Lower primary care physician quality rankings were more likely to be the
result of patient panels with greater proportions of underinsured, minority and
non-English speaking patients, according to results of a recent study.
Used to rate the quality of care of physicians, an assumption underlying
patient panels is that the measures accurately represent physician performance.
However, new research indicated that the specific panel of patients a primary
care physician manages may have an effect on his or her higher or lower
measured quality scores.
Researchers examined data from 125,303 adult patients who had visited
nine hospital-affiliated practices or four community health centers in Eastern
Massachusetts between January 2003 and December 2005. The analysis involved 162
primary care physicians in one organization linked by a common
electronic medical record system. The researchers used the
data to determine changes in physician quality ranking based on an aggregate of
Health Plan Employer and Data Information Set measures after adjusting for
practice site, visit frequency and patient panel characteristics.
Based on unadjusted composite quality rankings, patients of top tertile,
or one-third, physicians tended to be older (51 years vs. 46 years), had a
higher number of coexisting illnesses, made more frequent primary care practice
visits and were men compared with patients of bottom tertile physicians.
"Because older patients with more comorbidities are often seen more
frequently, they may have stronger relationships with their physicians, and
physicians caring for such patients may have more opportunities to complete
process measures," the researchers wrote in the study.
However, the proportion of minority patients (13.7% vs. 25.6%),
non-English-speaking patients (3.2% vs. 10.2%) and patients with
Medicaid coverage or no insurance (9.6% vs. 17.2%) was
significantly lower in top tertile physicians vs. bottom tertile physicians.
Patients of top vs. bottom tertile physicians also lived in neighborhoods with
higher median household incomes and higher high school graduation rates.
After accounting for practice site and visit frequency differences,
adjusting for patient panel factors resulted in a relative average change in
physician rankings of 7.6 percentiles per primary care physician, with more
than one-third (36%) of primary care physicians reclassified into different
The association between physician quality scores and patient panel
characteristics may lead to inaccurate physician performance rankings, may
implicate physician rewards and resources allocated within health care systems
and, overall, may penalize physicians for taking care of more vulnerable
patients, the researchers noted.
"Efforts to improve quality of care must address both fairness of
physician clinical performance assessment and the design of incentive schemes
to both provide equitable distribution of resources and reduce disparities in
care for vulnerable patients," the researchers said.