Musings: Blog of the JAAPA Editorial Board


Blog of the JAAPA editorial board.

Monday, January 25, 2016

Maintenance of certification practices—a look at internists and APRNs
Reamer L. Bushardt, PharmD, PA-C, DFAAPA; Harrison Reed, MMSc, PA-C
In our research for “Unraveling the recertification conundrum,” (JAAPA, March 2016) we learned about controversial perspectives among physicians about maintaining certification, former and emerging paradigms for physician maintenance of certification, and certification models for many advanced practice registered nurses. We wanted to share some highlights of what we discovered with you.
Maintenance of certification for physicians has been a controversial topic, especially in recent years. In 2002, Sharp and colleagues evaluated published studies tracking clinical outcomes and physician certification by an American Board of Medical Specialties member board.1 The authors performed the meta-analysis to shed light on specialty board certification, which they reported is often used as a standard of excellence but with limited systematic review describing the link between certification and clinical outcomes. The authors evaluated published studies tracking clinical outcomes and certification status. Of 33 findings evaluated, 16 reported a significant positive association between certification status and positive clinical outcomes, three revealed worse outcomes, and 14 demonstrated no association. One no-association finding and three negative findings were identified in two manuscripts with insufficient case-mix adjustments in the analyses. The authors also noted that a small minority of published studies (5%) used appropriate research methods for their research questions.
Gray and colleagues reported in 2014 results of their quasi-experimental comparison study to measure associations between the original American Board of Internal Medicine (ABIM) certification maintenance requirement and outcomes of care (such as ambulatory care-sensitive hospitalizations) by two groups of internal medicine physicians.2 The first certified group of internists (n=974) treated 69,830 Medicare beneficiaries in the sample, and the second certified group (n=956) treated 84,215 beneficiaries. The annual incidence of ambulatory care-sensitive hospitalizations increased pre- and post-certification maintenance requirement, but the results demonstrated imposition of the certification maintenance requirement was not associated with a difference in this increase in ambulatory care-sensitive hospitalizations.
Since 1936, the ABIM has administered written board certification examinations. These tests were time-unlimited before 1990. The requirement was then shifted to passing an examination every 10 years to maintain certification. The ABIM also began requiring physicians to complete ABIM-sanctioned certification maintenance programs before sitting for examinations. In 2015, ABIM changed its labeling for board-certified internists to describe their certification status as well as whether they are participating with maintenance of certification. Hayes and colleagues performed a retrospective analysis of 1 year’s performance data at four Veterans Affairs medical centers to examine whether there were differences in primary care quality between physicians holding time-limited or time-unlimited certification.3 The authors reported no difference in outcomes for patients receiving care by the internists with time-limited or time-unlimited certification, after adjustment for practice site, panel size, years since certification, and clustering by physician.
In a commentary published by the New England Journal of Medicine, Paul Teirstein, a physician who launched a web-based anti-certification maintenance petition, challenges the ABIM’s process.4 The author calls attention to inconsistent data linking certification maintenance to quality care, points out physicians that believe that the examination questions are not relevant to their practice or a reliable gauge of physicians' knowledge, and draws attention to financial incentives for the ABIM’s certification maintenance requirements, noting the organization in 2012 received more than $55 million in fees from physicians seeking certification. The author recommends reliance on continuing medical education as a more practical means for maintaining certification.
Adult, family, gerontologic, and adult-gerontology NPs are certified by the American Academy of Nurse Practitioners (AANP) certification program and must renew their certification every 5 years after initial certification.5 Recertification is achieved by either meeting current minimum clinical practice and continuing education requirements established by AANP for renewal and maintenance of certification or by taking the appropriate certification examination. The American Board of Nursing Specialties and the National Commission for Certifying Agencies accredit the AANP’s certification and recertification programs. According to the AANP, its certification program is recognized by all state boards of nursing, the Centers for Medicare and Medicaid Services, the Veterans Administration, private managed care organizations, institutions, and healthcare agencies for credentialing purposes.
The AANP certification program recognizes state boards of nursing as responsible for the regulation of nursing practice, with the duty to protect the public's health and welfare by overseeing and ensuring the safe practice of nursing, outlining the standards for safe nursing care, and issuing licenses to practice nursing. Their organization also acknowledges that nursing practice varies from state to state, and endorses the national Consensus Model for APRN Regulation, a regulatory model published in 2008 and an initiative to help align state regulation of APRNs across the United States.
Recertification, or certification renewal, by AANP aims to assure the public that NPs have met current professional standards of qualifications and adequate knowledge for practice. Two options are available for recertification every 5 years. First, NPs may meet requirements through continuing education (CE) and clinical practice hours: 1,000 hours of clinical practice as an NP appropriate for the population of certification, 75 hours of CE applicable to the NP’s population focus, and a current and unencumbered RN or APRN license during the period of certification. This requirement will change for certifications that expire on or after January 1, 2017, with changes that include requiring 100 hours of CE, including 25 hours in pharmacology. Secondly, NPs may recertify by examination, by taking the appropriate national certification examination consistent with their education, and by holding a current and unencumbered RN or APRN license during the period of certification. Interesting, the changes described for recertification also permit CE credit for precepting advanced practice graduate students within the NP’s role and population focus but may also part of a formal interprofessional education program (such as medicine, dentistry, pharmacy, or PA).
As the National Commission on Certification of Physician Assistants (NCCPA) investigates new models for recertification of PAs, we found it helpful to explore current and emerging practices for maintenance of certification among our peers in medicine and APRN roles. Given the unique characteristics of PA practice, we suspect an optimal model for maintenance of certification for PAs will be different from those used by physicians and APRNs.
1. Sharp LK, Bashook PG, Lipsky MS, et al. Specialty board certification and clinical outcomes: the missing link. Acad Med. 2002;77:534-542.
5. American Academy of Nurse Practitioners. Purpose of recertification and related documents. Candidate and renewal handbook.
Reamer L. Bushardt is professor and chair of the Department of Physician Assistant Studies and a program leader in the Clinical Translational Science Institute at Wake Forest School of Medicine in Winston-Salem, N.C., and editor-in-chief of JAAPA. Harrison Reed practices emergency medicine at Fremont Emergency Services in Las Vegas, Nev., and is associate editor of JAAPA. The views expressed in this blog post are those of the author and may not reflect AAPA policies.

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