Compliance rates for risk-appropriate VTE prophylaxis prescriptions attributed to residents (light blue) and attending physicians (dark blue) are compared for all adult trauma patients admitted to the Johns Hopkins Hospital during the 2012-2013 academic year. Seven residents were 0% compliant, and 42 residents were 100% compliant.
Lau BD, Streiff MB, Pronovost PJ, Haider AH, Efron DT, Haut ER. Attending Physician Performance Measure Scores and Resident Physicians’ Ordering Practices. JAMA Surg. 2015;150(8):813-814. doi:10.1001/jamasurg.2015.0891
Hospital-level metrics are used nationally to incentivize quality and drive payments.1 These programs attribute quality to the attending physician of record only. However, at academic medical centers, many common process measures are entirely dependent on resident physicians with minimal direct, real-time oversight or feedback from attending physicians.
As a process-linked outcome,2 prevention of venous thromboembolism (VTE) is one of the most common health care quality measures and is publicly reported by The Joint Commission’s Core Measures and the Centers for Medicare and Medicaid Services’ Meaningful Use program. We hypothesized that variation in measured and reported quality exists among residents, but not attending physicians, regarding prescription of appropriate VTE prophylaxis.
We included all adult patients admitted to the trauma service at the Johns Hopkins Hospital in Baltimore, Maryland, for 1 academic year (July 2012–June 2013). Residents and attending physicians are arbitrarily scheduled to staff the adult trauma service. We extracted data for prescription of risk-appropriate VTE prophylaxis from our provider order entry system (Sunrise Clinical Manager; Allscripts). Our study was approved by the Johns Hopkins Medicine institutional review board. Retrospective data for physicians and patients were collected and deidentified prior to analysis, and a waiver of consent was provided.
The primary outcome of interest was the proportion of patients prescribed risk-appropriate VTE prophylaxis as defined by compliance with our validated mandatory computerized clinical decision support tool.3,4 We compared the proportion of risk-appropriate VTE prophylaxis orders directly placed by each resident and attributed to the attending physician. Performance among residents was compared using a 2-sided Fisher exact test, and attributed performance among attending physicians was compared using a 2-sided χ2 test. A P value of .05 was considered statistically significant. All statistical analyses were performed using STATA version 12.0 (StataCorp).
Overall, 254 of 343 patients (74.1%) were prescribed risk-appropriate VTE prophylaxis. There were significant differences (P = .001) in performance among the 75 residents (median compliance rate, 100%; interquartile range, 73.2%-100%; range, 0%-100%). Over half of the residents (42 of 75 [56.0%]) prescribed optimal, risk-appropriate VTE prophylaxis for every patient whom they admitted, while 7 of 75 residents (9.3%) did not prescribe optimal prophylaxis to any patient. There was no difference (P = .87) among the 8 attending physicians (median compliance rate, 74.2%; interquartile range, 72.6%-77.3%; range, 63.6%-78.9%) (Figure).
Risk-appropriate VTE prophylaxis prescription varied dramatically among residents but not among attending physicians. Because residents are arbitrarily paired with attending physicians, variation in resident practice leads to the similar reported performance among attending physicians. Although attending physicians have final authority over the care provided to patients, in practice, attending physicians do not routinely scrutinize every decision made related to patient care. Most concerning, we have found that a substantial number of residents may habitually provide suboptimal care. This finding does not obviate the responsibility of attending physicians to supervise, educate, and intervene but rather highlights an opportunity to enhance learning and target quality improvement efforts for both residents and attending physicians.
The primary limitation of our study is the investigation of only a single process measure, for 1 service at 1 institution. However, we chose to explore VTE as one of the most common causes of preventable harm among hospitalized patients,5 and a highly generalizable measure across hospitals. Three of the 6 National Quality Forum VTE measures used by The Joint Commission and the Centers for Medicare and Medicaid Services specifically address prescription of VTE prophylaxis for hospitalized patients. Hundreds of process quality measures used by The Joint Commission and the Centers for Medicare and Medicaid Services to evaluate hospitals and/or attending physicians are influenced by resident practice, such as the prescription of antibiotics for patients with community-acquired pneumonia or of angiotensin-converting enzyme inhibitors for patients with congestive heart failure. With the adoption of electronic health records, where process measure documentation is linked to individual providers (ie, physicians, nurses, pharmacists, and anyone else who enters information into the electronic health record),6 it is possible to provide performance feedback to residents as we do to attending physicians.
Reported quality measures attributed to attending physicians at academic medical centers may not reflect the true performance of the attending physicians but rather the average performance of both high-performing and low-performing residents. Attribution of process measures to attending physicians at teaching institutions may be inappropriate. Residents may be a more reliable target for quality improvement efforts. Investigators using physician-specific data, such as the Physician Quality Reporting System, should consider using frontline health care professionals (ie, residents) in addition to attending physicians.
Corresponding Author: Brandyn D. Lau, MPH, CPH, Division of Acute Care Surgery, Department of Surgery, Johns Hopkins University School of Medicine, 600 N Wolfe St, Osler 714A, Baltimore, MD 21287 (email@example.com).
Published Online: June 17, 2015. doi:10.1001/jamasurg.2015.0891.
Author Contributions: Mr Lau and Dr Haut had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: All authors.
Acquisition, analysis, or interpretation of data: Lau, Streiff, Haut.
Drafting of the manuscript: Lau, Haider, Haut.
Critical revision of the manuscript for important intellectual content: Streiff, Pronovost, Efron, Haut.
Statistical analysis: Lau, Haider.
Administrative, technical, or material support: Haider.
Study supervision: Streiff, Pronovost, Haider, Haut.
Conflict of Interest Disclosures: Dr Haut receives royalties from Lippincott, Williams, & Wilkins for his book Avoiding Common ICU Errors and consulting fees from the Veterans Health Administration. Dr Pronovost reports consultancy fees from the Association for Professionals in Infection Control and Epidemiology, Inc; grant or contract support from the Agency for Healthcare Research and Quality, the National Institutes of Health, the Robert Wood Johnson Foundation, and The Commonwealth Fund; honoraria from various hospitals and the Leigh Bureau (Somerville, New Jersey); and royalties from his book Safe Patients Smart Hospitals. Dr Haider reports funding from National Institutes of Health/National Institute of General Medical Sciences (grant K23GM093112-01) and the American College of Surgeons C. James Carrico Fellowship for the study of Trauma and Critical Care. Mr Lau and Drs Haut, Streiff, and Pronovost are supported by a contract from the Patient-Centered Outcomes Research Institute entitled “Preventing Venous Thromboembolism: Empowering Patients and Enabling Patient-Centered Care via Health Information Technology.” Mr Lau and Dr Haider are supported by a contract from the Patient-Centered Outcomes Research Institute entitled “Patient-Centered Approaches to Collect Sexual Orientation/Gender Identity Information in the Emergency Department.” Dr Haut was the primary investigator of a Mentored Clinician Scientist Development Award (K08 1K08HS017952-01) from the Agency for Healthcare Research and Quality entitled “Does Screening Variability Make DVT an Unreliable Quality Measure of Trauma Care?” No other disclosures were reported.