Quality of care may vary in association with the characteristics of individual physicians and their practices

Jul 27 2005

Certain physician characteristics and practice-setting characteristics are associated with Medicare beneficiaries receiving routine preventive services below the national goals, according to a study in the July 27 issue of JAMA: The Journal of the American Medical Association.

An emerging body of literature suggests that quality of care may vary in association with the characteristics of individual physicians and their practices, according to background information in the article.

Hoangmai H. Pham, M.D., M.P.H., of the Center for Studying Health System Change, Washington, D.C., and colleagues examined the relationship between attributes of physicians and their practices and the extent to which their Medicare patients received preventive services. The researchers analyzed data from 3,660 U.S. physician respondents to the 2000-2001 Community Tracking Study Physician Survey linked to claims data on 24,581 Medicare beneficiaries 65 years and older who were treated in 2001. Physician variables included training and qualifications and sex. Practice setting variables included practice type, size, sources of revenue, and access to information technology. Analyses were adjusted for patient demographics and multiple diseases, as well as community characteristics.

The researchers determined the proportion of eligible beneficiaries who received each of 6 preventive services: diabetic monitoring with hemoglobin A1c measurement, eye examinations, screening for colon or breast cancer, and vaccination for influenza or pneumococcus.

The researchers found that overall, the proportion of beneficiaries receiving services was below national goals. Physician and, more consistently, practice-level characteristics were both associated with differences in the delivery of services. The strongest associations were with practice type and the percentage of practice revenue derived from Medicaid. For instance, beneficiaries receiving usual care in practices with less than 6 percent of revenue from Medicaid were more likely than those with more than 15 percent of revenue derived from Medicaid to receive diabetic eye examinations (48.9 percent vs. 43 percent), hemoglobin A1c monitoring (61.2 percent vs. 48.4), mammograms (52.1 percent vs. 38.9 percent), colon cancer screening (10.0 percent vs. 8.5 percent), and influenza (50.2 percent vs. 39.2 percent) and pneumococcal (8.2 percent vs. 6.4 percent) vaccinations.

Other variables associated with delivery of preventive services after adjustment for patient and geographic factors included obtaining usual health care from a physician who worked in group practices of 3 or more, who was a graduate of a U.S. or Canadian medical school, or who reported availability of information technology to generate preventive care reminders or access treatment guidelines.

"We found that this shortfall is neither uniform for all beneficiaries nor explained entirely by characteristics of the beneficiaries such as their race or income level. Rather, it appears that some beneficiaries are treated in practice settings or by physicians who deliver preventive services at particularly low rates. Our results suggest that these variations in quality are substantial and seem to be greatly influenced by the structure and revenue sources of physician practices. If we can understand the mechanisms underlying these relationships, it would be much easier to identify the key leverage points for quality improvement," the authors conclude. (JAMA. 2005;294:473–481.

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