Effect of Board Certification on Antihypertensive Treatment Intensification in Patients With Diabetes Mellitus

Alexander Turchin, MD, MS; Maria Shubina, DSc; Anna H. Chodos, BA; Jonathan S. Einbinder, MD, MPH; Merri L. Pendergrass, MD, PhD

Circulation. 2008;117:623-628


Dr Teirstein Comments

I did not find any conflicts on the part of the authors.

This was a retrospective cohort study looking at the association between the number of years since the physician’s last board certification and the probability of pharmacological antihypertensive treatment intensification at a given visit. The authors found frequency of treatment intensification decreased from 26.7% for physicians who were board certified the previous year to 6.9% for physician who were board certified 31 years before the visit. “Treatment intensification rate was 22.5% for physicians certified >10 years ago versus 16.9% for physicians last certified >10 years ago (P>0.0001).” The authors conclude that “intensification of pharmacological therapy for blood pressure levels above the recommended treatment goals decreases with time since the last board certification.”

If one looks at the key data in Figure 1 of the manuscript, we see that 30 years after certification there is a precipitous drop in treatment intensification. These are the much older doctors often with a different kind of practice compared to the recently certified. If you exclude this group (likely a very small number of doctors–we never learn how many) the number goes from about 6% to 16%, i.e. the docs who just were certified or recertified intensified treatment 26% of the time vs only 16% for the docs years away from taking the boards. This not a very impressive difference. Neither group demonstrated an impressive amount of treatment intensification, so the impact of recertification, if it exists, is rather small. Also, we are not told how high the patients’ blood pressure was. Is it possible that as doctors age their patients’ blood pressures are more likely in control so while the BP may be high on the day of appointment, perhaps, in the older, more established practices, the BP was not high enough to warrant medication intensification? A doctor who has seen a patient for a decade might see an isolated BP of 140/85 and say, “Come back and check it again in two weeks.”

Another criticism is that this data does not imply a causal relationship between re- certification/MOC and intensification of hypertension treatment. Rather, it is just an association.

Dr Cohen Comments

I agree with the summary of findings by Dr. Teirstein above. However, other than the observational nature of this study (which is true of virtually all the studies in this field), I do not find a lot of obvious methodologic flaws in this study. The authors did their best to adjust for differences in physician age as well as for the actual level of blood pressure and the frequency of BP checks, so many of the potential confounding factors noted have at least been considered in the analysis. The fact that the association between time from certification (or recertification) and the frequency of treatment intensification is somewhat weak does not detract from the main finding that there was a relationship in the hypothesized direction.

Overall, given that this is one of the few positive studies for MOC that was not written by an employee of ABIM or sponsored by ABIM lends further credence to the results.

Dr Ajay Kirtane Comments

This observational analysis assessed treatments of diabetic patients with hypertension, specifically addressing whether physicians differed in their frequency of intensification of antihypertensive treatment based upon years since last board certification. The study was conducted among patients treated by academically-affiliated internists at the MGH and Brigham from 2000-2005. Rates of treatment intensification (for BP above target range) were low overall, and there was a negative association between years after last board certification and the frequency of treatment intensification among these patients. This association was most pronounced for physicians >30 years after board certification, but remained relatively constant for physicians who were within 15 years of board certification. Physician age was not associated with the frequency of treatment intensification when years from board certification was also introduced into the multivariable model. Overall, these data do suggest some association between board certification and the outcome measured.