The relationship between physicians' qualifications and experience and the adequacy of prenatal care and low birthweight

Coverage of obesity and obesity disparities on American Board of Medical Specialties (ABMS) examinations

Obesity is a widespread disease which adversely impacts all organ systems and disproportionately affects African Americans and other minority groups. Physicians across medical specialties must possess current knowledge of obesity as an important, distinct disease with biological and social causes. Coverage of obesity on board certification examinations, which influence standards in medical knowledge and practice in each specialty, has not previously been examined. The member boards of the American Board of Medical Specialties offer a content outline or "blueprint" detailing material tested. We parsed the 24 available general certification exam blueprints for mentions of obesity and related keywords. We categorized blueprints into three tiers: mention of obesity (Tier 1), mention of related terminology but not obesity (Tier 2), and no mention of obesity or related terminology (Tier 3). We analyzed mentions of obesity and related terms by blueprint word count and procedural versus non-procedural specialties. Six (25.0%) of 24 board exam blueprints mentioned obesity (Tier 1), fifteen (62.5%) mentioned related terminology only (Tier 2), and three (12.5%) mentioned neither obesity nor related terminology (Tier 3). There was no significant difference in obesity-related mentions between procedural and non-procedural specialties (X2, p = .50). None of the blueprints included racial/ethnic disparities related to obesity. Word count was not significantly correlated with mentions of obesity in linear regression (p = .42). The absence of any mention of obesity on most content outlines and of racial/ethnic disparities on all content outlines indicates need for increased coverage of the diagnosis, prevention, and treatment of obesity across all board examinations.

Association Between Participation and Performance in MOCA Minute and Actions Against the Medical Licenses of Anesthesiologists

BACKGROUND

In January 2016, as part of the Maintenance of Certification in Anesthesiology (MOCA) program, the American Board of Anesthesiology launched MOCA Minute, a web-based longitudinal assessment, to supplant the former cognitive examination. We investigated the association between participation and performance in MOCA Minute and disciplinary actions against medical licenses of anesthesiologists.

METHODS

All anesthesiologists with time-limited certificates (ie, certified in 2000 or after) who were required to register for MOCA Minute in 2016 were followed up through December 31, 2016. The incidence of postcertification prejudicial license actions was compared between those who did and did not register and compared between registrants who did and did not meet the MOCA Minute performance standard.

RESULTS

The cumulative incidence of license actions was 1.2% (245/20,006) in anesthesiologists required to register for MOCA Minute. Nonregistration was associated with a higher incidence of license actions (hazard ratio, 2.93 [95% confidence interval {CI}, 2.15-4.00]). For the 18,534 (92.6%) who registered, later registration (after June 30, 2016) was associated with a higher incidence of license actions. In 2016, 16,308 (88.0%) anesthesiologists met the MOCA Minute performance standard. Of those not meeting the standard (n = 2226), most (n = 2093, 94.0%) failed because they did not complete the required 120 questions. Not meeting the standard was associated with a higher incidence of license actions (hazard ratio, 1.92 [95% CI, 1.36-2.72]).

CONCLUSIONS

Both timely participation and meeting performance standard in MOCA Minute are associated with a lower likelihood of being disciplined by a state medical board.

Relation between the number of board-certified gynecologic oncologists per hospital and survival of cervical cancer

AIMS

In cancer therapy, choice of treatment method has a tremendous influence on patient prognosis. We aimed to evaluate the impact of the number of Gynecologic Oncology (GO) Specialists on treatment outcomes of cervical cancer patients.

METHODS

We used data for 5-year treatment outcomes obtained from the annual treatment reports of the Gynecologic Oncology Committee of Japan Society of Obstetrics and Gynecology (JSOG). We compared this to data posted on the Japanese Society of Gynecologic Oncology (JSGO) website regarding the enrollment of GO Specialists at each hospital.

RESULTS

The 5-year survival ratio of cervical cancer patients treated in hospitals with 2-or-more GO Specialists was 79.0% (2010/2543). This was significantly higher than 75.4% (974/1292) for facilities with 0 or 1 specialist (P = 0.011); however, the number of GO Specialists was not an independent prognostic factor (P = 0.77, adjusted HR: 1.13 [0.38-2.03]). The 5-year survival ratio significantly increased in medical facilities whose number of GO Specialists increased from 0 to 1 or more, or from 1 to 2 or more (P = 0.045).

CONCLUSION

This study demonstrates a causal relationship between the numbers of GO Specialists and treatment outcomes of cervical cancer patients for the first time. Our study suggests that although JSGO board-certified gynecologic oncologists do clearly contribute to improving treatment outcome, the number of specialists was not an independent factor for improving the prognosis of the patients. Thus, it was not clear whether simply increasing the number of GO Specialists, beyond two, will lead to any significant improvement in cervical cancer patient prognosis.

A Call to Revisit the Prenatal Period as a Focus for Action Within the Reproductive and Perinatal Care Continuum

Objectives The broad maternal and child health community has witnessed increased attention to the entire continuum of reproductive and perinatal health concerns over the past few years. However, both recent discouraging trends in prenatal care access and utilization and a renewed understanding of prenatal care as a critical anchor of the reproductive/perinatal health continuum for women who do get pregnant demand a new effort to focus on the prenatal period as a gateway for maternal and infant health. Methods This commentary: describes the Medicaid expansions and the momentum for universal access to prenatal care of the 1980-1990s; examines the pivot away from this goal and its aftermath; provides a rationale for why renewed attention to prenatal care and the prenatal period is essential; and, explores the potential focus of an updated prenatal care agenda. Conclusion We conclude that increasing women's access to high quality prenatal care will require substantial effort at the clinical, community, policy, and system levels. Only when attention is paid to all phases of the reproductive/perinatal health continuum with an emphasis on continuity between all periods, and on the social determinants that affect health and well-being, will our nation be able to ensure the health of all women across the life course (whether or not they ever become mothers), while simultaneously fulfilling our nation's promise that all children-no matter their income or race/ethnicity-will have the opportunity to be born well.

The Impact of Emergency Physician Seniority on Clinical Efficiency, Emergency Department Resource Use, Patient Outcomes, and Disposition Accuracy

The ability of emergency physicians (EPs) to continue within the specialty has been called into question due to high stress in emergency departments (EDs).The purpose of this study was to investigate the impact of EP seniority on clinical performance.A retrospective, 1-year cohort study was conducted across 3 EDs in the largest health-care system in Taiwan. Participants included 44,383 adult nontrauma patients who presented to the EDs. Physicians were categorized as junior, intermediate, and senior EPs according to ≤5, 6 to 10, and >10 years of ED work experience. The door-to-order and door-to-disposition time were used to evaluate EP efficiency. Emergency department resource use indicators included diagnostic investigations of electrocardiography, plain film radiography, laboratory tests, and computed tomography scans. Discharge and mortality rates were used as patient outcomes. Disposition accuracy was evaluated by ED revisit rate.Senior EPs were found to have longer door-to-order (11.3, 12.4 minutes) and door-to-disposition (2, 1.7 hours) time than nonsenior EPs in urgent and nonurgent patients (junior: 9.4, 10.2 minutes and 1.7, 1.5 hours; intermediate: 9.5, 10.7 minutes and 1.7, 1.5 hours). Senior EPs tended to order fewer electrocardiograms, radiographs, and computed tomography scans in nonurgent patients. Adjusting for age, sex, disease acuity, and medical setting, patients treated by junior and intermediate EPs had higher mortality in the ED (adjusted odd ratios, 1.5 and 1.6, respectively).Compared with EPs with ≤10 years of work experience, senior EPs take more time for order prescription and patient disposition, use fewer diagnostic investigations, particularly for nonurgent patients, and are associated with a lower ED mortality rate.

Trends in the history of certification and recertification of the American Board of Internal Medicine

This commentary reviews the trends of pass rates for certification and recertification in internal medicine. This is true for certification since the 1930s and recertification since 2000. Predictors of performance, such as program director ratings and the in-training examination, are discussed in addition to positive clinical outcomes in relation to recertification. Differences in examinations pass rates due to gender, geographic location and number of attempts are reviewed. Recent trends in internal medicine demonstrate a decline, which may be multifactorial in reasoning. This is not unique to internal medicine as declines in certification rates have been noted in general surgery as well. Methods of preparing for the examination are discussed to maximize performance on the examination.

Assessing medical knowledge of emergency medicine residents

The Accreditation Council for Graduate Medical Education (ACGME) requires that emergency medicine (EM) residency graduates are competent in the medical knowledge (MK) core competency. EM educators use a number of tools to measure a resident's progress toward this goal; it is not always clear whether these tools provide a valid assessment. A workshop was convened during the 2012 Academic Emergency Medicine consensus conference "Education Research in Emergency Medicine: Opportunities, Challenges, and Strategies for Success" where assessment for each core competency was discussed in detail. This article provides a description of the validity evidence behind current MK assessment tools used in EM and other specialties. Tools in widespread use are discussed, as well as emerging methods that may form valid assessments in the future. Finally, an agenda for future research is proposed to help address gaps in the current understanding of MK assessment.

The chasm in neonatal outcomes in relation to time of birth in Lebanon

PURPOSE

The purpose of this study was to investigate the relationship between the time of birth and the mortality and morbidity of infants admitted to neonatal intensive care units.

DESIGN

This prospective, cohort study examined the records of women and infants admitted to the NICUs of four hospitals in Beirut, Lebanon, between July 1, 2002, and June 30, 2003. The hospitals selected were university affiliated and had a large number of deliveries (5,152 total for the year 2002-2003).

MAIN OUTCOME VARIABLES

Neonatal mortality and morbidity for infants admitted to the NICU were evaluated in relation to time of birth.

RESULTS

For the whole sample, mortality was higher for infants born during the night shift than for those born during the day shift. Mortality, morbidity, and brain asphyxia rates were also higher for infants born during the night shift and admitted to the NICU. Maternal risk factors and delivery complications were nor consistently higher on the night shift.

An exploratory study of primary care physician decision making regarding total joint arthroplasty

BACKGROUND

For patients to experience the benefits of total joint arthroplasty (TJA), primary care physicians (PCPs) ought to know when to refer a patient for TJA and/or optimize nonsurgical treatment options for osteoarthritis (OA).

OBJECTIVE

To evaluate the ability of physicians to make clinical treatment decisions.

DESIGN AND PARTICIPANTS

A survey, using ten clinical vignettes, of PCPs in Indiana.

MEASUREMENTS

A test score (range 0 to 10) was computed based on the number of correct answers consistent with published explicit appropriateness criteria for TJA. We also collected demographic characteristics and physicians' perceived success rate of TJA in terms of pain relief and functional improvement.

RESULTS

There were 149 PCPs (response rate = 61%) who participated. The mean test score was 6.5 +/- 1.5. Only 17% correctly identified the published success rate of TJA (i.e., > or =90%). In multivariate analysis, the only physician-related variables associated with test score were ethnicity, board status, and perceived success rate of TJA. Physicians who were white (P = .001), board-certified (P = .04), and perceived a higher success rate of TJA (P = .004) had higher test scores.

CONCLUSIONS

PCP knowledge with respect to guideline-concordant care for OA could be improved, specifically in deciding when to consider TJA versus optimizing nonsurgical options. Moreover, the perception of the success rate of TJA may influence a clinician's decision making.

Does specialty board certification influence clinical outcomes?

BACKGROUND

The public seems to crave a simplistic index of 'quality', analogous to 'The Good Housekeeping Seal of Approval', for the complex endeavour of clinical medicine. The American Board of Medical Specialties (ABMS) and its member boards have purported to fill the vacuum in an effort that bears many of the earmarks of a public relations publicity campaign. The author examined the validity of the evidence touted in support of that effort.

METHODS

By applying Hill's causal epidemiologic criteria and logical and statistical inference, the author evaluated: (i) published data sources consisting of the most comprehensive collection of studies yet gathered that purports to provide evidence of the relevance of board certification to clinical outcomes, a collection presented by Sharp et al. apparently with the advice and consent of ABMS, that they posited as containing 'relevant findings', to what purpose they left unspecified; and (ii) the review article of Sharp et al.

RESULTS

The data that Sharp et al. presented provided no credible link between specialty board certification and outcomes or 'quality' of clinical care. Sharp et al. ignored the evidence of absent evidence they found and proposed enthusiastic but unjustified conclusions in support of specialty board certification as an index of clinical 'expertise'.

CONCLUSIONS

No evidence supports the touted clinical benefit of specialty board certification. Specialists in clinical medicine and surgery are unamenable to simplistic evaluation by examination, yet specialty board certification remains an ersatz standard of doctors' clinical quality in the absence of supporting evidence.

Adequação do pré-natal e peso ao nascer: uma revisão sistemática

Esta foi uma revisão sistemática da literatura de publicações em que o pré-natal foi investigado com uma das variáveis preditoras do peso ao nascer. Os bancos de dados MEDLINE, Cochrane Library e SciELO foram rastreados usando-se a combinação dos seguintes descritores: "prenatal care", "antenatal care", "quality", "adequacy", "birthweight", e "low birthweight". Foram localizados 25 estudos: 17 transversais, quatro coortes, três caso-controle e um ensaio randomizado. Os indicadores de adequação empregados foram os de utilização (quantitativos) e os de conteúdo do cuidado (de processo ou qualitativos). A maioria dos autores aplicou indicadores de utilização, principalmente o Índice de Kessner e o Adequacy of Prenatal Care Utilization Index. Somente dois estudos usaram critérios qualitativos. De modo geral, os estudos transversais detectaram efeito protetor do pré-natal sobre o baixo peso ao nascer, enquanto que os resultados de investigações com outros desenhos foram conflitantes. Os achados desta revisão evidenciam que o impacto do pré-natal sobre o peso ao nascer não é inequívoco, principalmente devido ao efeito do viés de auto-seleção. Há a necessidade de realização de ensaios randomizados para esclarecer essa relação.

Relationship between general practitioner certification and characteristics of care

BACKGROUND

The introduction of mandatory or quasimandatory certification processes for general/family doctors has become common in many countries, including Australia. Whether certification effects the care provided is rarely investigated.

OBJECTIVES

The objective of this study was to determine whether certification of general/family physicians is associated with clinical performance.

RESEARCH DESIGN

We conducted a secondary comparative analysis of data from an Australian national cross-sectional survey (April 2000-March 2002).

SUBJECTS

Subjects consisted of a random sample of 1982 general practitioners (GPs)

METHODS

Each participant provided demographic details and information about 100 consecutive patient encounters (total 197,500). We compared characteristics of certified and uncertified general practitioners (GPs), their patients, encounters, problems, management actions, and tested 34 performance indicators. We investigated whether differences identified in descriptive analyses were explained by other factors.

RESULTS

Of 1975 GPs who indicated certification status, 659 (33.4%) were vocationally certified. Certificants were more likely to be female, younger, Australian graduates, working fewer sessions, in larger practices, in accredited practices, and using computers for clinical purposes. Their patients were younger, more often female, and less likely to hold a healthcare concession card. Their consultations were longer; they prescribed fewer medications and more clinical treatments and procedures, ordered more pathology tests, and referred more to other health professionals. After adjustment for GP/practice, patient and morbidity differences, certificants had longer consultations, did more therapeutic procedures, prescribed less overall, prescribed fewer nonsteroidal antiinflammatory drugs in the elderly, and fewer antibiotics for upper respiratory infections.

CONCLUSION

Certification of general practitioners has a significant association with consultation behavior and patient management.

Specialty board certification and clinical outcomes: the missing link

PURPOSE

Specialty board certification status is often used as a standard of excellence, but no systematic review has examined the link between certification and clinical outcomes. The authors evaluated published studies tracking clinical outcomes and certification status.

METHOD

Data sources consisted of studies cited between 1966 and July 1999 in OVID-Medline, psychological abstracts (PsycLit), and the Educational Research Information Clearinghouse (ERIC). Screening criteria included: only U.S. patients and physicians used as subjects; verified specialty board certification status by an American Board of Medical Specialties' (ABMS') member board using the ABMS database or derivative sources; described selection criteria for patients and physicians; selected nationally recognized standards of care for outcomes; and nested patient data by individual physician. The computerized searches that were conducted in 1999 identified 1,204 papers; one author and a research assistant selected 237 papers based on subject relevance, and reduced the list to 56 based on study quality. The authors independently applied inclusion and exclusion criteria to identify 13 of the 56 papers containing 33 separable relevant findings.

RESULTS

Of the 33 findings, 16 demonstrated a significant positive association between certification status and positive clinical outcomes, three revealed worse outcomes for certified physicians, and 14 showed no association. Three negative findings and one finding of no association were identified in two papers with insufficient case-mix adjustments in the analyses. Meta-analytic statistics were not feasible due to variability in outcome measures across studies.

CONCLUSIONS

Few published studies (5%) used research methods appropriate for the research question, and among the screened studies more than half support an association between board certification status and positive clinical outcomes.

Does delivery volume of family physicians predict maternal and newborn outcome?

BACKGROUND

The number of births attended by individual family physicians who practice intrapartum care varies. We wanted to determine if the practice-volume relations that have been shown in other fields of medical practice also exist in maternity care practice by family doctors.

METHODS

For the period April 1997 to August 1998, we analyzed all singleton births at a major maternity teaching hospital for which the family physician was the responsible physician. Physicians were grouped into 3 categories on the basis of the number of births they attended each year: fewer than 12, 12 to 24, and 25 or more. Physicians with a low volume of deliveries (72 physicians, 549 births), those with a medium volume of deliveries (34 physicians, 871 births) and those with a high volume of deliveries (46 physicians, 3024 births) were compared in terms of maternal and newborn outcomes. The main outcome measures were maternal morbidity, 5-minute Apgar score and admission of the baby to the neonatal intensive care unit or special care unit. Secondary outcomes were obstetric procedures and consultation patterns.

RESULTS

There was no difference among the 3 volume cohorts in terms of rates of maternal complications of delivery, 5-minute Apgar scores of less than 7 or admissions to the neonatal intensive care unit or the special care unit, either before or after adjustment for parity, pregnancy-induced hypertension, diabetes, ethnicity, lone parent status, maternal age, gestational age, newborn birth weight and newborn head circumference at birth. High- and medium-volume family physicians consulted with obstetricians less often than low-volume family physicians (adjusted odds ratio [OR] 0.586 [95% confidence interval, CI, 0.479-0.718] and 0.739 [95% CI 0.583-0.935] respectively). High- and medium-volume family physicians transferred the delivery to an obstetrician less often than low-volume family physicians (adjusted OR 0.668 [95% CI 0.542-0.823] and 0.776 [95% CI 0.607-0.992] respectively). Inductions were performed by medium-volume family physicians more often than by low-volume family physicians (adjusted OR 1.437 [95% CI 1.036-1.992].

INTERPRETATION

Family physicians' delivery volumes were not associated with adverse outcomes for mothers or newborns. Low-volume family physicians referred patients and transferred deliveries to obstetricians more frequently than high- or medium-volume family physicians. Further research is needed to validate these findings in smaller facilities, both urban and rural.

Does certification status of oncology nurses make a difference in patient outcomes?

PURPOSE/OBJECTIVES

To test hypotheses that patients cared for by Oncology Certified Nurses (OCNs(r)) have superior outcomes compared to those cared for by noncertified nurses.

DESIGN

Descriptive ex post facto.

SETTING

A homecare agency in the midwestern United States.

SAMPLE

20 nurses (7 certified and 13 noncertified) and charts for 181 of their patients.

METHODS

Retrospective chart review.

MAIN RESEARCH VARIABLES

Symptom management (i.e., pain and fatigue), adverse events (e.g., infection and decubitus ulcers), and episodic care utilization (e.g., visits to care facilities, admissions to care facilities, unscheduled home visits).

FINDINGS

Contrary to hypotheses, the two groups did not differ with respect to assessment of pain at admission, number of pain assessments subsequent to admission, assessment of fatigue at admission, number of unplanned visits to care facilities, admissions to care facilities, and number of unscheduled home visits. As hypothesized, the OCNs(r) documented a higher number of postadmission fatigue assessments (p less than 0.05). Contrary to hypotheses, patients of OCNs(r) had a greater number of infections and fewer documented instances of patient teaching regarding infection.

CONCLUSIONS

Little support was found for the hypothesis that nursing care by OCNs(r) results in superior patient outcomes in comparison to care by noncertified nurses.

IMPLICATIONS FOR NURSING

Further research is needed to examine the dimensions of clinical practice that may demonstrate the benefits of care by OCNs(r).

Improved birth outcomes among HIV-infected women with enhanced Medicaid prenatal care

OBJECTIVES

This study evaluated the impact of enhanced prenatal care on the birth outcomes of HIV-infected women.

METHODS

Medicaid claims files linked to vital statistics were analyzed for 1723 HIV-infected women delivering a live-born singleton from January 1993 to October 1995. Prenatal care program visits were indicated by rate codes. Logistic models controlling for demographic, substance use, and health care variables were used to assess the program's effect on preterm birth (less than 37 weeks) and low birthweight (less than 2500 g).

RESULTS

Of the women included in the study, 75.3% participated in the prenatal care program. Adjusted program care odds were 0.58 (95% confidence interval [CI] = 0.42, 0.81) for preterm birth and 0.37 (95% CI = 0.24, 0.58) for low-birthweight deliveries in women without a usual source of prenatal care. Women with a usual source had lower odds of low-birthweight deliveries if they had more than 9 program visits. The effect of program participation persisted in sensitivity analyses that adjusted for an unmeasured confounder.

CONCLUSIONS

A statewide prenatal care Medicaid program demonstrates significant reductions in the risk of adverse birth outcomes for HIV-infected women.