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Increasing Physician Knowledge About the Diagnosis and Management of CKD: How Can We Help Primary Care Providers?
VOL 54, NO 2, AUGUST 2009
EDITORIALS Increasing Physician Knowledge About the Diagnosis and Management of CKD: How Can We Help Primary Care Providers? Related Articles, pp. 227 and 238
C
hronic kidney disease (CKD) is a public health threat in the United States characterized by increasing prevalence and high costs.1,2 Early detection, evaluation, and management of CKD and its antecedent risk factors can delay and perhaps prevent the onset of end-stage renal disease. This information has been disseminated in multiple clinical practice guidelines and position papers.3-5 Despite the availability of this information, substantial variations in guidelinebased care and subsequent outcomes of CKD have been reported.6 This variable care has engendered interest in programs implemented by primary care providers to improve the detection and treatment of patients with early stages of CKD in the US population. For example, recommendations and supporting analyses for a comprehensive public health strategy to prevent the development, progression, and complications of CKD developed for the Centers for Disease Control and Prevention were recently published.7 In addition, in August 2008, the Centers for Medicare & Medicaid Services awarded contracts to Medicare Quality Improvement Organizations in 10 states (Florida, Georgia, New York, Nevada, Montana, Missouri, Rhode Island, Tennessee, Texas, and Utah) to develop pilot quality improvement programs to reduce disparities in CKD, with significant focus on the role of the primary care physician (PCP) in early CKD detection.8 Strengthening provider education is a central feature of efforts to facilitate the translation of evidence-based CKD care into community practice.8,9 This reflects evidence that continuing
medical education (CME), although not sufficient to remedy variations in care, contributes and enhances these efforts.10 Two articles in this issue of the American Journal of Kidney Diseases are relevant to physician education about CKD.11,12 Both reports assessed the knowledge of PCPs of the National Kidney Foundation’s Kidney Disease Outcomes and Quality Initiative (KDOQI) guidelines for management of CKD and related hypertension.3,13 Both drew national random samples of PCPs from the American Medical Association Physician Master file (US), and both achieved similar participation rates (31.7% by Charles et al11 and 32.4% by Israni et al12). Each probed PCP knowledge about CKD through hypothetical case scenarios in which kidney function and damage were reported with a serum creatinine value and dipstick proteinuria. These scenarios differ from the KDOQI guidelines, which recommend that CKD identification be based on the joint estimation of kidney function and damage by using either the Modification of Diet in Renal Disease (MDRD) Study estimated glomerular filtration rate (GFR) or the Cockcroft-Gault estimated creatinine clearance and a measurement of urinary albumin excretion. Finally, both report that although the recognition and patterns of evaluation and treatment of CKD assessed were not lamentable, Address correspondence to William McClellan, MD, MPH, Emory University, Rollins School of Public Health, 1518 Clifton Rd, Atlanta, GA 30322. E-mail: [email protected] © 2009 by the National Kidney Foundation, Inc. 0272-6386/09/5402-0001$36.00/0 doi:10.1053/j.ajkd.2009.05.002
American Journal of Kidney Diseases, Vol 54, No 2 (August), 2009: pp 187-190
187
188
there are substantial opportunities to improve the knowledge base in US PCPs about CKD. Charles et al11 reported that 99% of participants correctly identified CKD in a single case scenario, in which on 2 measurements separated by more than 3 months, serum creatinine levels were clearly increased and 1⫹ proteinuria was present. In contrast, Israni et al12 reported less satisfactory results with an average of 69% of respondents correctly identifying CKD in 12 scenarios, which presented serum creatinine and proteinuria levels in differing combinations that remained stable for 3 months. Israni et al12 found that successful CKD identification decreased with increasing patient age and when normal creatinine levels and persistent proteinuria were combined. From these results, it appears that in the absence of a reported estimated GFR, CKD identification is variable among US PCPs and that the greatest difficulty in recognition occurs, as expected, in the setting in which serum creatinine level is not increased, but estimated GFR is decreased (older age and stage 2 CKD). This observation reinforces the need to promote the broad routine reporting of estimated GFR, a goal that is slowly being achieved and that might be accelerated by additional CME.14 Charles et al11 assessed the adequacy of knowledge of the evaluation of newly recognized CKD. Respondents were provided lists of potential laboratory and imaging studies and were judged adherent if they selected any 5 of 6 (urinalysis, urine protein quantification, renal ultrasound, serum phosphorus level, intact parathyroid hormone level, and lipid profile) guideline-based recommendations for testing from the list. There was substantial variation in the numbers of tests ordered; only 12% of respondents ordered all 6 tests and 23% ordered 5 of 6 tests. The low rate of diagnostic testing adherence may reflect ambiguity about the multiple diagnostic tasks facing a clinician with a patient with newly diagnosed CKD, and it was not entirely clear if the testing included: (1) diagnosis of the degree and chronicity of impaired kidney function, (2) such comorbid conditions as anemia and mineral and bone disease associated with CKD, and/or (3) establishing a cause for the CKD. Adherent PCPs tended to order an average of 8.5 nonrecommended tests compared with only 2 additional nonrecommended tests for nonadherent PCPs, which sug-
Wasse and McClellan
gests that the 2 groups may have interpreted the question differently. Israni et al12 surveyed knowledge about the management of CKD with questions dealing with the choice of blood pressure goals and antihypertensive therapy in hypertensive individuals with stage 3 CKD (GFR, 30 to 60 mL/ min/1.73 m2). Adequate goal blood pressure was defined for analytical purposes as 140/90 mm Hg or less for nonproteinuric individuals with CKD and 130/80 mm Hg or less for those with proteinuria. These goals are at variance with the 2004 KDOQI hypertension guidelines and the 2003 Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure guidelines, which recommend a therapeutic target for patients with stages 3 and 4 CKD of 130/80 mm Hg or less.3,4 Responding PCPs selected a mean target blood pressure of approximately 124/78 mm Hg for patients with nonproteinuric and 121/76 mm Hg for patients with proteinuric CKD, levels consistent with published guidelines, and nearly all met the blood pressure targets stipulated by the study. An angiotensin-converting enzyme inhibitor or receptor blocker was selected by 96% of respondents for diabetic patients with CKD and by 75% for patients with proteinuric CKD attributed to glomerulonephritis. These results suggest that there are high levels of awareness among PCPs in the United States about the appropriate management of hypertension in patients with CKD. How can we use these results in our efforts to improve CKD care in the US population? First, these and similar survey data should be considered when developing the content for the next iteration of CKD educational programs by the National Kidney Disease Education Program, National Kidney Foundation, Renal Physicians Association, and others. Materials from these sources are broadly used for CKD CME activities and are the core of the educational resources in the 10 state Centers for Medicare & Medicaid Services pilot. In particular, if these results are supported by additional survey research, it would appear that attention to appropriate diagnostic evaluation of newly diagnosed CKD should be incorporated into contemporary CKD CME activities. As noted by Charles et al,11 the current guidelines are less than clear about how PCPs should use testing to establish the cause of CKD
Editorial
and stage, and to manage CKD-associated comorbid conditions. The next generation of guidelines might do well to address these issues. Another application arises from the observation that PCP performance decreases with age. Israni et al12 found that with each decade increase in age, the odds of lower performance increased 26%, whereas Charles et al11 found that each decade increase in length of practice was associated with a 50% greater odds of nonadherent testing. This raises the possibility that CME efforts to improve CKD care might be targeted at older physicians, perhaps by linking these activities to maintenance of certification requirements. For example, the American Board of Internal Medicine (ABIM) Maintenance of Certification requirement15 for “Self-Evaluation of Practice Performance” might increase the effectiveness of these educational activities. Practice Improvement Modules (PIMs) provided by the ABIM offer the recertifying physician a confidential means to evaluate the medical care delivered in his or her practice. PIMs allow a physician to collect and analyze practice-specific quality-of-care data and use that information to develop and implement an improvement plan. Increasingly, such medical societies as the American College of Cardiology and American College of Rheumatology are developing PIMs for the ABIM Maintenance of Certification.15,16 As nephrologists who are concerned with the rational design of CKD CME programs for PCPs, we might use these results to develop a CKD-related PIM. Such an effort would allow us to link the Maintenance of Certification requirements for PCPs to evidence-based efforts to improve CKD care. Additional methods for improving CKD clinical practice guideline adherence by PCPs include adoption of the chronic care model, which uses a team approach to care by allocating complex guideline-specific tasks to members of the health care team. Therefore, a single PCP is not relied upon to remember every guideline detail. Use of supplementary alerts built into electronic ordering and best practices alerts have certain drawbacks, but also can be effective. Overall, there is no silver bullet for increasing PCP recognition and implementation of CKD clinical practice guidelines, and implementation of more than one method is needed, all the while
189
emphasizing that physicians who follow clinical guidelines provide better patient care. Haimanot Wasse, MD, MPH William M. McClellan, MD, MPH Emory University Atlanta, Georgia
ACKNOWLEDGEMENTS Financial Disclosure: None.
REFERENCES 1. Castro AF, Coresh J: CKD surveillance using laboratory data from the population-based National Health and Nutrition Examination Survey (NHANES). Am J Kidney Dis 53:S46-S55, 2009 (suppl 3) 2. Levey AS, Stevens LA, Coresh J: Conceptual model of CKD: Applications and implications. Am J Kidney Dis 53:S4-S16, 2009 (suppl 3) 3. National Kidney Foundation: KDOQI Clinical Practice Guidelines and Clinical Practice Recommendations for Diabetes and Chronic Kidney Disease. Am J Kidney Dis 49:S12-S154, 2007 (suppl 2) 4. Chobanian AV, Bakris GL, Black HR, et al; Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, National Heart, Lung, and Blood Institute; National High Blood Pressure Education Program Coordinating Committee: Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension 42:1206-1252, 2003 5. American Diabetes Association: Nephropathy in diabetes. Diabetes Care 27:S79-S83, 2004 (suppl 1) 6. McClellan WM, Wasse H, McClellan AC, Kipp A, Waller LA, Rocco MV: Treatment center and geographic variability in pre-ESRD care associate with increased mortality. J Am Soc Nephrol 20:1078-1085, 2009 7. Levey AS, Schoolwerth AC, Burrows NR, Williams DE, Stith KR, McClellan W; Centers for Disease Control and Prevention Expert Panel: Comprehensive public health strategies for preventing the development, progression, and complications of CKD: Report of an expert panel convened by the Centers for Disease Control and Prevention. Am J Kidney Dis 53:522-535, 2009 8. Agency for Healthcare Research and Quality: 2007 National Healthcare Disparities Report. AHRQ Pub. No. 08-0041. (http://www.cms.hhs.gov/QualityImprovementOrgs). Rockville, MD, US Department of Health and Human Services, Agency for Healthcare Research and Quality, February 2008 9. Narva AS, Briggs M: The National Kidney Disease Education Program: Improving understanding, detection, and management of CKD. Am J Kidney Dis 53:S115-S120, 2009 (suppl 3) 10. Marinopoulos SS, Dorman T, Ratanawongsa N, et al: Effectiveness of continuing medical education. Evid Rep Technol Assess (Full Rep) Jan(149):1-69, 2007 11. Charles RF, Powe NR, Jaar BG, Troll MU, Parekh
190 RS, Boulware LE: Clinical testing patterns and cost implications of variation in the evaluation of CKD among US physicians. Am J Kidney Dis 54:227-237, 2009 12. Israni RK, Shea JA, Joffe MM, Feldman HI: Physician characteristics and knowledge of CKD management. Am J Kidney Dis 54:238-247, 2009 13. National Kidney Foundation: K/DOQI Clinical Practice Guidelines on Hypertension and Antihypertensive Agents in Chronic Kidney Disease. Am J Kidney Dis 43:S1-S290, 2004 (suppl 1) 14. Accetta NA, Gladstone EH, DiSogra C, Wright EC,
Wasse and McClellan Briggs M, Narva AS: Prevalence of estimated GFR reporting among US clinical laboratories. Am J Kidney Dis 52:778-787, 2008 15. Duffy FD, Lynn LA, Didura H, et al: Self-assessment of practice performance: Development of the ABIM Practice Improvement Module (PIM). J Continuing Educ Health Prof 28:38-46, 2008 16. American Board of Family Medicine: Maintenance of Certification: Part IV-Performance in Practice. Available at: https://www.theabfm.org/moc/part4.aspx. Accessed April 14, 2009
EDITORIALS Increasing Physician Knowledge About the Diagnosis and Management of CKD: How Can We Help Primary Care Providers? Related Articles, pp. 227 and 238
C
hronic kidney disease (CKD) is a public health threat in the United States characterized by increasing prevalence and high costs.1,2 Early detection, evaluation, and management of CKD and its antecedent risk factors can delay and perhaps prevent the onset of end-stage renal disease. This information has been disseminated in multiple clinical practice guidelines and position papers.3-5 Despite the availability of this information, substantial variations in guidelinebased care and subsequent outcomes of CKD have been reported.6 This variable care has engendered interest in programs implemented by primary care providers to improve the detection and treatment of patients with early stages of CKD in the US population. For example, recommendations and supporting analyses for a comprehensive public health strategy to prevent the development, progression, and complications of CKD developed for the Centers for Disease Control and Prevention were recently published.7 In addition, in August 2008, the Centers for Medicare & Medicaid Services awarded contracts to Medicare Quality Improvement Organizations in 10 states (Florida, Georgia, New York, Nevada, Montana, Missouri, Rhode Island, Tennessee, Texas, and Utah) to develop pilot quality improvement programs to reduce disparities in CKD, with significant focus on the role of the primary care physician (PCP) in early CKD detection.8 Strengthening provider education is a central feature of efforts to facilitate the translation of evidence-based CKD care into community practice.8,9 This reflects evidence that continuing
medical education (CME), although not sufficient to remedy variations in care, contributes and enhances these efforts.10 Two articles in this issue of the American Journal of Kidney Diseases are relevant to physician education about CKD.11,12 Both reports assessed the knowledge of PCPs of the National Kidney Foundation’s Kidney Disease Outcomes and Quality Initiative (KDOQI) guidelines for management of CKD and related hypertension.3,13 Both drew national random samples of PCPs from the American Medical Association Physician Master file (US), and both achieved similar participation rates (31.7% by Charles et al11 and 32.4% by Israni et al12). Each probed PCP knowledge about CKD through hypothetical case scenarios in which kidney function and damage were reported with a serum creatinine value and dipstick proteinuria. These scenarios differ from the KDOQI guidelines, which recommend that CKD identification be based on the joint estimation of kidney function and damage by using either the Modification of Diet in Renal Disease (MDRD) Study estimated glomerular filtration rate (GFR) or the Cockcroft-Gault estimated creatinine clearance and a measurement of urinary albumin excretion. Finally, both report that although the recognition and patterns of evaluation and treatment of CKD assessed were not lamentable, Address correspondence to William McClellan, MD, MPH, Emory University, Rollins School of Public Health, 1518 Clifton Rd, Atlanta, GA 30322. E-mail: [email protected] © 2009 by the National Kidney Foundation, Inc. 0272-6386/09/5402-0001$36.00/0 doi:10.1053/j.ajkd.2009.05.002
American Journal of Kidney Diseases, Vol 54, No 2 (August), 2009: pp 187-190
187
188
there are substantial opportunities to improve the knowledge base in US PCPs about CKD. Charles et al11 reported that 99% of participants correctly identified CKD in a single case scenario, in which on 2 measurements separated by more than 3 months, serum creatinine levels were clearly increased and 1⫹ proteinuria was present. In contrast, Israni et al12 reported less satisfactory results with an average of 69% of respondents correctly identifying CKD in 12 scenarios, which presented serum creatinine and proteinuria levels in differing combinations that remained stable for 3 months. Israni et al12 found that successful CKD identification decreased with increasing patient age and when normal creatinine levels and persistent proteinuria were combined. From these results, it appears that in the absence of a reported estimated GFR, CKD identification is variable among US PCPs and that the greatest difficulty in recognition occurs, as expected, in the setting in which serum creatinine level is not increased, but estimated GFR is decreased (older age and stage 2 CKD). This observation reinforces the need to promote the broad routine reporting of estimated GFR, a goal that is slowly being achieved and that might be accelerated by additional CME.14 Charles et al11 assessed the adequacy of knowledge of the evaluation of newly recognized CKD. Respondents were provided lists of potential laboratory and imaging studies and were judged adherent if they selected any 5 of 6 (urinalysis, urine protein quantification, renal ultrasound, serum phosphorus level, intact parathyroid hormone level, and lipid profile) guideline-based recommendations for testing from the list. There was substantial variation in the numbers of tests ordered; only 12% of respondents ordered all 6 tests and 23% ordered 5 of 6 tests. The low rate of diagnostic testing adherence may reflect ambiguity about the multiple diagnostic tasks facing a clinician with a patient with newly diagnosed CKD, and it was not entirely clear if the testing included: (1) diagnosis of the degree and chronicity of impaired kidney function, (2) such comorbid conditions as anemia and mineral and bone disease associated with CKD, and/or (3) establishing a cause for the CKD. Adherent PCPs tended to order an average of 8.5 nonrecommended tests compared with only 2 additional nonrecommended tests for nonadherent PCPs, which sug-
Wasse and McClellan
gests that the 2 groups may have interpreted the question differently. Israni et al12 surveyed knowledge about the management of CKD with questions dealing with the choice of blood pressure goals and antihypertensive therapy in hypertensive individuals with stage 3 CKD (GFR, 30 to 60 mL/ min/1.73 m2). Adequate goal blood pressure was defined for analytical purposes as 140/90 mm Hg or less for nonproteinuric individuals with CKD and 130/80 mm Hg or less for those with proteinuria. These goals are at variance with the 2004 KDOQI hypertension guidelines and the 2003 Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure guidelines, which recommend a therapeutic target for patients with stages 3 and 4 CKD of 130/80 mm Hg or less.3,4 Responding PCPs selected a mean target blood pressure of approximately 124/78 mm Hg for patients with nonproteinuric and 121/76 mm Hg for patients with proteinuric CKD, levels consistent with published guidelines, and nearly all met the blood pressure targets stipulated by the study. An angiotensin-converting enzyme inhibitor or receptor blocker was selected by 96% of respondents for diabetic patients with CKD and by 75% for patients with proteinuric CKD attributed to glomerulonephritis. These results suggest that there are high levels of awareness among PCPs in the United States about the appropriate management of hypertension in patients with CKD. How can we use these results in our efforts to improve CKD care in the US population? First, these and similar survey data should be considered when developing the content for the next iteration of CKD educational programs by the National Kidney Disease Education Program, National Kidney Foundation, Renal Physicians Association, and others. Materials from these sources are broadly used for CKD CME activities and are the core of the educational resources in the 10 state Centers for Medicare & Medicaid Services pilot. In particular, if these results are supported by additional survey research, it would appear that attention to appropriate diagnostic evaluation of newly diagnosed CKD should be incorporated into contemporary CKD CME activities. As noted by Charles et al,11 the current guidelines are less than clear about how PCPs should use testing to establish the cause of CKD
Editorial
and stage, and to manage CKD-associated comorbid conditions. The next generation of guidelines might do well to address these issues. Another application arises from the observation that PCP performance decreases with age. Israni et al12 found that with each decade increase in age, the odds of lower performance increased 26%, whereas Charles et al11 found that each decade increase in length of practice was associated with a 50% greater odds of nonadherent testing. This raises the possibility that CME efforts to improve CKD care might be targeted at older physicians, perhaps by linking these activities to maintenance of certification requirements. For example, the American Board of Internal Medicine (ABIM) Maintenance of Certification requirement15 for “Self-Evaluation of Practice Performance” might increase the effectiveness of these educational activities. Practice Improvement Modules (PIMs) provided by the ABIM offer the recertifying physician a confidential means to evaluate the medical care delivered in his or her practice. PIMs allow a physician to collect and analyze practice-specific quality-of-care data and use that information to develop and implement an improvement plan. Increasingly, such medical societies as the American College of Cardiology and American College of Rheumatology are developing PIMs for the ABIM Maintenance of Certification.15,16 As nephrologists who are concerned with the rational design of CKD CME programs for PCPs, we might use these results to develop a CKD-related PIM. Such an effort would allow us to link the Maintenance of Certification requirements for PCPs to evidence-based efforts to improve CKD care. Additional methods for improving CKD clinical practice guideline adherence by PCPs include adoption of the chronic care model, which uses a team approach to care by allocating complex guideline-specific tasks to members of the health care team. Therefore, a single PCP is not relied upon to remember every guideline detail. Use of supplementary alerts built into electronic ordering and best practices alerts have certain drawbacks, but also can be effective. Overall, there is no silver bullet for increasing PCP recognition and implementation of CKD clinical practice guidelines, and implementation of more than one method is needed, all the while
189
emphasizing that physicians who follow clinical guidelines provide better patient care. Haimanot Wasse, MD, MPH William M. McClellan, MD, MPH Emory University Atlanta, Georgia
ACKNOWLEDGEMENTS Financial Disclosure: None.
REFERENCES 1. Castro AF, Coresh J: CKD surveillance using laboratory data from the population-based National Health and Nutrition Examination Survey (NHANES). Am J Kidney Dis 53:S46-S55, 2009 (suppl 3) 2. Levey AS, Stevens LA, Coresh J: Conceptual model of CKD: Applications and implications. Am J Kidney Dis 53:S4-S16, 2009 (suppl 3) 3. National Kidney Foundation: KDOQI Clinical Practice Guidelines and Clinical Practice Recommendations for Diabetes and Chronic Kidney Disease. Am J Kidney Dis 49:S12-S154, 2007 (suppl 2) 4. Chobanian AV, Bakris GL, Black HR, et al; Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, National Heart, Lung, and Blood Institute; National High Blood Pressure Education Program Coordinating Committee: Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension 42:1206-1252, 2003 5. American Diabetes Association: Nephropathy in diabetes. Diabetes Care 27:S79-S83, 2004 (suppl 1) 6. McClellan WM, Wasse H, McClellan AC, Kipp A, Waller LA, Rocco MV: Treatment center and geographic variability in pre-ESRD care associate with increased mortality. J Am Soc Nephrol 20:1078-1085, 2009 7. Levey AS, Schoolwerth AC, Burrows NR, Williams DE, Stith KR, McClellan W; Centers for Disease Control and Prevention Expert Panel: Comprehensive public health strategies for preventing the development, progression, and complications of CKD: Report of an expert panel convened by the Centers for Disease Control and Prevention. Am J Kidney Dis 53:522-535, 2009 8. Agency for Healthcare Research and Quality: 2007 National Healthcare Disparities Report. AHRQ Pub. No. 08-0041. (http://www.cms.hhs.gov/QualityImprovementOrgs). Rockville, MD, US Department of Health and Human Services, Agency for Healthcare Research and Quality, February 2008 9. Narva AS, Briggs M: The National Kidney Disease Education Program: Improving understanding, detection, and management of CKD. Am J Kidney Dis 53:S115-S120, 2009 (suppl 3) 10. Marinopoulos SS, Dorman T, Ratanawongsa N, et al: Effectiveness of continuing medical education. Evid Rep Technol Assess (Full Rep) Jan(149):1-69, 2007 11. Charles RF, Powe NR, Jaar BG, Troll MU, Parekh
190 RS, Boulware LE: Clinical testing patterns and cost implications of variation in the evaluation of CKD among US physicians. Am J Kidney Dis 54:227-237, 2009 12. Israni RK, Shea JA, Joffe MM, Feldman HI: Physician characteristics and knowledge of CKD management. Am J Kidney Dis 54:238-247, 2009 13. National Kidney Foundation: K/DOQI Clinical Practice Guidelines on Hypertension and Antihypertensive Agents in Chronic Kidney Disease. Am J Kidney Dis 43:S1-S290, 2004 (suppl 1) 14. Accetta NA, Gladstone EH, DiSogra C, Wright EC,
Wasse and McClellan Briggs M, Narva AS: Prevalence of estimated GFR reporting among US clinical laboratories. Am J Kidney Dis 52:778-787, 2008 15. Duffy FD, Lynn LA, Didura H, et al: Self-assessment of practice performance: Development of the ABIM Practice Improvement Module (PIM). J Continuing Educ Health Prof 28:38-46, 2008 16. American Board of Family Medicine: Maintenance of Certification: Part IV-Performance in Practice. Available at: https://www.theabfm.org/moc/part4.aspx. Accessed April 14, 2009