Primary care physicians (PCPs) with
higher overall ambulatory volumes provided lower-quality care to
patients with diabetes, whereas PCPs with higher diabetes-specific
volume provided higher-quality care, a large cohort study suggests.
"Although a relationship
between volume and quality has previously been demonstrated with
procedural and hospital-based volumes, there has been less research
demonstrating associations between outpatient volumes and quality of
care in chronic disease management," the researchers write.
"Our study provides evidence of such a relationship in the
outpatient context."
Andrew Cheung, MD, from the Department
of Medicine, McMaster University, Health Sciences Centre, Hamilton,
Ontario, Canada, and colleagues reported their findings online December 13 in the Annals of Internal Medicine.
This is something that most of our
support group members have discovered on their own. Many PCP's try
to take our members off insulin and start them back on oral
medications. Our members have learned when this happens, it is time
to leave and not look back. Most of our insulin using members have
found a doctor that they are satisfied with seeing and those on oral
medications are always asking us questions about the doctor they
should see, if and when they feel the need to move to insulin.
The researchers analyzed data from
provincial healthcare administrative databases to examine the
relationships between overall ambulatory volume and diabetes-specific
volume for PCPs and quality of care among 1,018,647 patients with
diabetes in Ontario, Canada.
They used six indicators to evaluate
quality of care: eye examination, low-density lipoprotein (LDL)
cholesterol testing, hemoglobin A1c testing, prescriptions for
angiotensin-converting enzyme inhibitors (ACEIs) and
angiotensin-receptor blockers (ARBs), prescriptions for statins, and
emergency department (ED) visits for hypoglycemia or hyperglycemia.
Patients of PCPs with the highest
overall volume had lower rates of appropriate eye examination,
hemoglobin A1c testing, and LDL cholesterol testing — findings that
were indicative of lower quality of care. These patients were also
less likely to fill prescriptions for ACEIs, ARBs, or statins
compared with patients of physicians with the lowest overall volume.
These findings contrasted with those
for patients of PCPs with higher diabetes-specific volume. Marginal
rates of appropriate eye examinations, hemoglobin A1c testing, and
LDL cholesterol testing were higher among these patients, as were
rates of prescriptions for ACEIs or ARBs and statins.
In addition, marginal rates of ED
visits for hypoglycemia and hyperglycemia were lower among patients
of PCPs with increasing overall ambulatory volume, suggesting higher
quality of care, but this trend was not statistically significant.
Rates of ED visits for hypoglycemia and
hyperglycemia were also lower among patients of PCPs with higher
diabetes-specific volume. Patients of PCPs with lower
diabetes-specific volume were younger and were more likely to be
referred to an internist or endocrinologist.
"Referral to a specialist
substantially improved the likelihood that recommended process
measures would be achieved; however, referred patients had 3 times
the rate of ED visits," Kevin A. Peterson, MD, MPH, from the
University of Minnesota, Minneapolis, explains in an accompanying
editorial. "Clearly, better performance on process measures
does not guarantee better clinical outcomes. The study also suggests
an association between higher volume of patients with diabetes and
better performance on diabetes process measures, although whether
this association is causal remains unclear."
He continues, "Providing an
isolated focus on a single disease-based performance measure tells
only part of the story and can underestimate the effect of a PCP on
the medical needs of a community. Pursuing modestly higher-quality
care for substantially fewer people is not necessarily a step
forward. The question remains of how many patients with and without
diabetes should be empaneled with a PCP so that the dual goals of
comprehensive, evidence-based primary care and a manageable physician
workday can be achieved."
"These findings show that
relationships between physician volume and quality can be extended
from acute care to outpatient chronic disease care," the
researchers conclude.
The authors and editorialist have
disclosed no relevant financial relationships.
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