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Practice size, financial sharing and quality of care.

ABSTRACT: BACKGROUND: Although we are observing a general move towards larger primary care practices, surprisingly little is known about the influence of key components of practice organization on primary care. We aimed to determine the relationships between practice size, and revenue sharing agreements, and quality of care. METHODS: As part of a large cross sectional study, group practices were randomly selected from different primary care service delivery models in Ontario. Patient surveys and chart reviews were used to assess quality of care. Multilevel regressions controlled for patient, provider and practice characteristics. RESULTS: Positive statistically significant associations were found between the logarithm of group size and access, comprehensiveness, and disease prevention. Negative significant associations were found between logarithm group size and continuity. No differences were found for chronic disease management and health promotion. Practices that shared revenues were found to deliver superior health promotion compared to those who did not. Interacting group size with the presence of a revenue-sharing arrangement had a negative impact on health promotion. CONCLUSIONS: Despite the limitations of our study, our findings have provided preliminary evidence of the tradeoffs inherent with increasing practice size. Larger group size is associated with better access and comprehensiveness but worse continuity of care. Revenue sharing in group practices was associated with higher health promotion compared to sharing only common costs. Further work is required to better inform policy makers and practitioners as to whether the pattern revealed in larger practices mitigates any of the previously reported benefits of continuity of primary care. We found few benefits of revenue sharing--even then the effect of revenue sharing on health promotion seemed diminished in larger practices.

SUBMITTER: Devlin RA

PROVIDER: S-EPMC3819507 | biostudies-literature | 2013

REPOSITORIES: biostudies-literature

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Practice size, financial sharing and quality of care.

Devlin Rose Anne RA Hogg William W Zhong Jianwei J Shortt Michael M Dahrouge Simone S Russell Grant G

BMC health services research 20131028

<h4>Background</h4>Although we are observing a general move towards larger primary care practices, surprisingly little is known about the influence of key components of practice organization on primary care. We aimed to determine the relationships between practice size, and revenue sharing agreements, and quality of care.<h4>Methods</h4>As part of a large cross sectional study, group practices were randomly selected from different primary care service delivery models in Ontario. Patient surveys ...[more]

PMID: 24165413

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Project description:BackgroundPatients with osteoporosis can sustain fractures following falls or other minimal trauma. This risk of fracture can be reduced through appropriate diagnostic testing, pharmacologic therapy, and other readily measured standards of care.ObjectivesOur aim was to develop a credible clinical performance assessment to measure physicians' quality of osteoporosis care, and determine reasonable performance standards for both competent and excellent care.DesignThis was a retrospective cohort study.ParticipantsThree hundred and eighty one general internists and subspecialists with time-limited board certification were included in the study.Main measuresPerformance rates on eight evidence-based measures were obtained from the American Board of Internal Medicine (ABIM) Osteoporosis Practice Improvement Module® (PIM), a web-based tool that uses medical chart reviews to help physicians assess and improve care. We applied a patented methodology, using an adaptation of the Angoff standard-setting method and the Dunn-Rankin method, with an expert panel skilled in osteoporosis care to form a composite and establish standards for both competent and excellent care. Physician and practice characteristics, including a practice infrastructure score based on the Physician Practice Connections Readiness Survey (PPC-RS), were used to examine the validity of the inferences made from the composite scores.Key resultsThe mean composite score was 67.54 out of 100 maximum points with a reliability of 0.92. The standard for competent care was 46.87, and for excellent care it was 83.58. Both standards had high classification accuracies (0.95). Sixteen percent of physicians performed below the competent care standard, while 22 % met the excellent care standard. Specialists scored higher than generalists, and better practice infrastructure was associated with higher composite scores, providing some validity evidence.ConclusionsWe developed a rigorous methodology for assessing physicians' osteoporosis care. Clinical performance feedback relative to absolute standards of care provides physicians with a meaningful approach to self-evaluation to improve patient care.

Project description:Pay for performance is intended to align incentives to promote high-quality care, but results have been contradictory.To test the effect of explicit financial incentives to reward guideline-recommended hypertension care.Cluster randomized trial of 12 Veterans Affairs outpatient clinics with 5 performance periods and a 12-month washout that enrolled 83 primary care physicians and 42 nonphysician personnel (eg, nurses, pharmacists).Physician-level (individual) incentives, practice-level incentives, both, or none. Intervention participants received up to 5 payments every 4 months; all participants could access feedback reports.Among a random sample, number of patients achieving guideline-recommended blood pressure thresholds or receiving an appropriate response to uncontrolled blood pressure, number of patients prescribed guideline-recommended medications, and number who developed hypotension.Mean (SD) total payments over the study were $4270 ($459), $2672 ($153), and $1648 ($248) for the combined, individual, and practice-level interventions, respectively. The unadjusted baseline and final percentages and the adjusted absolute change over the study in patients meeting the combined blood pressure/appropriate response measure were 75% to 84% and 8.84% (95% CI, 4.20% to 11.80%) for the individual group, 80% to 85% and 3.70% (95% CI, 0.24% to 7.68%) for the practice-level group, 79% to 88% and 5.54% (95% CI, 1.92% to 9.52%) for the combined group, and 86% to 86% and 0.47% (95% CI, -3.12% to 4.04%) for the control group. The adjusted absolute estimated difference in the change between the proportion of patients with blood pressure control/appropriate response for individual incentive and control groups was 8.36% (95% CI, 2.40% to 13.00%; P=.005). The other incentive groups did not show a significant change compared with controls for this outcome. For medications, the unadjusted baseline and final percentages and the adjusted absolute change were 61% to 73% and 9.07% (95% CI, 4.52% to 13.44%), 56% to 65% and 4.98% (95% CI, 0.64% to 10.08%), 65% to 80% and 7.26% (95% CI, 2.92% to 12.48%), and 63% to 72% and 4.35% (95% CI, -0.28% to 9.28%), respectively. These changes in the use of guideline-recommended medications were not significant in any of the incentive groups compared with controls, nor was the incidence of hypotension. The effect of the incentive was not sustained after a washout.Individual financial incentives, but not practice-level or combined incentives, resulted in greater blood pressure control or appropriate response to uncontrolled blood pressure; none of the incentives resulted in greater use of guideline-recommended medications or increased incidence of hypotension compared with controls. Further research is needed on the factors that contributed to these findings.clinicaltrials.gov Identifier: NCT00302718.

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Practice size, financial sharing and quality of care.

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Practice size, financial sharing and quality of care.

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