New MOC Study: Comment on POLL

The latest article I posted on the Psychiatry Online Lifelong Learning (POLL) LinkedIn site (registration is free) describes a study, one of the very few, which seems to demonstrate that it’s feasible to measure how much Maintenance of Certification (MOC) improves the ability of physicians to improve medical management of a specific population of primary care patients, those with diabetes mellitus [1].

It was a retrospective pilot study which “investigated the ability to demonstrate an effect on 2  specific MOC modules for family physicians—the Self-Assessment Module (SAM) from Part II MOC and the Performance in Practice Module (PPM) from Part IV MOC—on the quality of care delivered by family physicians to their patients. The study focused on study physicians’ patients with an established diagnosis of type 2 diabetes mellitus.” The study assessed the feasibility of obtaining and using electronic health record data to investigate questions about MOC as a quality improvement process.

While it shows that the question of the usefulness (or not) of MOC can be studied, the method probably cannot be applied to measuring whether or not the quality of psychiatric treatment can be improved by participating in MOC. I ran this study by a colleague in my department and he doubted that that it could be applied to assess the use of MOC processes in the treatment of psychiatric illness.

The study has a number of limitations, which the authors point out, not the least of which is that the number of participating physicians recruited was low. The results are not generalizable to other physician specialists, including psychiatrists. And while the study seemed to support the potential for MOC to contribute to improving quality of medical care by family physicians, the authors point out “The results support the concept that participation in MOC activities is associated with improvements of care, although the ability to track impact based on the particular MOC activities seems limited, at least in clinical areas with significant overlap of measurements.”

In fact, this study seems to validate the major concern physicians have about specific MOC processes, especially the Performance in Practice modules.

This raises my suspicion about the American Board of Medical Specialties (ABMS) so-called “Evidence Library,” (http://evidencelibrary.abms.org/ ) which purports to prove the efficacy of MOC in producing improvements in the quality of medical care. I couldn’t access full articles and I didn’t see articles on psychiatric treatment studies involving MOC processes.

I continue to be impressed with the polarized nature of the battle between the ABMS and the opponents of MOC and the even more controversial Maintenance of Licensure (MOL). One article in which registered readers can readily see this is at link http://www.modernhealthcare.com/article/20130618/MODERNPHYSICIAN/306189952

Another, which I’m afraid readers can’t directly access is entitled “Debating Maintenance of Certification: A closer look at the pros and cons of the ABMS program,” by Marisa Torrieri and published in the April 2014 issue of Physicians Practice. The pro side says, essentially, that MOC is necessary because physicians need to prove to the public that they’re keeping up with the latest research in the evidence base in order to provide high-quality medical care. The con side points out that no patients ever ask about whether doctors are either certified or participating in MOC. They also reiterate the often cited time-consuming, expensive processes involved in MOC and—that there is no high level evidence-base yet proving that MOC actually improves patient care outcomes.

The side supporting MOC and MOL is regularly vilified as a pack of money-hungry bureaucrats by those opposed to MOC and the anti-MOC group is heavily seeded with the members of a group of right-wing conservatives which get whacked on Wikipedia (http://en.wikipedia.org/wiki/Association_of_American_Physicians_and_Surgeons  and see the criticism of the attorney, Andrew Schlafly, who filed the antitrust lawsuit against the ABMS about MOC at http://rationalwiki.org/wiki/Andrew_Schlafly ).

While arguments against the man, jumping to unjustified conclusions, straw arguments, and either-or assumptions abound on both sides in this war, it’s important to realize that college undergraduates, medical students, residents and fellows are listening. We need to ask ourselves if we’re setting a good example for them as clinicians, educators, and policy-makers. Leaders on either side of this controversy probably feel like they’re being cheated and mistreated.

Reference:

1. Galliher, J. M., B. K. Manning, et al. (2014). “Do Professional Development Programs for Maintenance of Certification (MOC) Affect Quality of Patient Care?” The Journal of the American Board of Family Medicine 27(1): 19-25.
Objective: The objective of this study was to examine the relationship between physicians’ completion of American Board of Family Medicine (ABFM) Maintenance of Certification (MOC) modules and the quality of medical care delivered.Methods: Physicians from the Electronic National Quality Improvement and Research Network (eNQUIRENet) were enrolled. Data from their electronic health records were compared before and after they completed one or more MOC modules for family physicians (Self-Assessment Module [Part II MOC] and Performance in Practice Module [Part IV MOC]; SAM/PPM). Process data and other quantitative clinical measures for all adult patients with a diagnosis of type 2 diabetes were gathered from each study physician. General linear mixed effects models were used to analyze data before and after the MOC modules, adjusting for clustering of patients within physicians.Results: Physicians participating in SAM/PPM activities demonstrated greater improvements over time in 11 of 24 measures in process and intermediate outcome measures related to type 2 diabetes care compared with non-SAM/PPM participants. All groups demonstrated improvements over time.Conclusion: Participation in SAM/PPM activities is associated with greater improvements in care, but the association between activity undertaken and specific improvements is difficult to demonstrate.

 

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