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期刊来源：JAMA

原文链接：https://doi.org/10.1001/jama.2024.5268

摘要内容如下：

重要性

尽管它对内科实习生的医学教育和能力评估很重要，但关于医生的里程碑式住院医师评级或美国内科医学委员会的初始认证考试与其住院患者的结果之间的关系的证据很少。

目的

检查医生的里程碑评级和认证考试分数与其患者的医院结果之间的关系。

设计、设置和参与者

对2016年至2018年在美国医院完成培训并在2017年至2019年住院期间照顾医疗保险付费服务受益人的6898名住院医师进行回顾性队列分析。

主要成果和措施

主要结果指标包括7天死亡率和再入院率。还评估了30天死亡率和再入院率、住院时间和专科会诊频率。分析考虑了医院固定效应，并根据患者特征、医师经验年数和年份进行了调整。

曝光

认证考试分数四分位数和里程碑评级，包括总体核心能力评级指标，该指标等于住院医师里程碑子能力评级（分类为低、中或高）结束时的平均值，以及知识核心能力指标（分类类似）。

结果

在455120名住院患者中，中位患者年龄为79岁（IQR，73-86岁），56.5%的患者为女性，1.9%为亚洲人，9.8%为黑人，4.6%为西班牙裔，81.9%为白人。7天死亡率和再入院率分别为3.5%（95%CI，3.4%-3.6%）和5.6%（95%CI，5.5%-5.6%），30天死亡率和再入院率分别为8.8%（95%CI，8.7%-8.9%）和16.6%（95%CI，16.5%-16.7%）。平均住院时间和专科会诊次数分别为3.6天（95%CI，3.6-3.6天）和1.01天（95%CI，1.00-1.03）。高与低的总体或知识里程碑核心能力评级与所评估的结果指标无关。例如，总体核心能力评级高与低与7天死亡率增加2.7%（95%CI，-5.2%至10.6%；P=.51）。相反，最高与最低检查评分四分位数与7天死亡率显著降低8.0%相关（95%CI，-13.0%至-3.1%；P=.002）和7天再入院率降低9.3%（95%CI，-13.0%至-5.7%；P<.001）。对于30天死亡率，这种相关性为-3.5%（95%CI，-6.7%至-0.4%；P=.03）。最高与最低检查分数四分位数与2.4%的多就诊相关（95%CI，0.8%-3.9%；P<.003），但与住院时间或30天再入院率无关。

结论和相关性

在新培训的住院医师中，认证考试分数，而不是住院医师里程碑评级，与住院医疗保险受益人的改善结果相关。

英文原文如下：

Abstracts

Importance  Despite its importance to medical education and competency assessment for internal medicine trainees, evidence about the relationship between physicians' milestone residency ratings or the American Board of Internal Medicine's initial certification examination and their hospitalized patients' outcomes is sparse.

Objective  To examine the association between physicians' milestone ratings and certification examination scores and hospital outcomes for their patients.

Design, Setting, and Participants  Retrospective cohort analyses of 6898 hospitalists completing training in 2016 to 2018 and caring for Medicare fee-for-service beneficiaries during hospitalizations in 2017 to 2019 at US hospitals.

Main Outcomes and Measures  Primary outcome measures included 7-day mortality and readmission rates. Thirty-day mortality and readmission rates, length of stay, and subspecialist consultation frequency were also assessed. Analyses accounted for hospital fixed effects and adjusted for patient characteristics, physician years of experience, and year.

Exposures  Certification examination score quartile and milestone ratings, including an overall core competency rating measure equaling the mean of the end of residency milestone subcompetency ratings categorized as low, medium, or high, and a knowledge core competency measure categorized similarly.

Results  Among 455 120 hospitalizations, median patient age was 79 years (IQR, 73-86 years), 56.5% of patients were female, 1.9% were Asian, 9.8% were Black, 4.6% were Hispanic, and 81.9% were White. The 7-day mortality and readmission rates were 3.5% (95% CI, 3.4%-3.6%) and 5.6% (95% CI, 5.5%-5.6%), respectively, and were 8.8% (95% CI, 8.7%-8.9%) and 16.6% (95% CI, 16.5%-16.7%) for mortality and readmission at 30 days. Mean length of stay and number of specialty consultations were 3.6 days (95% CI, 3.6-3.6 days) and 1.01 (95% CI, 1.00-1.03), respectively. A high vs low overall or knowledge milestone core competency rating was associated with none of the outcome measures assessed. For example, a high vs low overall core competency rating was associated with a nonsignificant 2.7% increase in 7-day mortality rates (95% CI, -5.2% to 10.6%; P = .51). In contrast, top vs bottom examination score quartile was associated with a significant 8.0% reduction in 7-day mortality rates (95% CI, -13.0% to -3.1%; P = .002) and a 9.3% reduction in 7-day readmission rates (95% CI, -13.0% to -5.7%; P < .001). For 30-day mortality, this association was -3.5% (95% CI, -6.7% to -0.4%; P = .03). Top vs bottom examination score quartile was associated with 2.4% more consultations (95% CI, 0.8%-3.9%; P < .003) but was not associated with length of stay or 30-day readmission rates.

Conclusions and Relevance  Among newly trained hospitalists, certification examination score, but not residency milestone ratings, was associated with improved outcomes among hospitalized Medicare beneficiaries.

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