ASSOCIATION BETWEEN LICENSING EXAMINATION SCORES AND RESOURCE USE ANDQUALITY OF CARE IN PRIMARY-CARE PRACTICE

Context.-Clinical competence is a determinant of the quality of care d elivered, and may be associated with use of health care resources by p rimary care physicians. Clinical competence is assumed to be assessed by licensing examinations, yet there is a paucity of information on wh ether scores achieved predict subsequent practice. Objective.-To deter mine if licensing examination scores were associated with selected asp ects of quality of care and resource use in initial primary care pract ice. Design.-Prospective cohort study of recently licensed family phys icians, followed up for the first 18 months of practice. Setting.-The Quebec health care system. Participants.-A total of 614 family physici ans who passed the licensing examination between 1991 and 1993 and ent ered fee-for-service practice in Quebec. Main Outcome Measures.-All pa tients seen by physicians were identified by the universal health insu rance board and all health services provided to these patients were re trieved for the 18 months prior to (baseline) and after (follow-up) th e physicians' entry into practice. Medical service and prescription cl aims files were used to measure rates of resource use (specialty consu ltation, symptom-relief prescribing compared with disease-specific pre scribing) and quality of care (inappropriate prescribing, mammography screening). Baseline data were used to adjust for differences in pract ice population. Results.-Study physicians saw a total of 1 116 389 pat ients, of whom 113 535 (10.2%) were elderly and 83 391 (7.5%) were wom en aged 50 to 69 years. Physicians with higher licensing examination s cores referred more of their patients for consultation (3.8/1000 patie nts per SD increase in score; 95% confidence interval [CI], 1.2-7.0; P =.005), prescribed to elderly patients fewer inappropriate medications (-2.7/1000 patients per SD increase in score; 95% CI, -4.8 to -0.7; P =.009) and more disease-specific medications relative to symptom-relie f medications (3.9/1000 patients per SD increase in score; 95% CI, 0.3 to 7.4; P=.03), and referred more women aged 50 to 69 years (6.6/1000 patients per SD increase in score; 95% CI, 1.2-11.9; P=.02) for mammo graphy screening. If patients of physicians with the lowest scores had experienced the same rates of consultation, prescribing, and screenin g as patients of physicians with the highest scores, an additional 302 7 patients would have been referred, 179 fewer elderly patients would have been prescribed symptom-relief medication, 912 more elderly patie nts would have been prescribed disease-specific medication, 189 fewer patients would have received inappropriate medication, and 121 more wo men would have received mammography screening. Conclusions.-Licensing examination scores are significant predictors of consultation, prescri bing, and mammography screening rates in initial primary care practice .