Recertification and relicensure in the allied health professions

This article identifies and clarifies some of the major issues concerning recertification and relicensure of allied health practitioners. Various methods of recredentialing are discussed; while mandatory continuing education may not provide evidence of competency, it may be more acceptable to health care practitioners than any other type of requirement. However, statewide peer review/audit, on-the-job performance evaluation, and a national written examination may be more suitable as recredentialing methods if certain conditions are met. Criteria are suggested for the evaluation of any proposed recredentialing program; for example, the program should be criterion-referenced based, valid, reliable, accessible, cost-effective, and acceptable. If such a recredentialing program is developed, the credentialing board and the practitioners--and ultimately employers, third-party payers, and consumers--must bear the additional costs. The major questions are "Is it necessary?" and "Is it worth it?"     

Providers question PROs' effectiveness. Critics contend peer review organizations are too costly and fail to improve the quality of care

The Health Care Financing Administration (HCFA) established physician review organizations (PROs) to ensure that Medicare recipients receive care that is medically necessary, of high quality, and provided in the appropriate setting. While arguing that oversight is necessary, many healthcare professionals believe PROs do not accomplish what they were set up to do because physicians focus on the possibility of being penalized rather than on improving patient care. PRO critics claim that the program's peer reviewers are not peers of the physician under review and that, to be effective, they should come from the same local area. They contend the best peer review is conducted within the hospital. They believe intrafacility review can be more effective at bringing about improvement because hospital peer reviewers act as supportive, nonthreatening consultants. The confidentiality of the physician-patient relationship is another issue PRO critics raise. HCFA staffers say hospitalized Medicare patients are required to sign a waiver allowing inspection of their charts, but critics counter that waivers are only for the release of records for payment claims. Changes encouraging cooperation between PROs and hospitals could improve the PRO program and enhance quality of care.     

A trial of structured implicit review of randomly selected peer review organization cases

OBJECTIVE: In order to learn more about peer review's acceptability, efficiency, and reliability, we performed structured implicit review with and without use of a structured case review form on a random selection of peer review organization cases. METHODS: We compared the results between methods and with previously obtained review results. Twenty-five charts with physician review completed during the Health Care Financing Administration's Third Scope of Work were randomly selected for rereview. Eight physician advisors, none of whom had seen any of these charts previously, were divided into two groups. Both groups received identical formal instruction in the structured implicit review method. Half of the physicians used a structured review form when performing chart review. The other half did not use this form but completed their reviews using the previously used reporting form. Participating physicians were instructed in the structured review method as described by Rand Corporation. The review process was examined regarding acceptability and efficiency. Review results were analyzed for reliability regarding identification of adverse and potential adverse effects and identification of the source of quality concerns. RESULTS: Instructions regarding structured implicit review methods were understood easily and accepted by physician advisors. Use of the structured review form was less efficient, averaging 50% longer per review. There was no difference in the rate at which adverse events were detected. Potentially serious adverse events were found less often using structured review than in the original review. There was greater agreement among reviewers using the structured form than among those using the historic worksheet, but structured review using the Rand form identified fewer potentially significant adverse events than did the reviewers using the historic worksheets. CONCLUSIONS: Application of structured implicit review methods is clearly feasible for peer review organization case review. Use of a simple worksheet was more time efficient than use of a highly structured form. There was not only less variation in review results but also identification of fewer potentially significant adverse events when the highly structured form was used. Teaching the structured approach to chart review may be more important to obtaining good results than using a structured review form.     

Assessment of family physicians' performance using patient charts: interrater reliability and concordance with chart-stimulated recall interview

Peer-assessment processes with chart review have been used for many years to assess the clinical performance of physicians. The Quebec medical licensing authority has been required by provincial law to assess the practicing Quebec physicians on a nonvoluntary basis. During the period from January 2001 to November 2004, 25 family physicians in active practice were randomly selected from a pool of about 300. For each physician, 25 to 40 patients' medical charts were randomly selected to evaluate the interrater reliability of peer-review assessment of medical charts and to compare ratings based on chart review with a chart-stimulated recall interview to those based on chart review alone. The concordance between chart review alone and that of chart review with chart-stimulated recall interview was 75% for chart keeping, 69% for clinical investigation, 81% for diagnostic accuracy, and 74% for treatment plan. Ratings based on chart review alone achieve moderate levels of reliability (Kappa = 0.44 to 0.56). It appears that some important information about quality of care is missed when only chart review is used.     

Physician peer assessments for compliance with methadone maintenance treatment guidelines

INTRODUCTION: Medical associations and licensing bodies face pressure to implement quality assurance programs, but evidence-based models are lacking. To improve the quality of methadone maintenance treatment (MMT), the College of Physicians and Surgeons of Ontario, Canada, conducts an innovative quality assurance program on the basis of peer assessments. Using data from this program, we assessed physician compliance with MMT guidelines and determined whether physician factors (e.g., training, years of practice), practice type, practice location, and/or caseload is associated with MMT guideline adherence. METHODS: Secondary analysis of methadone practice assessment data collected by the College of Physicians and Surgeons of Ontario, Canada. Assessment data from methadone prescribing physicians who completed their first year of methadone practice were analyzed. We calculated the mean percentage compliance per guideline per physician and global compliance across all guidelines per physician. Linear regression was used to assess factors associated with compliance. RESULTS: Data from 149 physician practices and 1,326 patient charts were analyzed. Compliance across all charts was greater than 90% for most areas of care. Compliance was less than 90% for take-home medication procedures; urine toxicology screening; screening for hepatitis B virus (HBV), hepatitis C virus (HCV), human immunodeficiency virus (HIV), tuberculosis, other sexually transmitted infections, and completion of a psychosocial assessment. Mean global compliance across all charts and guidelines per physician was 94.3% (standard deviation = 7.4%) with a range of 70% to 100%. Linear regression analysis revealed that only year of medical school graduation was a significant predictor of physician compliance. DISCUSSION: This is the first report of MMT peer assessments in Canada. Compliance is high. Few countries conduct similar assessment processes; none report physician-level results. We cannot quantify the contribution of peer assessment, training, or self-selection to the compliance rates, but compared to other areas of practice these rates suggest that peer assessment may exert a significant effect on compliance. A similar assessment process may in other areas of clinical practice improve physician compliance.     

Physician peer review surveys: a management tool for improving quality of patient care

An increasing number of patients are presenting multiple medical problems requiring the collaboration of two or more physician specialists or subspecialists for effective treatment. The quality of care delivered to multiple-problem patients depends greatly on how well the physician specialists interact with one another. The Cleveland Clinic Foundation (CCF) has developed and implemented a physician peer review survey that enables physicians to receive anonymous feedback on the service they provide to their colleagues. The survey has been implemented in both medical and surgical departments. Colleagues have identified areas for improvement to increase collaboration and enhance effectiveness in treating multiproblem patients. The data have led to a variety of specific service-related improvements and changes in physician behavior. Though originally conceived as a quality improvement technique, the physician review survey has become an internal marketing and management tool for physician managers.     

Improving blood pressure control in diabetes: limitations of a clinical reminder in influencing physician behavior

INTRODUCTION: Hypertension should be aggressively treated, especially in diabetic patients. But studies of physician prescribing habits reveal that physicians often delay making medication changes or initiating antihypertensive therapy. A chart-based reminder was designed to improve physician medication prescribing in this clinical situation. METHODS: A randomized controlled trial was conducted at the Veterans Affairs Medical Center in Richmond, Virginia. Patients with diabetes and hypertension were selected. A highly visible chart reminder was applied to the front of outpatient charts in the intervention group practice. A chart review was conducted to assess physician-directed medication changes. A successful outcome was defined as any antihypertensive medication increase or addition at that same visit. RESULTS: Physicians were more likely to intensify antihypertensive medication as the blood pressure increased regardless of the reminder. Overall, only 33% of visits resulted in a medication change, even though 93% of patients had elevations over target blood pressure at the follow-up visit. Physicians in the intervention and control groups made changes to medication at similar rates (chi 2 = 0.621, p = .511). DISCUSSION: In this study, a chart reminder failed to improve physician compliance with the clinical guideline for hypertension management in diabetics, Sixth Report of the Joint National Committee on the Detection, Evaluation, Prevention and Treatment of High Blood Pressure. To inform the design of effective intervention strategies, further research should explore specific barriers to guideline adherence in this clinical situation.     

Position statement on HCFA's Uniform Clinical Data Set (UCDS). American Health Information Management Association

The Uniform Clinical Data Set (UCDS) is a computerized data collection and case finding system that has been developed by the Health Care Financing Administration (HCFA). It is a new mechanism for the screening by peer review organizations (PROs) of inpatient cases for utilization and quality of care problems. The intent is to replace the traditional PRO review process with a collection of a standard set of data about each hospitalization, subject that data to an expert system, and provide to the physician reviewer a case summary that reflects the specific areas which are being questioned and highlights the issues that need to be addressed. The goal is to select cases for review in each state by the identical standards, thus eliminating the differences in PRO review results attributable to individual judgment. HCFA plans to use the abstracted clinical data to evaluate patterns of care and outcomes. However, the UCDS system may have impact beyond the Medicare program. UCDS may become a template for the collection and analysis of data by hospitals and third-party payers for quality and effectiveness review of all patients.     

The doctor on the patient's turf: assessing patient satisfaction with physician home visit programs.

We evaluated a physician home visit program (n = 23 patients) focusing on program implementation and quality. Quality was measured by evaluating patient satisfaction with services using a patient satisfaction scale and interviews with patients, caregivers, and providers. Scale results showed patients expressed the highest satisfaction with access to routine care and physician consideration. Patients expressed less satisfaction with access to emergency care and continuity of care. Physician communication and integration with home- and community-based service providers were other areas of concern. Recommendations include enhancing physician communication skills in the home, providing care for urgent medical conditions, improving chart documentation, and incorporating community-based chronic care experts into the program.     

The impact of a patient survey or a physician reminder on the provision of adolescent preventive health care.

BACKGROUND. The objective of this study was to determine if the use of a patient survey or a chart stamp could increase the implementation of adolescent preventive health care in a family practice center. METHODS. Subjects were all patients 13 to 18 years old (date of birth 1972 to 1977), who visited the Aultman Family Practice Centers from October 1, 1989, through September 30, 1990 (N = 801 patient visits). Three different 1-month interventions (patient questionnaire, physician stamp, and both patient questionnaire and physician stamp) as well as a 1-month control period were implemented. The effect of the intervention on adolescent preventive health care was measured by review of documentation in the patient's chart. RESULTS. Those charts that indicated that either the questionnaire or stamp had been used showed significantly more documented discussion of issues relating to mood, injury, sexuality, exposure to toxins, and lifestyle (all P < .01). These discussions most commonly took place during a visit for a physical examination. The percentage of visits with documented discussions did not vary significantly according to type of reminder, nor with any physician or patient characteristic. CONCLUSIONS. The use of a reminder, especially in the context of an office visit for a physical examination, significantly increased the implementation of adolescent preventive health care in this family practice center.     

Assessment of depression in a family practice center

This study examined the presence of depressive symptoms in an adult outpatient population. Through review of 100 randomly selected patient charts, it was found that a diagnosis of depression was recorded in 31 percent, with an additional 31 percent having symptoms and diagnoses suggestive of depression noted. Data collection on a sample of 123 patients in a second study phase designed to assess agreement among alternative methods for identifying depression included patient interviews (using the Beck Depression Inventory, the Zung Self-Rating Depression Scale, and a visual analog), physician interviews, and chart abstracts. The proportion of patients considered depressed using each of the measures ranged from 21 percent to 38 percent. The patient-reported measures were more closely correlated with each other than with the physician-reported measures. The finding that depressive symptoms are highly prevalent in this population supports the need for training physicians in recognition, treatment, and documentation of depression. Future research imperatives should include differentiating between depressive symptoms and diagnoses, investigating the use of interviewer-administered measures of depression as screening tools, and investigating the relationships between depression, physiologic disease, and use of health services.     

Methodology of retrospective chart review to detect adverse events: the reliability of physician judgment

PURPOSE: To establish a scientific basis for promoting patient safety, basic information related to the incidence of adverse events (AEs) is needed. In studies in several other countries, trained nurses screened for potential AEs using explicit criteria in the first stage, and physicians reviewed selected charts in the second stage. To assure the accuracy of retrospective chart review, it is important to verify the reliability of AE judgments by physician reviewers. The purpose of this study was to test this reliability of judgment of AEs (their presence, causation of healthcare management and preventability) by three physician reviewers. METHODS: This study used 100 selected charts of non-psychiatric inpatients in an acute care hospital. Three physicians independently assessed AEs and discussed their judgments with the physician who created the manual for judging AEs. We considered judgments of the AEs agreed on by the four physicians to be final AE judgments and compared the reliability of each measure related to AE judgments among the physician reviewers using the kappa statistic. RESULTS: The number of AE cases each physician reviewer judged ranged from 18 to 27. Agreement on the presence of an AE ranged from 83.0% to 90.0% (kappa=0.52-0.70). Ultimately, AEs were judged to have occurred in 16 cases while 7 cases were deferred. The agreement on the presence of an AE between the physician's and the final judgment ranged from 86.0% to 96.8% (kappa = 0.56-0.88). However, agreement on the causation of healthcare management and preventability between the physician's and the final judgment was not in the acceptable range. CONCLUSION: The reliability of each physician's judgments regarding the presence of an AE was satisfactory. However, the reliability of judgments related to the causation of health care management and preventability was not necessarily satisfactory. Therefore, it is considered important to judge causation and preventability based on discussion with clinical experts in the relevant field.     

Recredentialing in the allied health professions

Credentialing of allied health professionals is used to assure the public that they are receiving care from competent individuals, and recredentialing is a means to demonstrate continuing competence. There is considerable variability in the requirements that allied health professions have for recredentialing. Of the 16 national credentials representing 14 allied health professions that were included in this study, 50% had no continuing education (CE) or retesting requirement in order to maintain the credential. The remaining 50% required CE in amounts ranging from 10 to 50 hours per year, with a mean of 18.5 hours. One credential requires both CE and retesting. A review of the literature reveals that CE requirements are not linked to improved patient outcomes, and evidence linking retesting to improved outcomes is lacking. Therefore, even though there is external pressure to implement recredentialing requirements for the allied health professions, care needs to be taken to assure that the tools used to ensure continued competence are valid and reliable.     

Adverse perinatal outcomes: is physician specialty a risk factor?

An investigation was conducted in a community hospital to determine whether physician specialty (obstetrics vs family medicine) is a risk factor for adverse perinatal outcomes. Over a three-year period, there were 6,856 deliveries, of which 713 (10.4 percent) were attended by family physicians. Overall, there were 301 (4.4 percent) cases with adverse outcomes, of which 32 (10.6 percent) were attended by family physicians. The charts of a weighted random sample of 117 cases with adverse outcomes and 468 controls were reviewed to determine potential risk factors, including prenatal risk status, race, insurance, and specialty of the attending physician. The risk ratio for family physician as attending was 0.99 (95 percent confidence interval, 0.69 to 1.42) after multivariate adjustment for the other risk factors. Only high prenatal risk status was found to be an independent predictor (risk ratio 1.75, 95 percent confidence interval, 1.23 to 2.49). A chart review of a random sample of 146 patients (73 each of family physicians and obstetricians) revealed no difference in the proportion of high-risk patients in each specialty. It is concluded that in the setting studied, specialty is not a risk factor for adverse perinatal outcomes, and that this finding is not confounded by the patient's prenatal risk status.     

Methods to achieve high interrater reliability in data collection from primary care medical records

PURPOSE We assessed interrater reliability (IRR) of chart abstractors within a randomized trial of cardiovascular care in primary care. We report our findings, and outline issues and provide recommendations related to determining sample size, frequency of verification, and minimum thresholds for 2 measures of IRR: the κ statistic and percent agreement.METHODS We designed a data quality monitoring procedure having 4 parts: use of standardized protocols and forms, extensive training, continuous monitoring of IRR, and a quality improvement feedback mechanism. Four abstractors checked a 5% sample of charts at 3 time points for a predefined set of indicators of the quality of care. We set our quality threshold for IRR at a κ of 0.75, a percent agreement of 95%, or both.RESULTS Abstractors reabstracted a sample of charts in 16 of 27 primary care practices, checking a total of 132 charts with 38 indicators per chart. The overall κ across all items was 0.91 (95% confidence interval, 0.90–0.92) and the overall percent agreement was 94.3%, signifying excellent agreement between abstractors. We gave feedback to the abstractors to highlight items that had a κ of less than 0.70 or a percent agreement less than 95%. No practice had to have its charts abstracted again because of poor quality.CONCLUSIONS A 5% sampling of charts for quality control using IRR analysis yielded κ and agreement levels that met or exceeded our quality thresholds. Using 3 time points during the chart audit phase allows for early quality control as well as ongoing quality monitoring. Our results can be used as a guide and benchmark for other medical chart review studies in primary care.     

Influence of remedial professional development programs for poorly performing physicians

INTRODUCTION: The Collège des Médecins du Québec (CMQ) offers an individualized remedial professional development program to help physicians overcome selected clinical shortcomings. To measure the influence of the remedial professional development program, physicians who completed the program between 1993 and 2004 and who were assessed by peer review during a 2-year period preceding or following the remedial activities were tracked. METHODS: For each physician, 30 to 50 patient records were selected randomly for review. Ratings were assigned for the quality of record keeping and for 3 elements pertaining to the quality of care: the clinical investigation plan, diagnostic accuracy, and patient treatment and follow-up. The impact of the program was measured by comparing the proportion of physicians with satisfactory ratings assigned by peer review before and after the remedial professional development program. RESULTS: Statistically significant improvements (p < .05) were observed for a proportion of physicians (n = 51) with satisfactory ratings with regard to record keeping (20% before and 54% after remediation), the clinical investigation plan (13% before and 59% after remediation), diagnostic accuracy (32% before and 61% after remediation), and patient treatment and follow-up (31% before and 67% after remediation). DISCUSSION: Participation in a CMQ remedial professional development program can result in improved clinical performance, as assessed through peer review.     

Cancer screening by primary care physicians: a comparison of rates obtained from physician self-report, patient survey, and chart audit.

OBJECTIVES. This study measured the cancer screening rates of family physicians and compared the measures obtained through physician self-reports, chart audits, and patient surveys. METHODS. A cancer screening survey was sent to 50% of the members of the Washington Academy of Family Physicians, with 326 family physicians (74% response rate) completing the survey. Sixty physicians were recruited for the patient survey and chart audit phase, with a 90% participation rate. Patient surveys were conducted with about 350 patients per physician, and chart audits were conducted on a subset of about 50 patients per physician. Each physician's rate of providing each service was computed from the self-report, the patient survey, and the chart audit. RESULTS. Physicians provided many of these services at rates different from those commonly recommended. Large discrepancies were found between the rates measured by different methods. Correlations between rates derived from chart audits and patient surveys were high; however, correlations between rates from physician self-report and either patient survey or chart audit were much lower for all services. CONCLUSIONS. Studies of physicians' provision of cancer prevention services should not rely on physician self-report, but should obtain the rates through patient surveys or chart audits.     

Data bank has operational impact. Proper peer review can protect hospitals from antitrust and defamation suits

The Health Care Quality Improvement Act of 1986 can help protect medical professionals and healthcare facilities from antitrust and defamation claims and other forms of litigation arising from the peer review process. Some hospitals may need to make major changes in their peer review activity as a result of the act. The healthcare entity, not the physicians involved in peer review, has the burden of complying with the provisions of the act. Failure to comply with the act can lead to loss of immunity from damages, fines, and potential exclusion from the Medicare program. The potential for liability has sparked a need for hospitals to reexamine and possibly reorganize medical staff and update procedures and related governing documents. Healthcare entities may consider changes such as implementing a director of medical affairs function, choosing medical staff for multiple-year terms, and centralizing physician review files. In the 1980s many hospitals created quality assurance and risk management programs. Risk managers need to share data with quality assurance personnel, who must in turn share the information with medical staff involved with credentialing, peer review, and medical affairs management. Legal counsel will need to be familiar with the legalities of the act, as well as the hospital's peer review procedures and operations. General legal counsel should oversee coordination of hospital proceedings and assist in educating staff on the legalities of peer review.