Association between quality of care and the sociodemographic composition of physicians' patient panels: a repeat cross-sectional analysis

Differences based on patient gender in the management of hypertension: a multilevel analysis

The objective of our study was to investigate differences in the management of men and women treated for hypertension while considering the gender of their physicians. We used the data from the cross-sectional Paris Prevention in General Practice survey, where 59 randomly recruited general practitioners (42 men and 19 women) from the Paris metropolitan area enroled every patient aged 25-79 years taking antihypertensive medication and seen during a 2-week period (520 men and 666 women) in 2005-6. The presence in the medical files of six items recommended for hypertension management (blood pressure measurement, smoking status, cholesterol, creatinine, fasting blood glucose and electrocardiogram) was analysed with mixed models with random intercepts and adjusted for patient and physician characteristics. We found that the presence of all items was lower in the records of female than male patients (3.9 vs. 6.9%, p = 0.01), as was the percentage of items present (58.5 vs. 64.2%, p = 0.003). The latter gender difference was substantially more marked when the physician was a man (69.3 vs. 63.4%, p = 0.0002) rather than a woman (63.5 vs. 61.0%, p = 0.46). Although all guidelines recommend the same management for both genders, the practices of male physicians in hypertension management appear to differ according to patient gender although those of women doctors do not. Male physicians must be made aware of how their gender influences their practices.

Association Between Emergency Physician Length of Stay Rankings and Patient Characteristics

OBJECTIVE

Emergency physicians are commonly compared by their patients' length of stay (LOS). We test the hypothesis that LOS is associated with patient characteristics and that accounting for these features impacts physician LOS rankings.

METHODS

This was a retrospective observational study of all encounters at an emergency department in 2010 to 2015. We compared the characteristics of patients seen by physicians in different quartiles of LOS. Primary outcome was variation in patient characteristics at time of physician assignment (age, sex, comorbidities, Emergency Severity Index [ESI], and chief complaint) across LOS quartiles. We also quantified the change in LOS rankings after accounting for difference in characteristics of patients seen by different physicians.

RESULTS

A total of 264,776 encounters seen by 62 attending physicians met inclusion criteria. Physicians in the longest LOS quartile saw patients who were older (age = 49.1 vs 48.6 years, difference = +0.5 years, 95% confidence interval [CI] = 0.3 to 0.7) with more comorbidities (Gagne score = 1.3 vs. 0.9, difference = +0.4, 95% CI = 0.4 to 0.4) and higher acuity (ESI = 2.8 vs. 2.9, difference = -0.1, 95% CI = 0.1 to 0.1) than physicians in the shortest LOS quartile. The odds ratio (OR) of physicians in the longest LOS quartile seeing patients over age 50 compared to the shortest LOS quartile was 1.1 (95% CI = 1.0 to 1.1); the OR of physicians in the longest LOS quartile seeing patients with ESI of 1 or 2 was also 1.1 (95% CI = 1.0 to 1.1). Accounting for variation in patient characteristics seen by different physicians resulted in substantial reordering of physician LOS rankings: 62.9% (39/62) of physicians reclassified into a different quartile with mean absolute percentile change of 25.8 (95% CI = 20.3 to 31.3). A total of 62.5% (10/16) of physicians in the shortest LOS quartile and 56.3% (9/16) in the longest LOS quartile moved into a different quartile after accounting for variation in patient characteristics.

CONCLUSIONS

Length of stay was significantly associated with patient characteristics, and accounting for variation in patient characteristics resulted in substantial reordering of relative physician rankings by LOS. Comparisons of emergency physicians by LOS that do not account for patient characteristics should be reconsidered.

Measuring Satisfaction: Factors that Drive Hospital Consumer Assessment of Healthcare Providers and Systems Survey Responses in a Trauma and Acute Care Surgery Population

Hospital quality metrics now reflect patient satisfaction and are measured by Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys. Understanding these metrics and drivers will be integral in providing quality care as this process evolves. This study identifies factors associated with patient satisfaction as determined by HCAHPS survey responses in trauma and acute care surgery patients. HCAHPS survey responses from acute care surgery and trauma patients at a single institution between 3/11 and 10/12 were analyzed. Logistic regression determined which responses to individual HCAHPS questions predicted highest hospital score (a rating of 9–10/10). Demographic and clinical variables were also analyzed as predictors of satisfaction. Subgroup analysis for trauma patients was performed. In 70.3 per cent of 182 total survey responses, a 9–10/10 score was given. The strongest predictors of highest hospital ranking were respect from doctors (odds ratio [OR] = 24.5, confidence interval [CI]: 5.44–110.4), doctors listening (OR: 9.33, CI: 3.7–23.5), nurses’ listening (OR = 8.65, CI: 3.62–20.64), doctors’ explanations (OR = 8.21, CI: 3.5–19.2), and attempts to control pain (OR = 7.71, CI: 3.22–18.46). Clinical factors and outcomes (complications, intensive care unit/hospital length of stay, mechanism of injury, and having an operation) were nonsignificant variables. For trauma patients, Injury Severity Score was inversely related to score (OR = 0.93, CI: 0.87–0.98). Insurance, education, and disposition were also tied to satisfaction, whereas age, gender, and ethnicity were nonsignificant. In conclusion, patient perception of interactions with the healthcare team was most strongly associated with satisfaction. Complications did not negatively influence satisfaction. Insurance status might potentially identify patients at risk of dissatisfaction. Listening to patients, treating them with respect, and explaining the care plan are integral to a positive perception of hospital stay.

Practice context affects efforts to improve diabetes care for primary care patients: a pragmatic cluster randomized trial

BACKGROUND

Efforts to improve primary care diabetes management have assessed strategies across heterogeneous groups of patients and practices. However, there is substantial variability in how well practices implement interventions and achieve desired outcomes.

OBJECTIVE

To examine practice contextual features that moderate intervention effectiveness.

DESIGN

Secondary analysis of data from a cluster randomized trial of three approaches for implementing the Chronic Care Model to improve diabetes care.

PARTICIPANTS

Forty small to mid-sized primary care practices participated, with 522 clinician and staff member surveys. Outcomes were assessed for 822 established patients with a diagnosis of type 2 diabetes who had at least one visit to the practice in the 18 months following enrollment.

MAIN MEASURES

The primary outcome was a composite measure of diabetes process of care, ascertained by chart audit, regarding nine quality measures from the American Diabetes Association Physician Recognition Program: HgA1c, foot exam, blood pressure, dilated eye exam, cholesterol, nephropathy screen, flu shot, nutrition counseling, and self-management support. Data from practices included structural and demographic characteristics and Practice Culture Assessment survey subscales (Change Culture, Work Culture, Chaos).

KEY RESULTS

Across the three implementation approaches, demographic/structural characteristics (rural vs. urban + .70(p = .006), +2.44(p < .001), -.75(p = .004)); Medicaid: < 20 % vs. ≥ 20 % (-.20(p = .48), +.75 (p = .08), +.60(p = .02)); practice size: < 4 clinicians vs. ≥ 4 clinicians (+.56(p = .02), +1.96(p < .001), +.02(p = .91)); practice Change Culture (high vs. low: -.86(p = .048), +1.71(p = .005), +.34(p = .22)), Work Culture (high vs. low: -.67(p = .18), +2.41(p < .001), +.67(p = .005)) and variability in practice Change Culture (high vs. low: -.24(p = .006), -.20(p = .0771), -.44(p = .0019) and Work Culture (high vs. low: +.56(p = .3160), -1.0(p = .008), -.25 (p = .0216) were associated with trajectories of change in diabetes process of care, either directly or differentially by study arm.

CONCLUSIONS

This study supports the need for broader use of methodological approaches to better examine contextual effects on implementation and effectiveness of quality improvement interventions in primary care settings.

Diabetes care quality is highly correlated with patient panel characteristics

INTRODUCTION

Health care reimbursement is increasingly based on quality. Little is known about how clinic-level patient characteristics affect quality, particularly in community health centers (CHCs).

METHODS

Using data from electronic health records for 4019 diabetic patients from 23 primary care CHCs in the OCHIN practice-based research network, we calculated correlations between a clinic's patient panel characteristics and rates of delivery of diabetes preventive services in 2007. Using regression models, we estimated the proportion of variability in clinics' preventive services rates associated with the variability in the clinics' patient panel characteristics. We also explored whether clinics' performance rates were affected by how patient panel denominators were defined.

RESULTS

Clinic rates of hemoglobin testing, influenza immunizations, and lipid screening were positively associated with the percentage of patients with continuous health insurance coverage and negatively associated with the percentage of uninsured patients. Microalbumin screening rates were positively associated with the percentage of racial minorities in a clinic's panel. Associations remained consistent with different panel denominators.

CONCLUSIONS

Clinic variability in delivery rates of preventive services correlates with differences in clinics' patient panel characteristics, particularly the percentage of patients with continuous insurance coverage. Quality scores that do not account for these differences could create disincentives to clinics providing diabetes care for vulnerable patients.

Refining physician quality indicators for screening mammography in older women: distinguishing appropriate use from overuse

OBJECTIVES

To assess the feasibility of refining physician quality indicators of screening mammography use based on patient life expectancy.

DESIGN

Retrospective population-based cohort study.

SETTING

Texas.

PARTICIPANTS

Three thousand five hundred ninety-five usual care providers (UCPs) with at least 10 female patients aged 67 and older on January 1, 2008, with an estimated life expectancy of 7 years or more (222,584 women) and at least 10 women with an estimated life expectancy of less than 7 years (90,903 women), based on age and comorbidity.

MEASUREMENTS

Screening mammography use in 2008-09 by each provider in each population.

RESULTS

The average adjusted mammography screening rates for UCPs were 31.1% for women with a life expectancy of less than 7 years and 55.2% for women with a life expectancy of 7 years or longer. For women with limited life expectancy, 3.7% of UCPs had significantly lower and 9.2% had significantly higher than average adjusted mammography screening rates. For women with longer life expectancy, 16.7% of UCPs had significantly lower and 19.7% had significantly higher than average rates. UCP adjusted screening rates were stable over time (2006-07 vs 2008-09, correlation coefficient (r) = 0.65, P < .001). There was a strong correlation between UCP screening rates for their female patients with a life expectancy of less than 7 years and 7 years or longer (r = 0.67, P < .001). Most physician characteristics associated with higher screening rates (e.g., being female and foreign trained) in women with longer life expectancy were also associated with higher screening rates in women with limited life expectancy.

CONCLUSION

Providers with high mammography screening rates for women with longer life expectancy also tend to screen women with limited life expectancy. Quality indicators for screening practice can be improved by distinguishing appropriate use from overuse based on patient life expectancy.