Author Affiliations: Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada (Drs Kawasumi, Abrahamowicz, and Tamblyn); Department of Medicine, McGill University Health Centre, Montreal (Drs Ernst, Abrahamowicz, and Tamblyn); Center for Clinical Epidemiology, Lady Davis Research Institute, Jewish General Hospital, Montreal (Dr Ernst); and Centre for Health Services and Policy Research, University of British Columbia, Vancouver, British Columbia, Canada (Dr Kawasumi).
Asthma is a serious public health problem, and suboptimal asthma management has been identified as an important cause of asthma morbidity.1 Physicians play a pivotal role in establishing asthma control, but there is considerable variation among physicians in their approach to asthma management that does not appear to be explained by differences in patient populations.2
Effective management of asthma requires mastery of a number of interrelated physician skills. There is an increasing effort to directly teach these skills, particularly collaborative communication with patients, in medical school and specialty training programs. In 1993, Canada was the first country to require successful demonstration of clinical and communication skills on national medical licensure examination.3 The United States enacted the same requirement in 2005.4 Our objective was to determine whether higher scores in medical knowledge and clinical and communication skills would be associated with the quality and outcomes of management for patients with poorly controlled asthma in the first 1 to 8 years in practice, after adjusting for differences in patient, physician, and practice characteristics.
A cohort was assembled comprising all physicians who took the national clinical skills licensing examination (Medical Council of Canada: Qualifying Examination Part II) between 1993 and 1996. For each physician, we used linked longitudinal patient histories from prescription and health services administrative data5 to assemble a dynamic cohort of all patients aged 5 to 60 years with a diagnosis of asthma between 1993 and 2003. We focused our analysis on patients whose asthma was out of control at the time of the first visit to study physicians in outpatient settings, based on excess use (>250 doses) of fast-acting β-agonists (fenoterol, terbutaline, and salbutamol) in the past 3 months.6 We excluded patients with a diagnosis of chronic obstructive pulmonary disease in the 12 months prior to the visit.
Each patient was followed up for 6 months after the first visit to a study physician for out-of-control asthma to assess (1) multiple emergency department (ED) visits with a primary diagnosis of respiratory-related conditions (International Classification of Diseases, Ninth Revision 490.x [bronchitis], 493.x [asthma], 465.9 [upper respiratory infection], 466.x [acute bronchitis], and 786.x [symptoms involving the respiratory system]) and (2) use of an inhaled corticosteroid (ICS) (fluticasone propionate, budesonide, flunisolide, beclomethasone dipropionate, and triamcinolone acetonide).
We used the generalized estimation equation extension of multivariable logistic regression for correlated data with an autoregressive first-order AR(1) correlation structure. Patients were the unit of analysis and were clustered within study physicians. In addition to physician characteristics (physician sex, specialty, examination scores), we adjusted for practice characteristics (practice workload and practice population profile) and patient characteristics (age/sex, socioeconomic status, number of visits to study physicians). Examination scores were standardized to have SD = 100, and the adjusted change in odds of a given outcome was estimated per 1 SD in the respective score.
From 1993 to 2003, a total of 90 078 patients with asthma received care from 609 study physicians in an outpatient setting for respiratory-related conditions. Of these, 3981 patients (4.4%) had out-of-control asthma at the first respiratory-related visit to study physicians, and 1960 patients (2.2%) were prescribed asthma medication by the study physician at the visit.
During the 6-month follow-up, 380 (9.6%) of the 3981 patients with out-of-control asthma made multiple ED visits. The physicians of multiple ED users were more likely to be general practitioners and to have a lower practice volume. Of 1960 patients with out-of-control asthma who were prescribed any asthma medication by the study physician at the index visit, 1361 patients (69.4%) were prescribed an ICS. Female physicians and respiratory specialists were more likely to prescribe an ICS.
After adjusting for patient and physician characteristics, higher communication scores were associated with a significantly lower risk of multiple ED visits; a reduction in risk of 10% per 1-SD increase in score (odds ratio, 0.90; 95% confidence interval, 0.81-1.00). Higher medical knowledge, clinical decision making, and communication examination scores were all significantly associated with the increased likelihood of prescribing ICS (approximately a 4%-7% increase per 1-SD increase in each score) (Table).
Our study demonstrates that physicians with better knowledge, clinical skills, and communication ability engage in more appropriate asthma prescribing and their patients with out-of-control asthma have fewer subsequent multiple ED visits. Our results are consistent with previous studies that have supported the predictive validity of licensing examinations by demonstrating the association between higher scores and the ability to make appropriate diagnostic and treatment decisions.7,8
Moreover, our study suggests that each domain of asthma management is potentially related to a different component of clinical competence. As most medical schools use objective structured clinical examinations to assess performance during training,9 earlier remediation of suboptimal level of performance could ultimately improve the quality of asthma management in practice. Because these skills sets are required to manage other chronic conditions,10 the establishment of minimum performance benchmarks during training could have an overall positive effect on the quality of chronic disease management.
Correspondence: Dr Kawasumi, Centre for Health Services and Policy Research, University of British Columbia, 201-2206 East Mall, Vancouver, BC V6T 1Z3, Canada (firstname.lastname@example.org).
Author Contributions:Study concept and design: Kawasumi, Ernst, and Tamblyn. Acquisition of data: Tamblyn. Analysis and interpretation of data: Kawasumi, Abrahamowicz, Ernst, and Tamblyn. Drafting of the manuscript: Kawasumi. Critical revision of the manuscript for important intellectual content: Kawasumi, Abrahamowicz, Ernst, and Tamblyn. Statistical analysis: Kawasumi. Obtained funding: Tamblyn. Administrative, technical, and material support: Kawasumi. Study supervision: Abrahamowicz, Ernst, and Tamblyn.
Financial Disclosure: None reported.
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