Physician clinical knowledge, practice infrastructure, and quality of care

To understand if and how one dimension of physician skill, clinical knowledge, moderates the relationship between practice infrastructure and care quality.

We included 1301 physicians who certified in internal medicine between 1991 and 1993 or 2001 and 2003 and took the American Board of Internal Medicine (ABIM)'s Maintenance of Certification (MOC) exam and completed ABIM's diabetes or hypertension registry during their 10-year recertification period between 2011 and 2014. Composite quality scores (overall, process, and intermediate outcome) were based on chart abstractions. Practice infrastructure scores were based on a web-based version of the Physician Practice Connections Readiness Survey. Our measure of clinical knowledge was drawn from MOC exam performance.

We regressed a physician's composite care quality scores against the interaction between their practice infrastructure and MOC exam scores with controls for physician, practice, and patient panel characteristics.

We found that a physician's exam performance significantly moderated the association between practice infrastructure and care quality (P for interaction = .007). For example, having a top quintile practice infrastructure score was associated with a quality care score that was 7.7 (95% CI, 4.3-11.1) percentage points (P <.001) higher among physicians scoring in the top quintile of their MOC exam, but it was unrelated (0.7 [95% CI, -3.8 to 5.3] percentage points; P = .75) to quality among physicians scoring in the bottom quintile on the exam.

Physician skill, such as clinical knowledge, is important to translating patient-centered practice infrastructure into better care quality, and so it may become more consequential as practice infrastructure improves across the United States.