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Very little of the variation in quality of diabetes care is explained by practice factors

Physician practice management strategies and financial arrangements have very little impact on quality of diabetes care, according to a study supported by the Agency for Healthcare Research and Quality (HS09936). This suggests that other approaches may be needed for health care organizations to improve the quality of diabetes care, says Nancy L. Keating, M.D., M.P.H., of Harvard Medical School.

Dr. Keating and her colleagues studied medical records of 652 adult diabetes patients in three Minnesota health plans. They also surveyed 399 physicians in 135 practices who cared for these patients in order to correlate practice characteristics with diabetes quality of care indicators (for example, tests for blood-sugar level, cholesterol level, and blood pressure and assessments of diabetes-related eye, kidney, and foot problems).

Overall, 12 percent of physicians used a computerized medical record, about 65 percent had been provided with practice guidelines related to diabetes, 45 percent were paid by salary that depended on the performance of the physician or group, and 49 percent received incentive payments or bonuses. Also, 26 percent of physicians were dissatisfied with their overall career in medicine. Only 5 percent of the variation in quality could be attributed to these practice characteristics.

Quality of care scores were higher among patients whose physicians received quality performance reports from two or more sources (versus none), received diabetes-specific performance reports, and routinely enrolled patients with diabetes in disease management programs. Quality scores were lower for patients of dissatisfied physicians and for patients whose physicians were required to serve as a gatekeeper (authorize referrals, hospitalizations, and other services) for more than half of their patients and were paid according to fee-for-service arrangements (versus being paid a set salary), but the score differences were small.

See "The influence of physicians' practice management strategies and financial arrangements on quality of care among patients with diabetes," by Dr. Keating, Mary Beth Landrum, Ph.D., Bruce E. Landon, M.D., M.B.A., and others, in the September 2004 Medical Care 42(9), pp. 829-839.

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