Characteristics of patient panels may influence quality ratings of PCPs

Hong CS. JAMA. 2010;304:1107-1113.

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 in the Journal of the American Medical Association.

An assumption underlying patient panels, which are used to rate the quality of care of physicians, is that the measures accurately represent physician performance. However, new research indicated that the specific panel of patients a PCP manages may have an effect on his higher or lower measured quality scores.

Researchers examined data of 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 PCPs 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 the Healthcare Effectiveness Data and Information Set, measures after adjusting for practice site, visit frequency and patient panel characteristics.

Linking patient characteristics, physician ranking

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 PCP, with more than one-third (36%) of PCPs reclassified into different quality tertiles.

Effects of patient panel ranking

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 concluded.

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