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The American Journal of Managed Care October 2019
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Physician Clinical Knowledge, Practice Infrastructure, and Quality of Care
Jonathan L. Vandergrift, MS; and Bradley M. Gray, PhD
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Physician Clinical Knowledge, Practice Infrastructure, and Quality of Care

Jonathan L. Vandergrift, MS; and Bradley M. Gray, PhD
Patient-centered practice infrastructure was associated with better care quality only among physicians who scored well on their Maintenance of Certification exam.

Objectives: To understand if and how one dimension of physician skill, clinical knowledge, moderates the relationship between practice infrastructure and care quality.

Study Design: We included 1301 physicians who certified in internal medicine between 1991 and 1993 or 2001 and 2003 and took the American Board of Internal Medicine (ABIM)’s Maintenance of Certification (MOC) exam and completed ABIM’s diabetes or hypertension registry during their 10-year recertification period between 2011 and 2014. Composite quality scores (overall, process, and intermediate outcome) were based on chart abstractions. Practice infrastructure scores were based on a web-based version of the Physician Practice Connections Readiness Survey. Our measure of clinical knowledge was drawn from MOC exam performance.

Methods: We regressed a physician’s composite care quality scores against the interaction between their practice infrastructure and MOC exam scores with controls for physician, practice, and patient panel characteristics.

Results: We found that a physician’s exam performance significantly moderated the association between practice infrastructure and care quality (P for interaction = .007). For example, having a top quintile practice infrastructure score was associated with a quality care score that was 7.7 (95% CI, 4.3-11.1) percentage points (P <.001) higher among physicians scoring in the top quintile of their MOC exam, but it was unrelated (0.7 [95% CI, –3.8 to 5.3] percentage points; P = .75) to quality among physicians scoring in the bottom quintile on the exam.

Conclusions: Physician skill, such as clinical knowledge, is important to translating patient-centered practice infrastructure into better care quality, and so it may become more consequential as practice infrastructure improves across the United States.

Am J Manag Care. 2019;25(10):497-503
Takeaway Points

Physician clinical knowledge significantly moderated the relationship between patient-centered practice infrastructure and care quality.
  • We found that better practice infrastructure was associated with higher-quality care, especially performance on process measures, only among physicians scoring in the top 2 or 3 quintiles on their Maintenance of Certification exam.
  • These data suggest that individual physician skill may become more important as practice infrastructure improves across the country.
  • In addition, these findings highlight that it is important for patients to be informed about both practice infrastructure quality and a physician’s skill when selecting a doctor.
About a decade ago, several important policies were initiated that promoted practice infrastructure to support patient-centered care.1-4 In response, the adoption of basic electronic health records (EHRs) increased from 20% to more than 50% for office-based physicians between 2009 and 2015, and the number of providers participating in medical home initiatives, which utilize practice infrastructure to promote patient-centered care, increased from 14,000 to more than 63,000 during this period.4-7 Underlying these policies is the assumption that better practice infrastructure would lead to better patient care, although subsequent research consisting mostly of patient-centered medical home evaluations has yielded mixed evidence regarding the effectiveness of improving practice infrastructure.2,8-12 That said, heterogeneity observed across medical home interventions suggests that idiosyncratic aspects of the practices themselves may be critical to translating infrastructure improvements into higher-quality care.11

One such factor that may be important to effectively leveraging infrastructure is the underlying skill of the physicians whose care is supported by practice infrastructure. Conceivably, practice infrastructure could preferentially benefit physicians with either higher or lower skill. For example, it might be that lower-skilled physicians benefit more from infrastructure supports, such as embedded clinical reminders or guideline standards, when developing care plans. Alternatively, synergy could exist between a physician’s skills and the ready access to patient information and electronic tools that are embedded in higher-quality systems, and so higher-skilled providers might deliver better care than lower-skilled providers when supported by practice infrastructure. However, we are unaware of any studies examining whether and how physician skill affects the relationship between practice infrastructure and care quality.

We address this gap by examining whether one dimension of physician skill, namely a physician’s clinical knowledge as measured by performance on the American Board of Internal Medicine (ABIM)’s Maintenance of Certification (MOC) examination, moderates the relationship between practice infrastructure and the quality of diabetes or hypertension care among general internists.


We identified 1301 primary care physicians (ie, nonsubspecializing general internists) who initially certified between either 1991 and 1993 or 2001 and 2003 and participated in either a diabetes or hypertension Process Improvement Module (PIM) registry from 2011 through 2014.13,14 PIM registries were completed during either the first or second 10-year recertification cycle and involved physicians recording data used to assess their care quality and completing a web-based version of the Physician Practice Connections Readiness Survey (PPC-RS) developed by the National Committee for Quality Assurance.15,16 Data were compiled and merged using ABIM administrative identifiers, which were removed prior to analysis. The study was deemed exempt from review by the Advarra institutional review board.

Measures of Physician Care Quality

Each physician in the study abstracted information from 25 sequential (or randomly chosen) charts for patients aged 15 to 90 years with a visit in the past year and noted as having the applicable condition for at least a year. Prior research has demonstrated that patients treated by physicians who elected to complete the PIMs are representative of the patients with diabetes and hypertension typically treated by board-certified internists.17 From each chart, physicians abstracted the patient’s receipt of screening/monitoring tests, laboratory values, and demographics, which were used to assess concordance with process and intermediate outcome quality measures.18,19 Quality measures were used to construct 3 composites using an algorithm designed by an expert panel—(1) an overall quality composite, (2) a process composite, and (3) an intermediate outcomes composite—that each reflect the weighted average compliance across the individual measures (ranging from 0% to 100%; see eAppendix A [eAppendices available at] for individual measure criteria and scoring details).20-22

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