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Health Care Quality

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Level of education attained by patients is important when evaluating physician performance

One way to evaluate doctors' performance is to assess the physical and mental health status of their patients. In other words, if their patients are doing well, they are probably doing a good job. These evaluations, or physician profiles, usually are not adjusted for the educational level of the patients. Yet physicians who were caring for patients with less education were ranked significantly higher for patient physical and mental health status after adjustments were made for their patients' level of education, according to a study supported by the Agency for Healthcare Research and Quality (HS09397).

This finding challenges the validity of physician profiling that does not control for patients' socioeconomic status because it may underestimate the performance of doctors who care for the disadvantaged and overestimate the performance of those who care for socioeconomically advantaged patients. In fact, this bias in physician profiling may encourage selective enrollment of socioeconomically advantaged patients to improve physician performance ratings, conclude Kevin Fiscella, M.D., M.P.H., and Peter Franks, M.D., of the University of Rochester School of Medicine and Dentistry. Although routine adjustment of physician profiles or use of HMO report cards for patient socioeconomic status is clearly controversial, the authors recommend it.

The researchers surveyed patients of 100 primary care physician practices in New York on how they ranked their physicians. They then evaluated the effect of patients' educational level on the rank of physicians' practices, which was determined by three performance measures: patient physical health status, patient mental health status, and patient satisfaction. After adjustment for patients' level of education, each 1-year decrease in mean educational level was associated with a rank that improved by 8.1 for patient physical health status and by 4.9 for patient mental health status. Adjustment for education had similar effects for practices with more educated patients and those with less educated patients. This result was not seen for patient satisfaction.

More details are in "Influence of patient education on profiles of physician practices," by Drs. Fiscella and Franks, in the November 16, 1999, Annals of Internal Medicine 131, pp. 745-751.

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