Diabetes Care Linked to PCP Volume

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.