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Aiming at the problems of being vulnerable to internal attacks and frequent link interruption in flying ad hoc networks (FANETs), a trust-based ad hoc on-demand multipath distance vector routing protocol (TAOMDV) is proposed. Firstly, a trust evaluation model is established. The packet forward ratio, trusted interaction and probe packet receive ratio are introduced as trust evaluation factors. An adaptive fuzzy trust aggregation network (AFTAN) is designed to calculate the direct trust of nodes, while the indirect trust of reliable neighbor nodes is integrated as well to calculate node trust. Secondly, the trust fluctuation penalty mechanism is introduced to resist the on-off attack in the trust model. Finally, the trust model is applied to ad hoc on-demand multipath distance vector (AOMDV) protocol. In the route discovery phase, the path trust is introduced as the basis for routing selection to establish a trusted path. In the route maintenance phase, the path alarm mechanism is applied to respond to malicious nodes in a timely manner. The simulation results show that the TAOMDV can not only defend against common attacks, such as black hole attack, gray hole attack and on-off attack, but also reduce the impact of topology changes and link interruptions. Compared with light-weight trust-enhanced ad hoc on-demand multipath distance vector (TEAOMDV), the proposed protocol effectively improves the delivery ratio and throughput of the network, which contributes to the better performance in routing overhead and average end-to-end delay.

Background The pass rate on the American Board of Internal Medicine (ABIM) nephrology certifying exam has declined and is among the lowest of all internal medicine (IM) subspecialties. In recent years, there have also been fewer applicants for the nephrology fellowship match. Methods This retrospective observational study assessed how changes between 2010 and 2019 in characteristics of 4094 graduates of US ACGME-accredited nephrology fellowship programs taking the ABIM nephrology certifying exam for the first time, and how characteristics of their fellowship programs were associated with exam performance. The primary outcome measure was performance on the nephrology certifying exam. Fellowship program pass rates over the decade were also studied. Results Lower IM certifying exam score, older age, female sex, international medical graduate (IMG) status, and having trained at a smaller nephrology fellowship program were associated with poorer nephrology certifying exam performance. The mean IM certifying exam percentile score among those who subsequently took the nephrology certifying exam decreased from 56.7 (SD, 27.9) to 46.1 (SD, 28.7) from 2010 to 2019. When examining individuals with comparable IM certifying exam performance, IMGs performed less well than United States medical graduates (USMGs) on the nephrology certifying exam. In 2019, only 57% of nephrology fellowship programs had aggregate 3-year certifying exam pass rates ≥80% among their graduates. Conclusions Changes in IM certifying exam performance, certain trainee demographics, and poorer performance among those from smaller fellowship programs explain much of the decline in nephrology certifying exam performance. IM certifying exam performance was the dominant determinant.

ObjectiveTo determine whether internists’ initial specialty certification and the maintenance of that certification (MOC) is associated with lower in-hospital mortality for their patients with acute myocardial infarction (AMI) or congestive heart failure (CHF).DesignRetrospective cohort study of hospitalisations in Pennsylvania, USA, from 2012 to 2017.SettingAll hospitals in Pennsylvania.ParticipantsAll 184 115 hospitalisations for primary diagnoses of AMI or CHF where the attending physician was a self-designated internist.Primary outcome measureIn-hospital mortality.ResultsOf the 2575 physicians, 2238 had initial certification and 820 were eligible for MOC. After controlling for patient demographics and clinical characteristics, hospital-level factors and physicians’ demographic and medical school characteristics, both initial certification and MOC were associated with lower mortality. The adjusted OR for initial certification was 0.835 (95% CI 0.756 to 0.922; pConclusionsInitial certification was associated with lower mortality for AMI or CHF. Moreover, for patients whose physicians had initial certification, an additional advantage was associated with its maintenance.

BACKGROUND Older patients are often prescribed potentially inappropriate medications (PIMs) given their age. We measured the association between a physician's general knowledge and their PIM prescribing. METHODS Using a 2013-2017 cross-sectional design, we related a general internist's knowledge (n = 8196) to their prescribing of PIMs to fee-for-service Medicare beneficiaries, age ≥ 66 years with part D coverage, which they saw in the outpatient setting the year after their exam (n = 875,132). Physician knowledge was based on the American Board of Internal Medicine's (ABIM) Internal Medicine Maintenance of Certification (IM-MOC) exam scores. Medications included 72 PIMs from the American Geriatric Society's Beers Criteria and appropriate alternatives to these medications. Logistic regressions controlled for physicians practice/training characteristics and patient-risk factors. RESULTS Annually, 11.0% of patients received a PIM and 57.2% received an appropriate alternative medication. Patients seen by physicians scoring in the top versus bottom quartile were 8.6% less likely (95% confidence interval [CI]: -12.7 to -4.5, p

This cohort study examines the association between health care intensity in the region where physicians practice and their ability to practice high-value care, specifically for physicians who relocated after residency., Key Points Question How does the health care environment in a region influence internists’ clinical capabilities, particularly the ability to practice high-value care? Findings This cohort study of 2714 newly certified internists (in 2002) who relocated to a new region after completing residency found that higher intensity of use of health care services in a physician’s destination region was associated with reduced ability to practice appropriately conservative care 1 decade later compared with that ability measured at the end of residency. Meaning The demands of practicing in high-intensity service regions may erode internists’ ability to practice high-value, conservative care., Importance Use of health care services and physician practice patterns have been shown to vary widely across the United States. Although practice patterns—in particular, physicians’ ability to provide high-quality, high-value care—develop during training, the association of a physician’s regional practice environment with that ability is less well understood. Objective To examine the association between health care intensity in the region where physicians practice and their ability to practice high-value care, specifically for physicians whose practice environment changed due to relocation after residency. Design, Setting, and Participants This cohort study included a national sample of 3896 internal medicine physicians who took the 2002 American Board of Internal Medicine initial certification examination followed approximately 1 decade (April 21, 2011, to May 7, 2015) later by the Maintenance of Certification (MOC) examination. At the time of the MOC examination, 2714 of these internists were practicing in a new region. Data were analyzed from March 6, 2016, to May 21, 2018. Exposures Intensity of care in the Dartmouth Atlas hospital referral region (HRR), measured by per-enrollee end-of-life physician visits (primary) and current practice type (secondary). Main Outcomes and Measures The outcome, a physician’s ability to practice high-value care, was assessed using the Appropriately Conservative Management (ACM) score on the MOC examination, measuring performance across all questions for which the correct answer was the most conservative option. The exposure, regional health care intensity, was measured as per-enrollee end-of-life physician visits in the Dartmouth Atlas HRR of the physician’s practice. Results Among the 3860 participating internists included in the analysis (2030 men [52.6%]; mean [SD] age, 45.6 [4.5] years), those who moved to regions in the quintile of highest health care intensity had an ACM score 0.22 SD lower (95% CI, −0.32 to −0.12) than internists who moved to regions in the quintile of lowest intensity, controlling for postresidency ACM scores. This difference reflected scoring in the 44th compared with the 53rd percentile of all examinees. This association was mildly attenuated (0.18 SD less; 95% CI, −0.28 to −0.09) after adjustment for physician and practice characteristics. Conclusions and Relevance This study found that practice patterns of internists who relocate after residency training appear to migrate toward norms of the new region. The demands of practicing in high-intensity regions may erode the ability to practice high-value conservative care.

Rheumatoid arthritis (RA) is a long-standing and growing autoimmune disease. Therefore, the present study was intended to investigate the effect of Corynoline (COR) on CFA induced rheumatoid arthritis in a rat model. Results suggested that COR causes significant reduction in paw swelling, edema, arthritis score, thymus and spleen indexes and neutrophil infiltration (p

Objective To evaluate the effect of state continuing medical education (CME) requirements on physician clinical knowledge. Data Sources Secondary data for 19,563 general internists who took the Internal Medicine Maintenance of Certification (MOC) examination between 2006 and 2013. Study Design We took advantage of a natural experiment resulting from variations in CME requirements across states over time and applied a difference-in-differences methodology to measure associations between changes in CME requirements and physician clinical knowledge. We measured changes in clinical knowledge by comparing initial and MOC examination performance 10 years apart. We constructed difference-in-differences estimates by regressing examination performance changes against physician demographics, county and year fixed effects, trend–state indicators, and state CME change indicators. Data Collection Physician data were compiled by the American Board of Internal Medicine. State CME policies were compiled from American Medical Association reports. Principal Findings More rigorous CME credit-hour requirements (mostly implementing a new requirement) were associated with an increase in examination performance equivalent to a shift in examination score from the 50th to 54th percentile. Conclusions Among physicians required to engage in a summative assessment of their clinical knowledge, CME requirements were associated with an improvement in physician clinical knowledge.

Background Cardiovascular intensive care units ( CICUs ) have evolved from coronary care wards into distinct units for critically ill patients with primary cardiac diseases, often suffering from illnesses that cross multiple disciplines. Mounting evidence has demonstrated improved survival with the incorporation of dedicated CICU providers with expertise in critical care medicine ( CCM ). This is the first study to systematically survey dual certified physicians in order to assess the relevance of CCM training to contemporary CICU care. Methods and Results Utilizing American Board of Internal Medicine data through 2014, 397 eligible physicians had obtained initial certification in both cardiovascular disease and CCM . A survey to delineate the role of critical care training in the CICU was provided to these physicians. Among those surveyed, 120 physicians (30%) responded. Dual certified physicians reported frequent use of their CCM skills in the CICU , highlighting ventilator management, multiorgan dysfunction management, end‐of‐life care, and airway management. The majority (85%) cited these skills as the reason CCM training should be prioritized by future CICU providers. Few (17%) agreed that general cardiology fellowship alone is currently sufficient to care for patients in the modern CICU . Furthermore, there was a consensus that there is an unmet need for cardiologists trained in CCM (70%) and that CICU s should adopt a level system similar to trauma centers (61%). Conclusions Citing specific skills acquired during CCM training, dual certified critical care cardiologists reported that their additional critical care experience was necessary in their practice to effectively deliver care in the modern CICU .

This cross-sectional study compares the association of clinical knowledge with opioid prescribing from 2009 to 2011 when prescribing peaked nationally with 2015 to 2017 when guidelines shifted away from opioid prescribing., Key Points Question Is clinical knowledge associated with opioid prescribing and has this association changed over time? Findings In this cross-sectional study from 2009 to 2017 of 10 246 physicians, opioids were prescribed during 21.6% new onset low back pain office visits. From 2015 to 2017, opioid prescription rates were 4.6 percentage points lower in visits with physicians in the highest vs lowest quartile of performance on American Board Internal Medicine’s Maintenance of Certification examination despite there being no difference in the earlier 2009 to 2011 or 2012 to 2014 periods. Meaning These findings suggest that physicians with higher clinical knowledge scores had reduced opioid prescribing in 2015 to 2017, when guidelines were rapidly changed toward reduced opioid prescribing., Importance Opioid musculoskeletal pain overprescribing was widespread in the mid-2000s. The degree to which prescribing changed as awareness of the danger grew among physicians with different levels of clinical knowledge remains unstudied. Objective To compare the association of clinical knowledge with opioid prescribing from 2009 to 2011 when prescribing peaked nationally with 2015 to 2017 when guidelines shifted away from opioid prescribing. Design, Setting, and Participants This cross-sectional study included 10 246 midcareer general internal medicine physicians in the United States who saw patients who were Medicare beneficiaries with Part D enrollment from 2009 to 2017. Main Outcomes and Measures Any opioid prescription and high dosage or long duration (HDLD) (>7 days or >50 daily morphine milligram equivalents) opioid prescriptions filled within 7 days of applicable visits for new low back pain concerns. Associations between opioid prescribing for new low back pain concerns during outpatient visits and clinical knowledge measured by prior year American Board of Internal Medicine (ABIM) Maintenance of Certification examination performance were estimated using serial cross-sectional logit regressions. Regression covariates included yearly examination quartile (ie, knowledge quartile) interacted with 3-year group dummies (ie, early: 2009-2011; middle: 2012-2014; late: 2015-2017), state and year dummies, physician, practice, patient characteristics, and state opioid regulations. Results Of the 55 387 low back pain visits included in this study, 37 185 (67.1%) were visits with female patients, 41 978 (75.8%) were with White patients, and the mean (SE) age of patients was 76.2 (

Background Though the proportion of female Internal Medicine (IM) residents and faculty has increased, there is minimal large scale modern data comparing resident performance by gender. This study sought to examine the effects of resident and faculty gender on resident evaluations. Methods Retrospective observational study over 5 years in a single IM program. IM certifying examination pass rates were obtained from the American Board of IM. Results Four hundred eighty-eight residents (195 women, 293 men), evaluated by 430 attending physicians (163 women, 270 men) were included. Twelve thousand six hundred eighty-one evaluations between 2007 and 2012 were analyzed. Female residents scored higher in two domains (Medical Interviewing, and Interpersonal and Communication Skills) (p

Faculty Evaluation of Resident. (DOCX 17 kb)

Patients with osteoporosis can sustain fractures following falls or other minimal trauma. This risk of fracture can be reduced through appropriate diagnostic testing, pharmacologic therapy, and other readily measured standards of care. Our aim was to develop a credible clinical performance assessment to measure physicians’ quality of osteoporosis care, and determine reasonable performance standards for both competent and excellent care. This was a retrospective cohort study. Three hundred and eighty one general internists and subspecialists with time-limited board certification were included in the study. Performance rates on eight evidence-based measures were obtained from the American Board of Internal Medicine (ABIM) Osteoporosis Practice Improvement Module® (PIM), a web-based tool that uses medical chart reviews to help physicians assess and improve care. We applied a patented methodology, using an adaptation of the Angoff standard-setting method and the Dunn-Rankin method, with an expert panel skilled in osteoporosis care to form a composite and establish standards for both competent and excellent care. Physician and practice characteristics, including a practice infrastructure score based on the Physician Practice Connections Readiness Survey (PPC-RS), were used to examine the validity of the inferences made from the composite scores. The mean composite score was 67.54 out of 100 maximum points with a reliability of 0.92. The standard for competent care was 46.87, and for excellent care it was 83.58. Both standards had high classification accuracies (0.95). Sixteen percent of physicians performed below the competent care standard, while 22 % met the excellent care standard. Specialists scored higher than generalists, and better practice infrastructure was associated with higher composite scores, providing some validity evidence. We developed a rigorous methodology for assessing physicians’ osteoporosis care. Clinical performance feedback relative to absolute standards of care provides physicians with a meaningful approach to self-evaluation to improve patient care.

Given the rising burden of healthcare costs, both patients and healthcare purchasers are interested in discerning which physicians deliver quality care. We proposed a methodology to assess physician clinical performance in preventive cardiology care, and determined a benchmark for minimally acceptable performance. We used data on eight evidence-based clinical measures from 811 physicians that completed the American Board of Internal Medicine's Preventive Cardiology Practice Improvement Module(SM) to form an overall composite score for preventive cardiology care. An expert panel of nine internists/cardiologists skilled in preventive care for cardiovascular disease used an adaptation of the Angoff standard-setting method and the Dunn-Rankin method to create the composite and establish a standard. Physician characteristics were used to examine the validity of the inferences made from the composite scores. The mean composite score was 73.88 % (SD = 11.88 %). Reliability of the composite was high at 0.87. Specialized cardiologists had significantly lower composite scores (P = 0.04), while physicians who reported spending more time in primary, longitudinal, and preventive consultative care had significantly higher scores (P = 0.01), providing some evidence of score validity. The panel established a standard of 47.38 % on the composite measure with high classification accuracy (0.98). Only 2.7 % of the physicians performed below the standard for minimally acceptable preventive cardiovascular disease care. Of those, 64 % (N = 14) were not general cardiologists. Our study presents a psychometrically defensible methodology for assessing physician performance in preventive cardiology while also providing relative feedback with the hope of heightening physician awareness about deficits and improving patient care.

Assessing physicians' clinical performance using statistically sound, evidence-based measures is challenging. Little research has focused on methodological approaches to setting performance standards to which physicians are being held accountable.Determine if a rigorous approach for setting an objective, credible standard of minimally-acceptable performance could be used for practicing physicians caring for diabetic patients.Retrospective cohort study.Nine hundred and fifty-seven physicians from the United States with time-limited certification in internal medicine or a subspecialty.The ABIM Diabetes Practice Improvement Module was used to collect data on ten clinical and two patient experience measures. A panel of eight internists/subspecialists representing essential perspectives of clinical practice applied an adaptation of the Angoff method to judge how physicians who provide minimally-acceptable care would perform on individual measures to establish performance thresholds. Panelists then rated each measure's relative importance and the Dunn-Rankin method was applied to establish scoring weights for the composite measure. Physician characteristics were used to support the standard-setting outcome.Physicians abstracted 20,131 patient charts and 18,974 patient surveys were completed. The panel established reasonable performance thresholds and importance weights, yielding a standard of 48.51 (out of 100 possible points) on the composite measure with high classification accuracy (0.98). The 38 (4%) outlier physicians who did not meet the standard had lower ratings of overall clinical competence and professional behavior/attitude from former residency program directors (p = 0.01 and p = 0.006, respectively), lower Internal Medicine certification and maintenance of certification examination scores (p = 0.005 and p0.001, respectively), and primarily worked as solo practitioners (p = 0.02).The standard-setting method yielded a credible, defensible performance standard for diabetes care based on informed judgment that resulted in a reasonable, reproducible outcome. Our method represents one approach to identifying outlier physicians for intervention to protect patients.

Objective. To investigate the feasibility, reliability, and validity of comprehensively assessing physician-level performance in ambulatory practice. Data Sources/Study Setting. Ambulatory-based general internists in 13 states participated in the assessment. Study Design. We assessed physician-level performance, adjusted for patient factors, on 46 individual measures, an overall composite measure, and composite measures for chronic, acute, and preventive care. Between- versus within-physician variation was quantified by intraclass correlation coefficients (ICC). External validity was assessed by correlating performance on a certification exam. Data Collection/Extraction Methods. Medical records for 236 physicians were audited for seven chronic and four acute care conditions, and six age- and gender-appropriate preventive services. Principal Findings. Performance on the individual and composite measures varied substantially within (range 5–86 percent compliance on 46 measures) and between physicians (ICC range 0.12–0.88). Reliabilities for the composite measures were robust: 0.88 for chronic care and 0.87 for preventive services. Higher certification exam scores were associated with better performance on the overall (r=0.19; p

Managing diabetes and preventing its associated morbidities require active partnerships between physicians and patients. Studies to date lack the level of detail to quantify the degree to which interventions that are more controlled by physicians influence outcomes versus those that are more controlled by patients. Using the Archimedes model, we simulated a thirty-year clinical trial and compared the effects of three sets of interventions over which physicians have progressively less control: compliance with process-of-care standards, such as conducting foot and retinal exams and screening for signs of early kidney disease; control of biomarkers, such as hemoglobin A1c and blood pressure; and lifestyle modifications, such as patients' switching to healthier diets and losing weight. We found that if all US adults diagnosed with type 2 diabetes met quality targets in all of these areas, they would experience a nearly 16 percent increase in quality-adjusted life-years and a nearly 23 percent reduction in fifteen-year mortality over the thirty-year simulation period. Meeting aggressive biomarker targets yielded the most benefit. Meeting conservative biomarker targets came next, followed closely by meeting process-of-care standards. The incremental benefits of complying fully with diet and smoking cessation yielded the least benefit. Thus, through measures more readily within their control, and through collaboration with their patients, physicians have a substantial opportunity to improve outcomes. These findings can inform policy makers' rational resource allocation decisions and the design of programs to improve diabetes care.

PURPOSE: To examine the association between physicians' cognitive skills and their performance on a composite measure of diabetes care that included process, outcome, and patient experience measures. METHOD: The sample was 676 physicians from the United States with time-limited certification in general internal medicine between 2005 and 2009. Scores from the American Board of Internal Medicine (ABIM) internal medicine maintenance of certification (MOC) examination were used to measure practicing physicians' cognitive skills (scores reflect fund of medical knowledge, diagnostic acumen, and clinical judgment). Practice performance was assessed using a diabetes composite measure aggregated from clinical and patient experience measures obtained from the ABIM Diabetes Practice Improvement Module. RESULTS: Using multiple regression analyses and controlling for physician and patient characteristics, MOC examination scores were significantly associated with the diabetes composite scores (β = .22, P < .001). The association was particularly stronger with intermediate outcomes than with process and patient experience measures. Performance in the endocrine disease content domain of the examination was more strongly associated with the diabetes composite scores (β = .19, P < .001) than the performance in other medical content domains (β = .06-.14). CONCLUSIONS: Physicians' cognitive skills significantly relate to their performance on a comprehensive composite measure for diabetes care. Although significant, the modest association suggests that there are unique aspects of physician competence captured by each assessment alone and that both must be considered when assessing a physician's ability to provide high-quality care.

Nearly 10 years ago the Institute of Medicine (IOM) released its seminal report on the state of the quality of health care in the United States entitled Crossing the Quality Chasm (IOM 2001). In addition to providing ample evidence about the deficiencies of the quality of care, the IOM laid out six aims for improving quality; medical care should be effective, efficient, equitable, timely, safe, and patient centered. Progress in improving the quality of health care since the release of this report has been slow, and one hypothesis for the lack of more substantial progress is the eroding state of primary care in the United States. Multiple lines of evidence include the increased administrative hassles faced in a primary care practice, poor reimbursement, loss of physicians from primary care, and declining interest among medical students (Lipner et al. 2006; American College of Physicians 2008; Hauer et al. 2008). However, others also point to the failure of primary care to adopt new approaches to care delivery, quality improvement, and systems science (Baron and Cassel 2008). These concerns led to the creation of, and subsequently intense interest in, a new model of primary care called the patient-centered medical home (PCMH) that is now the subject of multiple demonstration projects across the United States (American College of Physicians 2007; Landon et al. 2010). Principles for the PCMH were developed collaboratively and released by four primary care–related societies in 2007 (American College of Physicians 2007). This PCMH group then worked with the National Committee for Quality Assurance (NCQA) to revise NCQA's existing Physician Practice Connections (PPC) program to create a process for “qualifying” practices as a PCMH at one of three levels (American College of Physicians 2007). NCQA's current tool, the Provider Practice Connections – Patient Centered Medical Home (PPC-PCMH), is being used to “qualify” medical homes for many of these pilots and is almost exclusively focused on the primary care practice's infrastructure (NCQA 2010b). This tool has become the “industry standard” operational definition of the PCMH and is being used by Medicare and private sector payers to qualify physician practices as a medical home (Abrams 2008 Mathematica 2008; Bitton et al. 2010). Recent policy discussion has emphasized adoption of key practice infrastructure capabilities to improve patient care by promoting care management and coordination, and establishing processes to improve access to care and communication (Berenson et al. 2008; Friedberg et al. 2009). Advocacy for the PCMH has formalized assumptions about the link between these infrastructure capabilities and patient-centered care, offering enhanced reimbursement for practices that provide evidence of having such capabilities. However, two recent studies have raised questions about the association between presence of system infrastructure components and quality of care (Friedberg et al. 2009; Holmboe et al. 2010a). In the end, the ultimate success of the PCMH will depend on whether patients’ health care needs are being met. A substantial shortcoming to the current approach to “qualifying” PCMHs is the lack of assessment of patient experience with the practice. One might reasonably ask, “how can we provide patient-centered care if we do not ask the patient about their experience of care?” Yet the 2008 revisions to the PPC-PCMH criteria included only a modest component for patient assessment of the practice (NCQA 2008), despite substantial progress in developing instruments to assess patients’ experiences with their care, such as the Consumer Assessment of Health Plans and Systems (CAHPS) surveys (Safran et al. 1998; Hays et al. 1999). Recognizing the importance of this, NCQA is currently proposing an optional patient experience module to the PCMH process (NCQA 2010a). With this in mind, we examined four hypotheses central to the debate around the importance of the patient's voice when evaluating PCMH qualification. First, NCQA's PCMH infrastructure measure was not strongly associated with patient rating of physician quality. Second, patient-centered care measures from the CAHPS patient survey were strongly associated with patient rating of physician quality. Third, PCMH infrastructure measure was unrelated to patient-centered care measures. Final, PCMH infrastructure measure and patient rating of care quality rendered by their physician accounted for important but distinctly different aspects of an intermediate outcome quality measure (blood pressure [BP] control).

Much research has been devoted to addressing challenges in achieving reliable assessments of physicians’ clinical performance but less work has focused on whether valid and accurate classification decisions are feasible. This study used 957 physicians certified in internal medicine (IM) or a subspecialty, who completed the American Board of Internal Medicine (ABIM) Diabetes Practice Improvement Module (PIM). Ten clinical and two patient-experience measures were aggregated into a composite measure. The composite measure score was highly reliable (r = .91) and classification accuracy was high across the entire score scale (>0.90), which indicated that it is possible to differentiate high-performing and low-performing physicians. Physicians certified in endocrinology and those who scored higher on their IM certification examination had higher composite scores, providing some validity evidence. In summary, it is feasible to create a psychometrically robust composite measure of physicians’ clinical performance, specifically for the quality of care they provide to patients with diabetes.

Health reform legislation grants authority for patient-centered medical home pilot projects to test changes in the way primary care is provided. There is concern that using a measurement tool to qualify medical homes that is solely based on the presence or absence of "system elements" may miss the point conceptually and lead physicians astray in attempts to transform their entire practices. To find out whether and how practice characteristics explain health care quality, we examined risk-adjusted composite measures of quality for common chronic and acute care conditions and preventive care from 202 general internists working primarily in small primary care office settings. We found that current conceptions and measures of what constitutes "successful" practice systems and care are incomplete, and have limited associations with measures of health care quality. Future research should explore more fully the issues around physician competence, including competence in systems and quality improvement; the interactive nature of clinical practice; and other important system elements not captured by current tools.

BACKGROUND To assess the psychometric properties of the three components of the Diabetes Practice Improvement Module, to compare reliabilities of composites to individual measures, and to identify associations among practice-based and patient-based measures. METHOD Data include practice systems surveys of 626 physicians, 13,965 chart audits, and 12,927 patient surveys. Quality composites were identified using factor analysis. Means with reliabilities (intraclass correlation coefficient [ICC] and Cronbach's alpha) are reported. Associations among patient-based quality measures and practice measures with case-mix adjustments were estimated via hierarchical models. RESULTS Composite ICCs range from 0.11 to 0.54, and single items range from 0.05 to 0.49. Staff communication, efficiency, care access, and patient knowledge correlate with patient satisfaction (P < .001). Clinical outcomes are associated with clinical processes (e.g., annual foot exam) and appropriate treatment (P < .001). Patient adjusters (e.g., overall health or factors limiting self-care) are important for the models; physician characteristics used (e.g., age, practice size) seem less important. CONCLUSIONS Composites require smaller patient sample sizes and result in more reliable measures than do individual items. Additionally, the data show meaningful relationships between composites; physician-directed components (i.e., clinical processes and treatments) are related to clinical outcomes, and patients are clearly more satisfied with care if it is easily accessible and if communication about care is good.