‘Low-value’ clinical care in general practice: associations of low value care in GP trainees’ practice, including formative and summative examination performance – protocol for cross-sectional and retrospective cohort study analyses using the QUestionable In Training Clinical Activities (QUIT-CA) index

Magin, Parker; Ralston, Anna; Tapley, Amanda; Holliday, Elizabeth G.; Ball, Jean; Driel, Mieke van; Davey, Andrew; Klein, Linda; FitzGerald, Kristen; Spike, Neil; Fielding, Alison

doi:10.1136/bmjopen-2021-058989

Cited by 3 publications

(1 citation statement)

References 26 publications

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“…Currently, we are using ReCEnT data to compile an index of low-value or inappropriate clinical activities (the QUestionable In-Training Clinical Activities, QUIT-CA index) [66]. Combining this data with data collected by GP Synergy as part of registrars' formative assessment program (observed in-consultation performance [67] and in-training formative examinations) along with data on registrars' summative examination (RACGP Fellowship examination) performance, we will be able to explore the relationship of unobserved ('actual') clinical performance with observed clinical performance and with formative and summative examination performance.…”

Section: Combination Of Recent Data With Data From Other Sourcesmentioning

confidence: 99%

The Registrar Clinical Encounters in Training (ReCEnT) cohort study: updated protocol

et al. 2022

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Background During vocational general practice training, the content of each trainee’s (in Australia, registrars’) in-consultation clinical experience is expected to entail a breadth of conditions that exemplify general practice, enabling registrars to gain competency in managing common clinical conditions and common clinical scenarios. Prior to the Registrar Clinical Encounters in Training (ReCEnT) project there was little research into the content of registrars’ consultations despite its importance to quality of training. ReCEnT aims to document the consultation-based clinical and educational experiences of individual Australian registrars. Methods ReCEnT is an inception cohort study. It is comprised of closely interrelated research and educational components. Registrars are recruited by participating general practice regional training organisations. They provide demographic information about themselves, their skills, and their previous training. In each of three 6-month long general practice training terms they provide data about the practice where they work and collect data from 60 consecutive patient encounters using an online portal. Analysis of data uses standard techniques including linear and logistic regression modelling. The ReCEnT project has approval from the University of Newcastle Human Research Ethics Committee, Reference H-2009–0323. Discussion Strengths of the study are the granular detail of clinical practice relating to patient demographics, presenting problems/diagnoses, medication decisions, investigations requested, referrals made, procedures undertaken, follow-up arranged, learning goals generated, and in-consultation help sought; the linking of the above variables to the presenting problems/diagnoses to which they pertain; and a very high response rate. The study is limited by not having information regarding severity of illness, medical history of the patient, full medication regimens, or patient compliance to clinical decisions made at the consultation. Data is analysed using standard techniques to answer research questions that can be categorised as: mapping analyses of clinical exposure; exploratory analyses of associations of clinical exposure; mapping and exploratory analyses of educational actions; mapping and exploratory analyses of other outcomes; longitudinal ‘within-registrar’ analyses; longitudinal ‘within-program’ analyses; testing efficacy of educational interventions; and analyses of ReCEnT data together with data from other sources. The study enables identification of training needs and translation of subsequent evidence-based educational innovations into specialist training of general practitioners.

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Section: Combination Of Recent Data With Data From Other Sourcesmentioning

confidence: 99%

The Registrar Clinical Encounters in Training (ReCEnT) cohort study: updated protocol

et al. 2022

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‘Low-value’ clinical care in general practice: a cross-sectional analysis of low-value care in early-career GPs’ practice

Ralston,

Fielding,

Holliday

et al. 2023

International Journal for Quality in Health Care

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Background Non-evidence-based and ‘low value’ clinical care and medical services are ‘questionable’ clinical activities that are more likely to cause harm than good or whose benefit is disproportionately low compared with its cost. This study sought to establish general practitioner (GP), patient, practice, and in-consultation associations of an index of key non-evidence-based or low-value ‘questionable’ clinical practices. Methods The study was nested in the Registrar Clinical Encounters in Training (ReCEnT) study - an ongoing (from 2010) cohort study in which Australian GP registrars (specialist GP trainees) record details of their in-consultation clinical and educational practice 6-monthly. The outcome factor in analyses, performed on ReCEnT data from 2010 to 2020, was score on the Questionable in-Training Clinical Activities Index (QUIT-CAI) which incorporates recommendations of the Australian Choosing Wisely campaign. A cross-sectional analysis used negative binomial regression (with the model including an offset for the number of times the registrar was at risk of performing a questionable activity) to establish associations of QUIT-CAI scores. Results 3,206 individual registrars (response rate 89.9%), recorded 406,812 problems/diagnoses where they were at risk of performing a questionable activity. Of these problems/diagnoses, 15,560 (3.8%) involved questionable activities being performed. In multivariable analyses, higher QUIT-CAI scores (more questionable activities) were significantly associated with earlier registrar training term: incidence rate ratio (IRR) 0.91 (95% CI 0.87, 0.95) and 0.85 (0.80, 0.90) for Term 2 and Term 3, respectively, compared to Term 1. Other significant associations of higher scores included the patient being new to the registrar (IRR 1.27; 95% CI 1.12-1.45), the patient being of non-English speaking background (IRR 1.24 [1.04, 1.47]), the practice being in a higher socioeconomic area decile (IRR 1.01; 1.00-1.02), small practice size (IRR 1.05; [1.00, 1.10]), shorter consultation duration (IRR 0.99 per minute [0.99, 1.00]), and fewer problems addressed in the consultation (IRR 0.84 [0.79-0.89] for each additional problem). Conclusion Senior registrars’ clinical practice entailed less ‘questionable’ clinical actions than junior registrars’ practice. The association of lower QUIT-CAI scores with a measure of greater continuity of care (the patient not being new to the registrar) suggests continuity should be supported and facilitated during GP training (and in established GPs’ practice).

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Prediction of general practice licensure/certification examination performance by a measure of ‘questionable’ activities in clinical practice: a retrospective cohort study

Magin,

Ralston,

Fielding

et al. 2024

Postgraduate Medical Journal

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Purpose ‘Low-value’ clinical care and medical services are ‘questionable’ activities, being more likely to cause harm than good or with disproportionately low benefit relative to cost. This study examined the predictive ability of the QUestionable In Training Clinical Activities Index (QUIT-CAI) for general practice (GP) registrars’ (trainees’) performance in Australian GP Fellowship examinations (licensure/certification examinations for independent GP). Methods The study was nested in ReCEnT, an ongoing cohort study in which Australian GP registrars document their in-consultation clinical practice. Outcome factors in analyses were individual registrars’ scores on the three Fellowship examinations (‘AKT’, ‘KFP’, and ‘OSCE’ examinations) and pass/fail rates during 2012–21. Analyses used univariable and multivariable regression (linear or logistic, as appropriate). The study factor in each analysis was ‘QUIT-CAI score percentage’—the percentage of times a registrar performed a QUIT-CAI clinical activity when ‘at risk’ (i.e. when managing a problem where performing a QUIT-CAI activity was a plausible option). Results A total of 1265, 1145, and 553 registrars sat Applied Knowledge Test, Key Features Problem, and Objective Structured Clinical Exam examinations, respectively. On multivariable analysis, higher QUIT-CAI score percentages (more questionable activities) were significantly associated with poorer Applied Knowledge Test scores (P = .001), poorer Key Features Problem scores (P = .003), and poorer Objective Structured Clinical Exam scores (P = .005). QUIT-CAI score percentages predicted Royal Australian College of General Practitioner exam failure [odds ratio 1.06 (95% CI 1.00, 1.12) per 1% increase in QUIT-CAI, P = .043]. Conclusion Performing questionable clinical activities predicted poorer performance in the summative Fellowship examinations, thereby validating these examinations as measures of actual clinical performance (by our measure of clinical performance, which is relevant for a licensure/certification examination).

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Cited by 3 publications

References 26 publications

The Registrar Clinical Encounters in Training (ReCEnT) cohort study: updated protocol

The Registrar Clinical Encounters in Training (ReCEnT) cohort study: updated protocol

‘Low-value’ clinical care in general practice: a cross-sectional analysis of low-value care in early-career GPs’ practice

Prediction of general practice licensure/certification examination performance by a measure of ‘questionable’ activities in clinical practice: a retrospective cohort study

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