Disparities in Quality of Primary Care by Resident and Staff Physicians: Is There a Conflict Between Training and Equity?

Abstract

BACKGROUND: Outpatient primary care experience is vital to internal medicine resident training but may impact quality and equity of care delivered in practices that include resident physicians. Understanding whether quality differences exist among resident and staff primary care physicians (PCPs) may present an opportunity to address health disparities within academic medical centers. OBJECTIVE: To determine whether there are differences in the quality of primary care provided by resident PCPs compared to staff PCPs. DESIGN: A retrospective cohort study with a propensitymatched analysis. PARTICIPANTS: 143,274 patients, including 10,870 patients managed by resident PCPs, seen in 16 primary care practices affiliated with an academic medical center. MAIN MEASURES: Guideline-concordant chronic disease management of diabetes (HbA1c, LDL) and coronary artery disease (LDL), preventive breast, cervical, and colorectal cancer screening, and resource utilization measures including emergency department (ED) visits, hospitalizations, high-cost imaging, and patient-reported health experience. KEY RESULTS: At baseline, there were significant differences in sociodemographic and clinical characteristics between resident and staff physician patients. Resident patients were less likely to achieve chronic disease and preventive cancer screening outcome measures including LDL at goal (adjusted OR [aOR] 0.77 [95% CI 0.65, 0.92]) for patients with coronary artery disease; HbA1c at goal (aOR 0.73 [95% CI 0.62, 0.85]) for patients with diabetes; breast (aOR 0.56 [95% CI 0.49, 0.63]), cervical (aOR 0.66 [95% CI 0.60, 0.74]), and colorectal (aOR 0.72 [95% CI 0.65, 0.79] cancer screening. Additionally, resident patients had higher rates of ED visits and hospitalizations but lower rates of high-cost imaging. Resident patients reported lower rates of satisfaction with certain access to care and communication measures. Similar outcomes were noted in propensity-matched sensitivity analyses.CONCLUSION: After controlling for differences in sociodemographic and clinical factors, resident patients were less likely to achieve chronic disease and preventive cancer screening outcomes compared to staff patients. Further efforts to address ambulatory trainee education and primary care quality along with novel approaches to the management of the disproportionately disadvantaged resident patient panels are needed.

Physicians’ clinical experience and its association with healthcare quality: a systematised review

“…The study by Essien and colleagues included 143 274 patients of both resident and staff primary care physicians. 58 They collected details regarding patient’s ethnicity, insurance status, poverty and education, in addition to quality outcomes such as guideline-concordant disease management, screening, resource use and patient-reported health experience. They found that resident physicians had a higher proportion of typically underserved populations than staff physicians and that when controlling for patient factors, residents had lower scores for all quality-outcome measures, except for patient experience.…”

Integrating Interprofessional Trainees into a Complex Care Program for Veterans Experiencing Homelessness: Effects on Health Services Utilization

“…11 In contrast, one study showed that trainees deliver poorer quality of preventive care compared to faculty. 12 In general, the discontinuous schedules of trainees and faculty in academic ambulatory clinics 13,14 can make continuity of care and same-day clinic access challenging. We believe that our structured team-based approach, supported by organizational funding, workload management, 14 and dedicated supervising faculty from multiple professions 7 , contributed to our findings.…”

Primary care physician involvement during hospitalisation: a qualitative analysis of perspectives from frequently hospitalised patients

“…Previous studies found that, as compared with patients with attending PCPs, patients with resident PCPs were more likely to have multiple health conditions, and be non-white, of low socioeconomic status, and on Medicare or Medicaid insurance. [25][26][27][28][29] Patients who transition care to a new resident reported challenges including missed tests and difficulty building a relationship with a new provider. 30 Patients may also experience PCP discontinuity due to the resident clinic schedule.…”