Great strides have been made toward improving the adoption and effective use of health system infrastructure with the aim of supporting high quality patient care. However, these improvements seem to only loosely relate to better quality care. One possible explanation is that physician ability might affect this relationship. For example, physicians with higher cognitive ability might better take advantage of the information gained from integrated electronic health records in improving care quality. Alternatively, clinical reminders might better support lower ability physicians. Our objective was to examine the degree to which cognitive ability moderates the relationship between a general internal medicine (GIM) physician's adoption and effective use of practice infrastructure and care quality.

Population Studied: Diabetes/hypertension patients cared for by GIM physicians.

Study Design: We included 1,301 GIM physicians certified 1991-1993/2001-2003 who completed an ABIM diabetes or hypertension Process Improvement Module (PIM) in 2011-2014. PIMs were completed as part of ABIM's Maintenance of Certification (MOC) program and are designed to provide feedback on care quality.

Physician care quality was measured using an ambulatory quality measure (QM) composite constructed from individual process and intermediate outcome QMs (e.g., LDL testing, HbA1c control) derived from chart abstractions (25 per physician). QM composites were constructed using an expert panel's assessment of the relative value of individual measures and scored on a 0-100 scale. Practice infrastructure adoption and effective use was measured using a survey that mirrors the NCQA's PPC-Readiness Survey v.2. Physician cognitive ability was based on the physician's performance on the Internal Medicine MOC exam.

Linear regression was applied to measure the association between QM composites and the physician's exam and practice infrastructure scores. We included an interaction term between exam score and infrastructure score to assess whether physician ability moderated the association between infrastructure score and clinical quality. We also examined the difference between high (top quintile) and low (bottom quintile) infrastructure scores among higher (top quintile) or lower (bottom quintile) ability physicians. Regressions included PIM type and year; MOC rounds completed; physician sex, solo practitioner, country of birth and medical school training indicators; adjusted Dartmouth Atlas Medicare mortality rates for the physician's health service area; and zip code level median household income.

Principal Findings: We observed a significant regression-adjusted positive interaction between physician cognitive ability and practice infrastructure score (p=0.005). For lower ability physicians, there was no discernable care quality difference between low or high infrastructure scores (0.9 percentage points, p = 0.69). Among higher ability physicians, a high infrastructure score was associated with an 8.1 percentage point larger QM composite score than low system infrastructure score (p<.001). Similar patterns were observed for process and intermediate outcomes QM composites.

Conclusions: Higher physician cognitive ability bolsters the relationship between system infrastructure score and better ambulatory care quality.

Implication for Policy or Practice Differences in physician cognitive ability may partially explain the variation in the effectiveness of system infrastructure adoption and use on improvements in care quality. Additional support or training may be required to ensure that physicians with lower cognitive ability are able to derive the same benefits from high quality system infrastructure as higher ability physicians.

For more information about this presentation, please contact Research@abim.org.