Defining the Resident Continuity Clinic Panel Along Patient Outcomes: a Health Equity Opportunity

Abstract

BACKGROUND: Continuity clinics are a critical component of outpatient internal medicine training. Little is known about the population of patients cared for by residents and how these physicians perform. OBJECTIVES: To compare resident and faculty performance on standard population health measures. To identify potential associations with differences in performance, specifically medical complexity, psychosocial vulnerability, and rates of patient loss. SETTING AND PARTICIPANTS: Large academic primary care clinic caring for 40,000 patients. One hundred ten internal medicine residents provide primary care for 9,000 of these patients; the remainder are cared for by faculty. STUDY DESIGN: Descriptive analysis using review of the medical record and hospital administrative data. MAIN MEASURES: We compared resident and faculty performance on standard population health measures, including cancer screening rates, chronic disease care, acute and chronic medical complexity, psychosocial vulnerability, and rates of patient loss. We evaluated the success of resident transition by measuring rates of kept continuity visits 18 months after graduation. KEY RESULTS: Performance on all clinical outcomes was significantly better for faculty compared to residents. Despite similar levels of medical complexity compared to faculty patients, resident patients had significantly higher levels of psychosocial vulnerability across all measured domains, including health literacy, economic vulnerability, psychiatric illness burden, high-risk behaviors, and patient engagement. Resident patients experienced higher rates of patient loss than faculty patients (38.5 vs. 18.8%) with only 46.5% of resident patients with a kept continuity appointment in the practice 18 months after graduation. CONCLUSIONS: In this large academic practice, resident performance on standard population health measures was significantly lower than faculty. This may be explained in part by the burden of psychosocial vulnerability of their patients and systems that do not effectively transition patients after graduation. These findings present an opportunity to improve structural equity for these vulnerable patients and developing physicians.

How Should Academic Health Centers Desegregate Health Professions Education?

“…Frequently, AHCs have separate faculty or attending physician clinics for patients with private insurance, resident-run clinics for those on Medicaid, and sometimes student clinics for the uninsured. 37,38,39,40 Ostrer et al showed that resident-run clinics at the Icahn School of Medicine at Mount Sinai had longer wait times and less availability than their counterpart faculty clinics. 41 Another study found that patients treated by residents at one Boston AHC network were less likely to be up-to-date on chronic disease and cancer screenings.…”

Resident Perceptions of Continuity Clinic Patient Metrics Differ From EHR Data: Pilot Use of Population Health Dashboards

“…[4][5][6][7] Programs have also harnessed electronic health record (EHR) data for this purpose; however, few have reported on clinical outcomes. [8][9][10] More recently, EHR data have been incorporated into PHM dashboards, which can visually represent summarized practice data. 11,12 Such dashboards have also been proposed as a mechanism to deliver practice data to residents.…”

“…Initial efforts published in the literature involved patient chart audits, structured curricula combined with patient outreach, and measurement of real-time performance 4–7. Programs have also harnessed electronic health record (EHR) data for this purpose; however, few have reported on clinical outcomes 8–10. More recently, EHR data have been incorporated into PHM dashboards, which can visually represent summarized practice data 11,12.…”