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Research Letter
April 1, 2019

Quality of Outpatient Care With Internal Medicine Residents vs Attending Physicians in Veterans Affairs Primary Care Clinics

Author Affiliations
  • 1Section of General Internal Medicine, VA Portland Health Care System, Portland, Oregon
  • 2Division of General Internal Medicine and Geriatrics, Oregon Health & Science University, Portland
  • 3Center for Health Systems Effectiveness, Oregon Health & Science University, Portland
  • 4Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon
  • 5Oregon Health & Science University–Portland State University School of Public Health, Portland
JAMA Intern Med. 2019;179(5):711-713. doi:10.1001/jamainternmed.2018.8624

Concerns persist that care provided by resident physicians is of lower quality than that provided by more experienced attending physicians.1 In this study, we compared quality of outpatient care between internal medicine residents and attending physicians in US Department of Veterans Affairs (VA) primary care clinics.

As part of an evaluation of the Centers of Excellence in Primary Care Education, an interprofessional education initiative, we examined 10 geographically diverse VA medical centers with affiliated internal medicine residencies. This work was determined to be a quality improvement activity per Veterans Health Administration policies, with a waiver of informed consent. We identified patients seen in teaching primary care clinics at each site who were assigned to the panel of either a resident physician or attending physician (staff physician who supervised resident’s care) and who had at least 1 primary care visit in calendar year 2014. We collected demographic characteristics, comorbidity,2 and quality of care and health service utilization measures from the VA Corporate Data Warehouse in 2014. Outcomes included measures of diabetes care quality (annual glycated hemoglobin [HbA1c] testing, HbA1c poor control [>9% or unmeasured (to convert HbA1c concentration to a proportion of total hemoglobin, multiply by 0.01)], and annual renal testing [urine microalbumin to creatinine ratio or prescription of an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker]), use of a high-risk medication3 in patients older than 65 years, hypertension control (blood pressure <140/90 mm Hg), emergency department visits, and hospitalizations (all-cause hospitalizations and from ambulatory care–sensitive conditions). We selected these measures because they are common primary care measures that we could extract reliably. We compared outcome measures using logistic mixed models adjusted for demographic characteristics, comorbidities, and years under VA care and included site as a random effect to control for site-level effects. We used a 2-sided P < .05 as a significance threshold.

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