Figure 3. Association of Regional Care Intensity of Practice Location (Exposure) and Ability to Practice Conservatively (Primary Outcome).

The hospital referral regions (HRRs), ordered according to end-of-life visit index, were divided into quintiles of approximately equal numbers of physicians; practice and residency location HRR quintiles were categorized according to the same definition. The primary outcome was measured by the Appropriately Conservative Management (ACM) score on the Maintenance of Certification (MOC) examination adjusted for the initial ACM score. Movers include 2714 internists who moved to a different HRR after completing residency training; stayers, 1146 internists who stayed in the same HRR where they completed residency training. Parts C and D display the same association for the secondary outcome, clinical competence (MOC overall score). All scores are standardized to a mean of 0 and an SD of 1. The standard score is reported at the midpoint of each quintile after adjusting for the score from the initial American Board of Internal Medicine certifying examination. Error bars indicate 95% CIs.