Study guide
17.5 Quality Improvement Methods, Health Disparities & Health Equity
ABIM Internal Medicine Exam
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1 Chapter 0: The ABIM Exam, Blueprint & Study Strategy
0.1 Exam Format, Question Types & the 2026 Blueprint 0.2 Eligibility, Registration, Fees & Exam-Day Logistics 0.3 Scoring, the Passing Standard & Score Reports 0.4 Building a Blueprint-Weighted Study Plan
2 Chapter 1: Cardiovascular Disease (14% of Exam)
1.1 Ischemic Heart Disease & Acute Coronary Syndromes 1.2 Antithrombotic Therapy, Secondary Prevention & Mechanical Complications of MI 1.3 Atrial Fibrillation, Atrial Flutter & Stroke Prevention 1.4 Supraventricular Tachycardias, Ventricular Arrhythmias & Bradycardias 1.5 Heart Failure: Classification, Staging & Guideline-Directed Medical Therapy 1.6 Device Therapy, HFpEF & the Cardiomyopathies 1.7 Valvular Heart Disease & Endocarditis Prophylaxis 1.8 Pericardial Disease & Acute Aortic Syndromes 1.9 Hypertension: Classification, Diagnosis & Secondary Causes 1.10 Hypertensive Crises & Dyslipidemia 1.11 Adult Congenital Heart Disease & Coarctation of the Aorta 1.12 Syncope: Reflex, Orthostatic & Cardiac Causes 1.13 Cardiac Physical Examination, Murmurs & Antithrombotic Selection
3 Chapter 2: Endocrinology, Diabetes & Metabolism (9% of Exam)
2.1 Diabetes Mellitus: Diagnosis, Glycemic Targets & Pharmacotherapy 2.2 Insulin Therapy, Hyperglycemic Emergencies & Chronic Complications 2.3 Thyroid Function Testing & Hypothyroidism 2.4 Thyrotoxicosis, Thyroid Storm & Thyroid Nodules 2.5 Adrenal & Pituitary Disorders 2.6 Hypercalcemia, Hypocalcemia & Disorders of Mineral Metabolism 2.7 Osteoporosis & Paget Disease of Bone 2.8 Ovarian, Testicular & Reproductive Endocrine Disorders 2.9 Hypoglycemia, Endocrine Tumors, Polyglandular Syndromes & Severe Hypertriglyceridemia
4 Chapter 3: Gastroenterology & Hepatology (9% of Exam)
3.1 Esophageal Disease 3.2 Stomach & Duodenal Disease and Gastrointestinal Hemorrhage 3.3 Inflammatory Bowel Disease 3.4 Celiac Disease & Irritable Bowel Syndrome 3.5 Diverticular Disease & Colorectal Cancer Screening 3.6 Viral Hepatitis, Steatotic & Alcohol-Associated Liver Disease 3.7 Cirrhosis & the Complications of Portal Hypertension 3.8 Acute Pancreatitis 3.9 Chronic Pancreatitis & Biliary Tract Disease 3.10 Inherited, Autoimmune & Drug-Induced Liver Disease 3.11 Small Intestinal Disease, Ischemia & Gastrointestinal Complications of HIV
5 Chapter 4: Infectious Disease (9% of Exam)
4.1 Lower Respiratory Tract Infections & Sepsis Syndromes 4.2 Viral Respiratory Pathogens & Tuberculosis 4.3 Central Nervous System Infections 4.4 Skin, Soft Tissue, Bone & Joint Infections 4.5 Infective Endocarditis & Cardiovascular Infection 4.6 Clostridioides difficile & Catheter-Related Bloodstream Infection 4.7 HIV Diagnosis, Antiretroviral Therapy & Prevention 4.8 Opportunistic Infections & Sexually Transmitted Infections 4.9 Fever of Unknown Origin, Neutropenic Fever & Toxic Shock 4.10 Travel-Related Illness, Vector-Borne Disease & Outbreaks 4.11 Infection Prevention, Nosocomial Infection & Postexposure Prophylaxis 4.12 Rheumatic Fever, Poststreptococcal Disease, Enteric & Hepatic Infections
6 Chapter 5: Pulmonary Disease (9% of Exam)
5.1 COPD: Diagnosis, GOLD Classification & Initial Pharmacotherapy 5.2 Interventions That Reduce COPD Mortality & Exacerbation Management 5.3 Asthma: Diagnosis, Stepwise Therapy & Status Asthmaticus 5.4 Interstitial Lung Disease & Idiopathic Pulmonary Fibrosis 5.5 Sarcoidosis, Hypersensitivity Pneumonitis & Occupational Lung Disease 5.6 Pulmonary Embolism: Diagnosis, Risk Stratification & Anticoagulation 5.7 Pulmonary Hypertension & Sleep-Disordered Breathing 5.8 Acute Respiratory Distress Syndrome & Mechanical Ventilation 5.9 Pleural Disease, Empyema & Pneumothorax 5.10 Bronchiectasis, Cystic Fibrosis & Restrictive Lung Disease 5.11 Evaluation of Cough, Dyspnea, Hemoptysis & the Solitary Pulmonary Nodule
7 Chapter 6: Rheumatology & Orthopedics (9% of Exam)
6.1 Rheumatoid Arthritis: Diagnosis & Systemic Manifestations 6.2 Antirheumatic Pharmacotherapy & the Spondyloarthropathies 6.3 Gout: Pathophysiology & Acute Management 6.4 Urate-Lowering Therapy & Calcium Pyrophosphate Deposition Disease 6.5 Osteoarthritis 6.6 Systemic Lupus Erythematosus 6.7 Systemic Sclerosis, Sjogren Syndrome & Inflammatory Myopathies 6.8 The Vasculitides 6.9 Regional Musculoskeletal Syndromes, Back Pain & Sports Injuries 6.10 Other Primary Rheumatic Disorders & Mixed Connective Tissue Disease 6.11 Osteonecrosis & Metabolic Bone Disease
8 Chapter 7: Hematology (6% of Exam)
7.1 Approach to Anemia & the Microcytic Anemias 7.2 Macrocytic, Normocytic & Hemolytic Anemias 7.3 Hemoglobinopathies, Thalassemias & Paroxysmal Nocturnal Hemoglobinuria 7.4 Platelet Disorders, Thrombocytopenia & the Bleeding Patient 7.5 Coagulation Factor Disorders, Thrombophilia & Anticoagulant Reversal 7.6 Acute Leukemias, Chronic Leukemias & Myeloproliferative Neoplasms 7.7 Lymphomas & Plasma Cell Disorders 7.8 Myelodysplastic Syndrome, Myeloproliferative Neoplasms & Porphyria 7.9 Transfusion Medicine & Late Complications of Transplantation
9 Chapter 8: Medical Oncology (6% of Exam)
8.1 Breast, Lung, Colorectal & Prostate Cancer 8.2 Oncologic Emergencies 8.3 Genitourinary & Gynecologic Malignancies 8.4 Head and Neck, Bone & Soft Tissue Cancer and Cancer of Unknown Primary 8.5 Complications of Cancer & Its Treatment 8.6 Cancer Prevention, Survivorship & Psychosocial Care
10 Chapter 9: Nephrology & Urology (6% of Exam)
9.1 Acute Kidney Injury: Staging, Etiology & Urine Microscopy 9.2 Glomerular Disorders & Nephrotic Syndrome 9.3 Nephritic Syndromes, RPGN & Indications for Renal Replacement Therapy 9.4 Chronic Kidney Disease: Staging & Progression Retardation 9.5 Complications of Chronic Kidney Disease: Anemia, CKD-MBD & Acidosis 9.6 Hyponatremia, Hypernatremia & Water Balance 9.7 Potassium Disorders & Systematic Acid-Base Analysis 9.8 Renal Tubular Acidosis & Nephrolithiasis 9.9 Prostate Disorders, Urinary Incontinence & Other Urologic Conditions 9.10 Cystic Kidney Disease, Obstructive Uropathy, Tubulointerstitial Disease & Hematuria
11 Chapter 10: Neurology (4% of Exam)
10.1 Acute Ischemic Stroke: Syndromes & Reperfusion 10.2 Transient Ischemic Attack, Secondary Prevention & Hemorrhagic Stroke 10.3 Headache & Facial Pain 10.4 Seizures, Epilepsy & Movement Disorders 10.5 Multiple Sclerosis & Neuromuscular Junction Disorders 10.6 Motor Neuron Disease & Acute Peripheral Neuropathy 10.7 Cranial Neuropathies & Neuro-Ophthalmology 10.8 Peripheral Neuropathies, CNS Tumors & Other Neurologic Disorders
12 Chapter 11: Psychiatry & Behavioral Health (4% of Exam)
11.1 Major Depressive Disorder & Medical Mimics 11.2 Antidepressant Pharmacotherapy & Treatment-Resistant Depression 11.3 Bipolar Disorder, Mood Stabilizers & Lithium Toxicity 11.4 Anxiety, Stress-Related & Obsessive-Compulsive Disorders 11.5 Alcohol Use Disorder & Withdrawal 11.6 Pharmacotherapy for Alcohol & Opioid Use Disorder 11.7 Toxidromes, Psychiatric Emergencies & Suicide Risk Assessment 11.8 Psychotic, Somatic Symptom, Factitious & Personality Disorders 11.9 Eating Disorders, Sleep Disorders & Sexual Health
13 Chapter 12: Dermatology (3% of Exam)
12.1 Dermatitis, Papulosquamous & Inflammatory Dermatoses 12.2 Acne, Rosacea & Cutaneous Infections 12.3 Herpes Zoster & Autoimmune Blistering Diseases 12.4 Nodules, Tumors & Cutaneous Oncology 12.5 Dermatologic Emergencies & Severe Cutaneous Adverse Reactions 12.6 Pigment Disorders, Alopecia, Nail Disease & Photosensitivity 12.7 Vascular Dermatoses, Environmental Injury & Cutaneous Signs of Systemic Disease
14 Chapter 13: Obstetrics & Gynecology / Women's Health (3% of Exam)
13.1 Contraception, Preconception Care & Teratogenicity 13.2 Hypertensive Disorders of Pregnancy & Gestational Diabetes 13.3 Thyroid Disease & Venous Thromboembolism in Pregnancy 13.4 Menopause & Menopausal Hormone Therapy 13.5 Abnormal Uterine Bleeding, Endometrial Disease & Gynecologic Cancer Screening 13.6 Breast Disorders & Diseases of the Vulva and Vagina 13.7 Menstrual Disorders, Fibroids, Endometriosis & Early Pregnancy Complications
15 Chapter 14: Geriatric Syndromes (3% of Exam)
14.1 Comprehensive Geriatric Assessment & Frailty 14.2 Falls, Gait Assessment & Polypharmacy 14.3 Urinary Incontinence & Pressure Injuries in Older Adults 14.4 Mild Cognitive Impairment, Dementia & Its Subtypes 14.5 Delirium & the Pharmacotherapy of Cognitive Disorders 14.6 Palliative Care, Hospice & Advance Care Planning 14.7 Chronic Wounds, Nutrition, Swallowing, Constipation & Hip Fracture 14.8 Sensory Impairment, Dizziness, Elder Mistreatment & Care Settings
16 Chapter 15: Allergy & Immunology (2% of Exam)
15.1 Anaphylaxis: Recognition & Emergency Management 15.2 Urticaria & Angioedema 15.3 Drug Allergy, Desensitization & Adult Immunodeficiency 15.4 Food Allergy, Insect Venom Hypersensitivity, Serum Sickness & Contrast Reactions 15.5 Rhinitis, Conjunctivitis, Eosinophilic & Mast Cell Disorders
17 Chapter 16: Preventive Medicine, Immunization & Clinical Epidemiology
16.1 The USPSTF Framework & Evidence-Based Cancer Screening 16.2 Cardiovascular & Metabolic Screening and Primary Prevention 16.3 Adult Immunization & Vaccines in Special Populations 16.4 Clinical Epidemiology, Biostatistics & Study Design
18 Chapter 17: Miscellaneous - Ethics, Patient Safety & Quality Improvement (2% of Exam)
17.1 Principles of Bioethics & Decisional Capacity 17.2 Informed Consent, Treatment Refusal & Special Scenarios 17.3 Surrogate Decision-Making, Advance Directives & Confidentiality 17.4 Patient Safety Science, Medical Error & Diagnostic Reasoning 17.5 Quality Improvement Methods, Health Disparities & Health Equity
19 Chapter 18: Perioperative Medicine & Medical Consultation
18.1 Preoperative Cardiovascular Risk Assessment 18.2 Preoperative Pulmonary Risk & Perioperative Medication Management 18.3 Perioperative Anticoagulation, Bridging & Postoperative Complications
20 Chapter 19: Ophthalmology (1% of Exam)
19.1 The Acute Red Eye & Ophthalmic Emergencies 19.2 Painless Vision Loss & Chronic Ophthalmic Disease 19.3 Uveitis, Scleritis & Orbital Disease
21 Chapter 20: Otolaryngology & Dental Medicine (1% of Exam)
20.1 Dizziness, Vertigo & Epistaxis 20.2 Ear Disorders, Hearing Loss & Upper Respiratory Infections 20.3 Oral Cavity, Salivary Gland, Laryngeal & Taste and Smell Disorders
17.5 Quality Improvement Methods, Health Disparities & Health Equity
Key Takeaways Explain This Topic AI
ABIM states that health equity content clinically important to each discipline will be included in its assessments.
Donabedian classifies quality measures as structure, process and outcome, with balancing measures added to detect unintended consequences.
The Model for Improvement pairs an aim, measures and change ideas with iterative plan-do-study-act cycles.
Run charts and control charts distinguish common cause variation from special cause variation, so that stable systems are not adjusted needlessly.
Health disparities arise from social determinants, access barriers, structural racism and implicit bias rather than from biological differences between groups.
Last updated: August 2026
- 1. Quality Improvement (QI) Frameworks & Statistical Process Control
- A. The Institute for Healthcare Improvement (IHI) Model for Improvement
The IHI Model for Improvement guides clinical quality initiatives by addressing three fundamental questions, followed by iterative testing:
Question 1: What are we trying to accomplish?
Formulate a SMART Aim Statement : S pecific, M easurable, A chievable, R elevant, and T ime-bound.
Example: "To reduce the central line-associated bloodstream infection (CLABSI) rate in the medical ICU from 3.2 to <1.0 per 1,000 line-days by December 31, 2026."
Question 2: How will we know that a change is an improvement?
Establish a Balanced Measurement Framework composed of three interrelated measurement types:
Outcome Measures: Reflect the direct impact on patient health and clinical endpoints (e.g., CLABSI rate per 1,000 line-days, 30-day readmission rate, surgical site infection rate).
Process Measures: Evaluate whether specific steps in the care delivery system are functioning as intended (e.g., percentage compliance with the central line insertion bundle checklist, percentage of patients receiving timely prophylactic antibiotics within 60 minutes of surgical incision).
Balancing Measures: Monitor for unintended negative consequences or downstream bottlenecks elsewhere in the system (e.g., increased peripheral IV infiltration rates or delays in emergency central line placement due to bundle checklist verification).
Question 3: What changes can we make that will result in improvement?
Identify evidence-based change concepts (e.g., standardized insertion kits, chlorhexidine skin antisepsis, daily line necessity audits).
B. Plan-Do-Study-Act (PDSA) Cycles
Plan: State the objective, formulate a hypothesis/prediction, determine who/what/where/when, and establish a data collection plan.
Do: Carry out the test on a small, controlled scale (e.g., testing a new discharge checklist with 1 nurse and 3 patients for 2 days), document unexpected observations, and gather quantitative data.
Study: Analyze data, plot results on run charts, compare observed outcomes against predictions, and summarize learnings.
Act: Based on findings, decide to:
- Adopt: Standardize and expand the change to larger hospital units if highly successful,
- Adapt: Modify components of the intervention and launch a subsequent PDSA cycle, OR
Abandon: Discard the ineffective change concept and test an alternative approach.
C. Statistical Process Control (SPC) & Run Charts
Statistical Process Control uses visual time-series charts to distinguish between random system noise and meaningful improvement.
SPC Chart Type Components & Construction Rules for Identifying Non-Random (Special Cause) Variation
Run Chart Data plotted chronologically on the y-axis against time on the x-axis, with a central Median line . 1. Shift: >= 6 consecutive data points falling entirely above or entirely below the median.; 2. Trend: >= 5 consecutive data points continually increasing or continually decreasing.; 3. Runs: An unusually high or low total number of crossings of the median.; 4. Astronomical Point: An obvious, blatant outlier data point.
Shewhart Control Chart Data plotted against a central Process Mean , bounded by an Upper Control Limit (UCL) and a Lower Control Limit (LCL) calculated at ±3 standard deviations (±3σ) from the mean. 1. Any single point outside the control limits (above UCL or below LCL).; 2. Shift: >=8 consecutive points on one side of the center line.; 3. Trend: >=6 consecutive points increasing or decreasing.; 4. 2 out of 3 consecutive points near a control limit (outer one-third zone).
Common Cause Variation: Inherent, predictable, baseline random variation built into the system design. To improve a process with common cause variation, the entire system must be redesigned .
Special Cause Variation: Unpredictable, non-random variation caused by specific external factors (e.g., a sudden spike in infections following the introduction of a defective batch of catheters). Special cause variation requires targeted investigation to isolate and eliminate the specific cause.
- 2. Healthcare Disparities, Social Determinants of Health & Health Equity
- A. Social Determinants of Health (SDOH)
Social Determinants of Health are non-medical factors that influence health outcomes, health functioning, and quality of life. SDOH account for up to 80% of modifiable health outcomes , whereas direct clinical medical care accounts for only ~20%.
The Five Core SDOH Domains (Healthy People 2030):
Economic Stability: Poverty, employment status, food security (access to nutritious food), housing stability (homelessness, rent burden), medical debt.
Education Access and Quality: High school graduation, literacy levels, early childhood education, language proficiency.
Healthcare Access and Quality: Health insurance coverage, health literacy, access to primary and specialized medical care, transportation barriers.
Neighborhood and Built Environment: Quality of housing, crime rates, environmental hazards (lead pipes, air pollution), access to clean water, walkable sidewalks.
Social and Community Context: Discrimination, social cohesion, civic participation, incarceration history, social isolation.
Clinical Practice Standard: Systematic screening for unmet health-related social needs using validated screening tools (e.g., the PRAPARE tool, AAFP EveryONE Project) and establishing direct linkages to medical-legal partnerships, community food pantries, housing navigation, and utility assistance programs.
B. Health Literacy & Culturally Effective Care
Epidemiology: Nearly 90% of US adults have limited health literacy , struggling to navigate complex healthcare systems, interpret medication instructions, or understand diagnostic results.
The "Teach-Back" Method: An evidence-based communication technique where clinicians ask patients to explain in their own words or demonstrate what they need to know or do, without placing blame or making them feel tested.
Effective Scripting: "I want to make sure I gave you clear instructions about how to take this new blood thinner. When you go home, how will you explain to your spouse how and when you will take this medicine?"
Impact: Demonstrates statistically significant reductions in 30-day hospital readmissions, medication dosing errors, and glycemic variability in diabetes.
Plain Language Standards: Replace medical terminology with clear, conversational words (e.g., "high blood pressure" instead of "hypertension", "kidney problem" instead of "renal insufficiency", "spread" instead of "metastasize"). Patient educational materials should be written at a 5th- to 6th-grade reading level .
Qualified Medical Interpreters (Title VI Civil Rights Act & Section 1557 ACA):
Healthcare institutions receiving federal funding are legally mandated to provide qualified professional medical interpreters (in-person, video remote, or telephonic) at no cost to patients with Limited English Proficiency (LEP) or hearing impairment.
Ad Hoc Interpreters (Family Members, Children, Untrained Staff) Are STRICTLY INAPPROPRIATE: Utilizing children or family members violates patient privacy (HIPAA), distorts clinical history, causes emotional distress, and is associated with a >50% rate of medical interpretation errors (omissions of drug allergies, false reassurance, incorrect dosing instructions).
C. Implicit Bias, Structural Racism & Health Equity
Implicit Bias: Unconscious attitudes, stereotypes, or cognitive associations that unconsciously influence clinical perceptions, communication, diagnostic testing, and treatment recommendations.
Documented Disparities in Clinical Medicine:
Pain Management: Racial and ethnic minorities are significantly less likely to receive adequate opioid analgesia for acute fractures, appendicitis, and cancer-related pain compared to white patients.
Cardiovascular Interventions: Black patients presenting with acute coronary syndromes receive guideline-directed medical therapy and invasive cardiac catheterization at significantly lower rates than white patients with identical clinical presentations.
Maternal Mortality: Black women in the United States experience a 3- to 4-fold higher rate of pregnancy-related mortality compared to white women, independent of income or education level.
Renal Transplantation: Historical use of race-adjusted eGFR formulas systematically delayed kidney transplant waitlist eligibility for Black patients (modern guidelines mandate race-free eGFR equations based on CKD-EPI 2021).
Evidence-Based Mitigation Strategies:
Individuation: Consciously focusing on specific personal attributes of the individual patient rather than relying on social group categorizations.
Perspective-Taking: Imagining the clinical encounter and healthcare barriers from the patient's lived experience.
Standardization of Clinical Pathways: Implementing objective, standardized clinical algorithms, order sets, and diagnostic checklists that minimize discretionary variations in care.