Assessment Of The Aging Physician: The Ontario Experience Bill McCauley MD, MHPE Medical Advisor Practice Assessment and Enhancement College of Physicians and Surgeons of Ontario QUALITY PROFESSIONALS | HEALTHY SYSTEM | PUBLIC TRUST

College of Physicians and Surgeons of Ontario Provincial equivalent to State Medical Board Sort of Broader mandate Complaints/Investigations/Discipline Quality Management Division Registration Quality Assurance Program

Ontario Population 13 million It’s big Really big 30,000 physicians

CPSO Physician Assessments Quality Management Division Peer Assessments Registration Assessments Physician Review Program (PREP™) Specialties Assessment Program (SAP) Out of Hospital Premises Inspection Program Methadone prescribers assessments Independent Health Facilities Assessments Investigations and Resolutions Complaints Inspections Registrar’s Investigations Comprehensive Practice Assessment

Objectives By the end of the session participants will be able to… …describe differences in outcomes of peer assessments for physicians over and under age 70 in Ontario …describe differences in outcomes of complaints and investigations of physicians over and under age 70 in Ontario

Peer Assessment Program: A Brief History 1977 CPSO approved Peer Assessment Pilot Pilot in ‘78-79 to identify physicians who are practicing at an unacceptable level to designate methods of correcting the deficiencies to ensure that these methods are effective McAuley RG, Paul WM et al, CAN MED ASSOC J 1990; 143 (I 1)

Peer Assessment History Program began in 1981 Data from first 5 years 923 physicians assessed 663 (72%) GP’s or FP’s

Table 1: Distribution of physicians in Ontario randomly selected for assessment of office practices. 1981-85 Year: No of physicians Type of specialist 1981 1982 1983 1984 1985 Total General Practitioner (GP) or Family Physician (FP) 120 140 160 83 663 Internist 20 -- 60 Surgeon Pediatrician Obstetrician/Gynecologist Psychiatrist 30 70 Ophthalmologist Orthopedic Surgeon 10 Otolaryngologist 15 Dermatologist Urologist Neurologist 5 200 123 923

Number (and %) of physicians Overall results 1981 - 86…..   Finding Number (and %) of physicians GP’s and FP’s Specialists Total No major deficiencies in records or level of care 510 (77) 239 (93) 749 (82) Deficient records but no major deficiencies in level of care 55 (8) 13 (5) 68 (7) Grossly deficient records or unsatisfactory level of care or both 97 (15) 4 (2) 101 (11) 662 (100) 256 (100 918 (100)

Results Based on Age, Membership in CFPC and Practice Type (1981 – 86) Variable Number assessed No. (%) with grossly deficient records, unsatisfactory care or both  Χ2 p2 value Age group   ≥ 75 63 22(35) 50 – 74 324 51(16) < 50 275 24(9) Total 662 97 (15) 28.72 < 0.00001 CFPC Membership Nonmember 434 79 (18) Member but not certificant 111 14 (13) Certifcant 117 4 (3) 16.55 < 0.0003 Type of Practice Solo 453 78 (17) Not solo 209 19 (9) 7.56 0.006

Relationship between quality of record keeping and quality of care   Level of Patient Care Quality of Record Keeping Unsatisfactory Satisfactory Total Likelihood ratio 55 (43.6%) 71 126 7.8 4 (0.77%) 515 519 0.08 59 586 645

Peer Assessment Currently An Educational Program Provide feedback on performance Occasionally find problems Currently approximately 1400 per year Target to get to 2000 per year Every doc every 10 years Current practice: Starting age 70, assessment every 5 years

Data Review Years 2005 – 2009 538 – 625 – 772 – 1076 – 1072 Total 4083 assessments over 5 years 2740 < age 70 680 = 70 663 > 70

Peer Assessment Categories Category 1 = No problems identified Generally NFA Category 2 = Some issues, usually record-keeping only Often record-keeping course with reassessment Category 3 = Some care concerns OR severe record keeping deficiencies Generally interview with committee +/- higher level assessment

PREP™ and SAP – High Stakes Assessment PREP™: GP/FP’s MCQ Standardized Patients Chart – Stimulated Recall SAP - Specialists Chart review Interview stakeholders Directly observe in practice (clinic, OR, office) Patient surveys

PREP™ and SAP Categories 1 - 5 NO OR MINIMAL DEFICIENCY MINOR DEFICIENCY MODERATE DEFICIENCY SEVERE DEFICIENCY – POTENTIAL RISK TO PATIENT SAFETY CRITICAL DEFICIENCY – IMMEDIATE RISK TO PATIENT SAFETY

Observations for Peer/PREP Compared to their younger colleagues, physicians 70 and older: More frequently have serious record-keeping deficiencies More frequently have care concerns Once identified as potentially having concerns Physicians older than 55 perform significantly more poorly than those < 55 Physicians > 70 may not be much worse than those 55 - 69

What about public complaints/reports/investigations? Coded investigations = 8030 (represents 53% of total of 15150 investigations) Decisions Percent Frequency Committee Action 26% 2047 No Action 35% 2839 Departmental Resolutions 19% 1558 Departmental Closures 20% 1586 Grand Total 100% 8030

Committee Actions - Categories Issues divided into Clinical – Treatment, documentation, consent, prescribing, narcotics, diagnosis Conduct – Sex, confidentiality, unprofessional communication, ungovernability, fraud, disruptiveness, money Capacity – substance abuse, mental impairment (psych and cognition), physical impairment

Complaints/ICRC Committee Options Refer to: Incapacity hearing Discipline Fitness to practice QA SCERP Undertaking Cautions (written or in person) Counsel

Physicians =/> 70 Years of Age Clinical Issues Actions by Committee Clinical Physicians Physicians =/> 70 Years of Age < 70 Years of Age Percent Frequency <70   =/>70 Treatment 25% 452 29% 76 Documentation 15% 263 16% 44 Assessment 11% 204 8% 21 Communication (patient care) 135 7% 19 Prescribing Controlled Substance 4% 70 16 Prescribing General 66 6% 17 Consent 3% 53 13 Diagnosis 2% 43 1% 4

Physicians =/> 70 Years of Age Conduct Issues Considered by Committee Conduct Physicians Physicians =/> 70 Years of Age < 70 Years of Age Percent Frequency <70   =/>70 Sexual Impropriety 4% 64 12 Breach of Confidentiality 2% 44 0% Unprofessional Communication 37 9% 27 Ungovernability / Breach of Undertaking 36 5% OHIP Billing / Fraud 26 1% 1 Disruptive Physician 28 Conflict of Interest Money Issues 21

Physicians =/> 70 Years of Age Capacity Issues Considered by Committee Incapacity Physicians Physicians =/> 70 Years of Age < 70 Years of Age Percent Frequency <70   =/>70 Substance Abuse 3.0% 46 1.0% 2 Mental Impairment (Psychiatric) 2.0% 27 Mental Impairment (Cognitive) 0.0% 5 Physical Impairment 9

Physicians =/> 70 Years of Age Committee Decisions by Age – 26% of all investigations Committee Decisions Physicians Physicians =/> 70 Years of Age < 70 Years of Age Percent Frequency <70   =/>70 Refer to Discipline 8% 144 15% 42 Refer to Quality Assurance 1% 18 3 Accept PHP 3% 55 1 Accepted Undertaking 10% 184 19% 51 Caution In Person 345 18% 48 Caution In Writing 22% 388 53 Counsel 31% 552 23% 64

No Action Decisions by Age Physicians =/> 70 Years of Age Percent Frequency <70   =/>70 No Action 31% 144 4% 42 No Action by Committee – 35% of all investigations

Departmental Resolution by Age Physicians =/> 70 Years of Age Departmental Resolutions by Age – 19% of all investigations Departmental Resolution by Age Physicians Physicians =/> 70 Years of Age < 70 Years of Age Percent Frequency <70   =/>70 Departmental Resolution 18% 1412 1% 146

Departmental Closure by Age Physicians =/> 70 Years of Age Departmental Closures by Age – 20% of investigations Departmental Closure by Age Physicians Physicians =/> 70 Years of Age < 70 Years of Age Percent Frequency <70   =/>70 Departmental Closure 18% 1395 2% 191

Observations about Complaints and physician age – types of issues Physicians over age 70 for which an action is necessary are more likely to have complaints related to: Treatment General prescribing Prescribing of controlled substances Unprofessional communication Ungovernability Cognitive issues

Observations about Complaints and physician age – types of issues Physicians over age 70 for which an action are necessary are LESS likely to have complaints related to: Confidentiality Fraud Disruptiveness Conflict of interest Substance abuse Mental health issues Physical health issues

Observations about Complaints and physician age – committee decisions Compared to younger peers, physicians > 70 who have a complaint that requires a committee decision are more likely to… …be referred to a discipline committee …sign an undertaking to restrict their practice

Observations about Complaints and physician age – General Compared to younger peers, physicians > 70 who have a complaint that requires a committee decision are LESS likely to… …have a No Action by the committee …have departmental resolution of their complaint …have departmental closure of their files

For Consideration Older physicians are… …at risk of poor performance Should likely be assessed routinely Probably younger than age 70 …in need of ongoing education and support Professional communication Professionalism/Professional regulation Current management Prescribing, including controlled sub’s …at risk for cognitive difficulties Should be screened

QUESTIONS? Movember - Canada