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

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 [HbA_1c] testing, HbA_1c poor control [>9% or unmeasured (to convert HbA_1c 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.

Of 76 392 patients, mean (SD) age was 62.3 (15.7) years, 69 677 (90.6%) were male, 55 082 (72.1%) were white, 10 986 (14.4%) were black, 2568 (3.4%) were Hispanic, and 7756 (10.1%) were of another race/ethnicity. We identified 19 324 patients cared for by resident physicians and 57 068 patients cared for by attending physicians in 2014. Residents cared for a greater proportion of younger, female, and black patients (Table 1). Patients of resident physicians had a higher mean comorbidity score (14.1 [16.1] vs 12.5 [15.1] for attending physicians; P < .001), were more commonly diagnosed as having substance use disorders (3656 [18.9%] vs 7797 [13.7%]; P < .001) and depression (4270 of 19 324 [22.1%] vs 10 212 of 57 068 [17.9%]; P < .001), and were under VA care for less time.

Diabetes quality-of-care measures were similar (Table 2), but patients of residents were more likely to have appropriate renal testing (difference, 3.2 percentage points; P = .001). Patients of residents were less likely to have controlled hypertension (difference, 2.9 percentage points; P = .02), but older patients of residents were less likely to be prescribed high-risk medications (difference, 4.2 percentage points; P < .001). Patients of residents also were slightly more likely to have at least 1 emergency department visit in 2014 (difference, 1.3 percentage points; P < .001).

Although studies have shown that primary care provided by residents is similar to that provided by attending physicians, earlier studies have been limited to small samples⁴ and measures based on self-reported data.⁵ In this large, national study using electronic health record–based measures, we found that residents provide access for new patients and play an important role in caring for vulnerable patient groups with complex care needs.

Quality-of-care measures were similar between patients of resident physicians and patients of attending physicians, and absolute differences were small. Residents’ better performance on some measures could be a product of training in evidence-based medicine and the use of clinical guidelines, or precepting, and supervision from attending physicians.

Limitations of this work include the VA-specific context, analysis of only VA data, and use of only 10 sites. In addition, unmeasured differences between patients of resident and attending physicians, such as differences in frailty or behavioral health history, could cause residual confounding and bias our results against clinicians who care for more complex patients.

Current measures of primary care quality are limited and typically focus on disease-specific process measures and short-term outcomes.⁶ However, according to these measures, residents appear to be providing near-equivalent care to attending physicians. More investigation is needed to understand how residents perform more complex primary care functions, such as integrating and prioritizing patient needs and delivering coordinated, whole-person, relationship-based care.

Accepted for Publication: December 18, 2019.

Corresponding Author: Samuel T. Edwards, MD, MPH, Section of General Internal Medicine, VA Portland Health Care System, 3710 SW US Veterans Hospital Rd (R&D199), Portland, OR 97239 (samuel.edwards@va.gov).

Published Online: April 1, 2019. doi:10.1001/jamainternmed.2018.8624

Author Contributions: Dr Edwards had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Edwards, Hooker, Niederhausen, Tuepker.

Acquisition, analysis, or interpretation of data: Edwards, Kim, Shull, Hooker, Niederhausen.

Drafting of the manuscript: Edwards.

Critical revision of the manuscript for important intellectual content: Kim, Shull, Hooker, Niederhausen, Tuepker.

Statistical analysis: Edwards, Kim, Hooker, Niederhausen.

Obtained funding: Edwards, Tuepker.

Administrative, technical, or material support: Shull, Tuepker.

Conflict of Interest Disclosures: Dr Edwards reported receiving grants from the US Department of Veterans Affairs during the conduct of the study. No other disclosures were reported.

Funding/Support: This work was supported by the VA Quality Enhancement Research Initiative and Office of Academic Affiliations’ Interprofessional Learning & Practice Partnered Evaluation Center grant PEC-15-247. Dr Edwards was supported by VA Health Services Research & Development grant CDA 16-152.

Role of the Funder/Sponsor: The funding organizations had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: The ideas expressed in this article are solely those of the authors and do not represent any official position of the US Department of Veterans Affairs.