July 27, 2005
Journal of the American Medical Association , Vol. 294, No. 4 (July 27, 2005)
Hoangmai H. Pham, Deborah Schrag, J. Lee Hargraves, Peter B. Bach
Objective: To identify characteristics of physicians and their practices that are associated with the quality of preventive care their patients receive.
Design: Cross-sectional analysis of data on US physician respondents to the 2000-2001 Community Tracking Study Physician Survey linked to claims data on Medicare beneficiaries they 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 comorbidity, as well as community characteristics.
Setting and Participants: Primary care delivered by 3660 physicians providing usual care to 24581 Medicare beneficiaries aged 65 years and older.
Main Outcome Measures: Proportion of eligible beneficiaries receiving each of 6 preventive services: diabetic monitoring with hemoglobin A1c measurement or eye examinations, screening for colon or breast cancer, and vaccination for influenza or pneumococcus in 2001.
Results: 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% of revenue from Medicaid were more likely than those with more than 15% of revenue derived from Medicaid to receive diabetic eye examinations (48.9% vs 43%; P=.02), hemoglobin A1c monitoring (61.2% vs 48.4%; P<.001), mammograms (52.1% vs 38.9%; P<.001), colon cancer screening (10.0% vs 8.5%; P=.60), and influenza (50.2% vs 39.2%; P<.001) and pneumococcal (8.2% vs 6.4%; P<.001) 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 US or Canadian medical school, or who reported availability of information technology to generate preventive care reminders or access treatment guidelines.
Conclusions: Delivery of routine preventive services is suboptimal for
Medicare beneficiaries. However, patients treated within particular practice
settings and by particular subgroups or physicians are at particular risk of
low-quality care. Profiling these practices may help develop tailored interventions
that can be directed to sites where the opportunities for quality improvement
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