Patient Panel Characteristics and PCP Clinical Performance Rankings

Many healthcare systems use primary care physician (PCP) clinical performance assessment when making decisions about recredentialing; pay-for-performance and public reporting programs are common methods for influencing physician performance. Programs use performance incentives such as cash payments and public reports to encourage clinicians, practice groups, and healthcare systems to reach specific healthcare quality goals. According to researchers, a physician may have higher or lower measured quality scores depending on the panel of patients he or she manages, and this possible association of characteristics of the patient panel with the physician quality scores could lead to inaccurate performance rankings, affecting how the physician is rewarded and how healthcare system resources are allocated. To test the hypothesis that a physician’s patient panel characteristics are independently associated with changes in his or her relative quality ranking, the researchers conducted a cohort study utilizing data from a large academic primary care network. Study results were reported in the Journal of the American Medical Association [2010;304(10):1107-1113]. The primary outcome measure was the composite physician clinical performance score based on 9 Healthcare Effectiveness Data and Information Set (HEDIS) measures. After adjusting for practice site, frequency of visits, and patient panel characteristics, the researchers determined changes in physician quality ranking based on the HEDIS scores. The study utilized data from 125,303 adult patients who had visited any of the 9 hospital-affiliated practices in the network or 4 community health centers between January 1, 2003, and December 31, 2005. The practices included 162 PCPs in 1 physician organization that was linked by a common electronic medical record system in eastern Massachusetts. The physicians were divided into tertiles based on their unadjusted composite quality rankings and assessed for reclassification into different postadjustment tertiles. Of the 162 PCPs eligible for inclusion, mean years from medical school graduation was 18.6 (95% confidence interval [CI], 16.9-20.2 years). Compared with bottom-tertile PCPs, fewer top-tertile PCPs were in community health centers (47.2% [95% CI, 33.7%-60.6%) vs 17.0% [95% CI, 6.9%-27.1%, respectively; P=.001). A greater proportion of female compared with male PCPs were in the top tertile of unadjusted PCP composite ranking (62.3% [95% CI, 49.2%-75.3%] vs 34.0% [95% CI, 21.2%-46.7%], respectively; P=.004). The mean eligible patient panel consisted of 773 patients (95% CI, 706-841 patients). Compared with patients of bottom-tertile PCPs, patients of top-tier PCPs were older (46.4 years [95% CI, 43.8-49.5 years] vs 51.1 years [95% CI, 49.6-52.6], respectively; P<.001), had a higher number of comorbidities (0.80 [95% CI, 0.66-0.95] vs 0.91 [95% CI, 0.83-0.98], respectively; P=.008), made more frequent primary care visits (61.8% [95% CI, 57.3%-66.3%] vs 71.0% [95% CI, 68.5%-73.5%] with >3 visits per year; P=.003), and were less often female (47.5% [95% CI, 42.0%-53.0%] vs 34.2% [95% CI, 27.6%-40.8%]; P=.002). Compared with bottom-tertile PCPs, top-tertile PCPs had fewer minority patients (25.6% [95% CI, 20.2%-31.1%] vs 13.7% [95% CI, 10.6%-16.7%], respectively; P<.001), fewer non–English-speaking patients (10.2% [95% CI, 5.5%-14.9%] vs 3.2% [95% CI, 0.7%-5.6%], respectively; P<.001), and fewer patients with no insurance coverage or with Medicaid coverage (17.2% [95% CI, 13.5%-21.0%] vs 9.6% [95% CI, 7.5%-11.7%], respectively; P<.001). After accounting for practice site visits and differences in visit frequency, adjusting for patient panel factors resulted in a relative mean change in physician rankings of 7.6 percentiles (95% CI, 6.6-8.7 percentiles) per PCP, with 59/162 (36%) of PCPs reclassified into different quality tertiles. In conclusion, the researchers summarized the results: “Among primary care physicians practicing within the same large academic primary care system, patient panels with greater proportions of underinsured, minority, and non–English-speaking patients were associated with lower quality rankings for primary care physicians.”