The Comprehensive Care Project: Measuring Physician Performance in Ambulatory Practice

Holmboe, Eric S.; Weng, Wei-Hung; Arnold, G; Kaplan, Sherrie H.; Normand, Sharon‐Lise T.; Greenfield, Sheldon; Hood, Sarah; Lipner, Rebecca S.

doi:10.1111/j.1475-6773.2010.01160.x

Cited by 36 publications

(34 citation statements)

References 29 publications

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“…Ultimately, setting a standard across conditions is desirable, but sampling and other methodological challenges presently make this task quite complex. 30 We focused on a specific disease (diabetes) rather than assessing quality of care across conditions because diabetes is highly prevalent and exacts a tremendous toll on patients and the health care system. More research needs to be done before a defensible and meaningful standard could be used in a high-stakes assessment within MOC programs.…”

Section: Resultsmentioning

confidence: 99%

Setting a Fair Performance Standard for Physicians’ Quality of Patient Care

et al. 2010

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BACKGROUND: Assessing physicians' clinical performance using statistically sound, evidence-based measures is challenging. Little research has focused on methodological approaches to setting performance standards to which physicians are being held accountable. OBJECTIVE: Determine if a rigorous approach for setting an objective, credible standard of minimally-acceptable performance could be used for practicing physicians caring for diabetic patients. DESIGN: Retrospective cohort study. PARTICIPANTS: Nine hundred and fifty-seven physicians from the United States with time-limited certification in internal medicine or a subspecialty. MAIN MEASURES: The ABIM Diabetes Practice Improvement Module was used to collect data on ten clinical and two patient experience measures. A panel of eight internists/subspecialists representing essential perspectives of clinical practice applied an adaptation of the Angoff method to judge how physicians who provide minimallyacceptable care would perform on individual measures to establish performance thresholds. Panelists then rated each measure's relative importance and the Dunn-Rankin method was applied to establish scoring weights for the composite measure. Physician characteristics were used to support the standard-setting outcome. KEY RESULTS: Physicians abstracted 20,131 patient charts and 18,974 patient surveys were completed. The panel established reasonable performance thresholds and importance weights, yielding a standard of 48.51 (out of 100 possible points) on the composite measure with high classification accuracy (0.98). The 38 (4%) outlier physicians who did not meet the standard had lower ratings of overall clinical competence and professional behavior/attitude from former residency program directors (p=0.01 and p=0.006, respectively), lower Internal Medicine certification and maintenance of certification examination scores (p= 0.005 and p< 0.001, respectively), and primarily worked as solo practitioners (p=0.02). CONCLUSIONS: The standard-setting method yielded a credible, defensible performance standard for diabetes care based on informed judgment that resulted in a reasonable, reproducible outcome. Our method represents one approach to identifying outlier physicians for intervention to protect patients.

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Section: Resultsmentioning

confidence: 99%

Setting a Fair Performance Standard for Physicians’ Quality of Patient Care

et al. 2010

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“…An audit of 254 general practitioners (GPs) in the USA between 2007 and 2009, using quality indicators from the National Quality Forum and RAND Corporation, found that eligible patients with coronary artery disease were prescribed lipid-lowering medication on 76% of occasions and that beta-blockers were prescribed post myocardial infarction (MI) on 84% of occasions, though achievement for a quality indicator assessing prescriptions of antiplatelet therapy was lower at 48%. 15 Fürthauer et al…”

Section: Cardiovascular Diseasementioning

confidence: 99%

The dynamics of quality: a national panel study of evidence-based standards

Hardcastle

Mounce

Richards

et al. 2015

Health Services and Delivery Research

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BackgroundShortfalls in the receipt of recommended health care have been previously reported in England, leading to preventable poor health.ObjectivesTo assess changes over 6 years in the receipt of effective health-care interventions for people aged 50 years or over in England with cardiovascular disease, depression, diabetes or osteoarthritis; to identify how quality varied with participant characteristics; and to compare the distribution of illness burden in the population with the distributions of diagnosis and treatment.Setting and participantsInformation on health-care quality indicators and participant characteristics was collected using face-to-face structured interviews and nurse visits in participants’ homes by the English Longitudinal Study of Ageing in 2004–5, 2006–7, 2008–9 and 2010–11. A total of 16,773 participants aged 50 years or older were interviewed at least once and 5114 were interviewed in all four waves; 5404 reported diagnosis of one or more of four conditions in 2010–11.Main outcome measuresPercentage of indicated health care received by eligible participants for 19 quality indicators: seven for cardiovascular disease, three for depression, five for diabetes and four for osteoarthritis, and condition-level quality indicator achievement, including achievement of a bundle of three diabetes indicators.AnalysisChanges in quality indicator achievement over time and variations in quality with participant characteristics were tested with Pearson’s chi-squared test and logistic regression models. The size of inequality between the hypothetically wealthiest and poorest participants, for illness burden, diagnosis and treatment, was estimated using slope indices of wealth inequality.ResultsAchievement of indicators for cardiovascular disease was 82.7% [95% confidence interval (CI) 79.9% to 85.5%] in 2004–5 and 84.2% (95% CI 82.1% to 86.2%) in 2010–11, for depression 63.3% (95% CI 57.6% to 69.0%) and 59.8% (95% CI 52.4% to 64.3%), for diabetes 76.0% (95% CI 74.1% to 77.8%) and 76.5% (95% CI 74.8% to 78.1%), and for osteoarthritis 31.2% (95% CI 28.5% to 33.8%) and 35.6% (95% CI 34.2% to 37.1%). Achievement of the diabetes care bundle was 67.8% (95% CI 64.5% to 70.9%) in 2010–11. Variations in quality by participant characteristics were generally small. Diabetes indicator achievement was worse in participants with cognitive impairment [odds ratio (OR) 0.5, 95% CI 0.4 to 0.7] and better in those living alone (OR 1.7, 95% CI 1.3 to 2.0). Hypertension care was better for those aged over 74 years (vs. 50–64 years) (OR 3.2, 95% CI 2.0 to 5.3). Osteoarthritis care was better for those with severe (vs. mild) pain (OR 1.8, 95% CI 1.4 to 2.2), limiting illness (OR 1.8, 95% CI 1.5 to 2.1), and obesity (OR 1.6, 95% CI 1.2 to 2.0). Previous non-achievement of the diabetes care bundle was the biggest predictor of non-achievement 2 years later (OR 3.3, 95% CI 2.2 to 4.7). Poorer participants were always more likely than wealthier participants to have illness burden (statistically significant OR 3.9 to 16.0), but not always more likely to be diagnosed or receive treatment (0.2 to 5.3).ConclusionsShortfalls in quality of care for these four conditions have persisted over 6 years, with only half of the level of indicated health care achieved for osteoarthritis, compared with the other three conditions. Quality for osteoarthritis improved slightly over time but remains poor. The relatively high prevalence of specific illness burden in poorer participants was not matched by an equally high prevalence of diagnosis or treatment, suggesting that barriers to equity may exist at the stage at diagnosis. Further research is needed into the association between quality and health system characteristics at the level of clinicians, general practices or hospitals, and regions. Linkage to routinely collected data could provide information on health service characteristics at the individual patient level.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

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“…91 Another study shows that higher certification exam scores are associated with better performance on overall chronic care and preventive services for internal medicine. 92 Across 23 specialties, certified physicians score higher on a quality performance composite derived from 124 quality measures (3.3 percentage points). 93 Certified endocrinologists provide better diabetes care than certified general internists as measured by a composite score, and those failing to meet a minimum level of competence are more likely to be in solo practice, receive lower ratings from their residency program directors, and perform poorer on the internal medicine exam for both initial certification and MOC.…”

Section: Clinical Quality Measuresmentioning

confidence: 99%