Associations Between Structural Capabilities of Primary Care Practices and Performance on Selected Quality Measures

Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA.
Annals of internal medicine (Impact Factor: 17.81). 10/2009; 151(7):456-63. DOI: 10.7326/0003-4819-151-7-200910060-00006
Source: PubMed


Recent proposals to reform primary care have encouraged physician practices to adopt such structural capabilities as performance feedback and electronic health records. Whether practices with these capabilities have higher performance on measures of primary care quality is unknown.
To measure associations between structural capabilities of primary care practices and performance on commonly used quality measures.
Cross-sectional analysis.
412 primary care practices.
During 2007, 1 physician from each participating primary care practice (median size, 4 physicians) was surveyed about structural capabilities of the practice (responses representing 308 practices were obtained). Data on practice structural capabilities were linked to multipayer performance data on 13 Healthcare Effectiveness Data and Information Set (HEDIS) process measures in 4 clinical areas: screening, diabetes, depression, and overuse.
Frequently used multifunctional electronic health records were associated with higher performance on 5 HEDIS measures (3 in screening and 2 in diabetes), with statistically significant differences in performance ranging from 3.1 to 7.6 percentage points. Frequent meetings to discuss quality were associated with higher performance on 3 measures of diabetes care (differences ranging from 2.3 to 3.1 percentage points). Physician awareness of patient experience ratings was associated with higher performance on screening for breast cancer and cervical cancer (1.9 and 2.2 percentage points, respectively). No other structural capabilities were associated with performance on more than 1 measure. No capabilities were associated with performance on depression care or overuse.
Structural capabilities of primary care practices were assessed by physician survey.
Among the investigated structural capabilities of primary care practices, electronic health records were associated with higher performance across multiple HEDIS measures. Overall, the modest magnitude and limited number of associations between structural capabilities and clinical performance suggest the importance of continuing to measure the processes and outcomes of care for patients.
The Commonwealth Fund.

Download full-text


Available from: Eric Carl Schneider,
  • Source
    • "The National Committee for Quality Assurance (NCQA) defined structural elements in practices with a focus on information technology to quality practices as medical homes according to the patient-centred medical home model [13]. However, key relationships between structural capabilities of practices and their performance on measures of clinical quality in routine primary care settings have not been clearly detected [12,13]. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Prevention of cardiovascular diseases (CVD) is a major health issue worldwide. Primary care plays an important role in cardiovascular risk management (CVRM). Guidelines and quality of care measures to assess CVRM in primary care practices are available. In this study, we assessed the relationship between structural and organisational practice characteristics and the quality of care provided in individuals at high risk for developing CVD in European primary care. An observational study was conducted in 267 general practices from 9 European countries. Previously developed quality indicators were abstracted from medical records of randomly sampled patients to create a composite quality measure. Practice characteristics were collected by a practice questionnaire and face to face interviews. Data were aggregated using factor analysis to four practice scores representing structural and organisational practice features. A hierarchical multilevel analysis was performed to examine the impact of practice characteristics on quality of CVRM. The final sample included 4223 individuals at high risk for developing CVD (28% female) with a mean age of 66.5 years (SD 9.1). Mean indicator achievement was 59.9% with a greater variation between practices than between countries. Predictors at the patient level (age, gender) had no influence on the outcome. At the practice level, the score 'Preventive Services' (13 items) was positively associated with clinical performance (r = 1.92; p = 0.0058). Sensitivity analyses resulted in a 5-item score (PrevServ_5) that was also positively associated with the outcome (r = 4.28; p < 0.0001). There was a positive association between the quality of CVRM in individuals at high risk for developing CVD and the availability of preventive services related to risk assessment and lifestyle management supported by information technology.
    Implementation Science 03/2013; 8:27. DOI:10.1186/1748-5908-8-27 · 4.12 Impact Factor
  • Source
    • "Halladay estimated that the cost of implementing PQRI in primary care practices from $920 to $22,000 [28]. While much of the cost associated with modifications to billing and health record systems [19] [29], planning, staff training, registry maintenance , visit coding, and modification of existing electronic records and billing systems were estimated to add to the Table 3 Physician-reported impact of the PQRI on health care quality. burden of program implementation [28]. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Medicare established the Physicians Quality Reporting Initiative (PQRI, recently renamed the Physicians Quality Reporting System) to increase reporting of quality metrics and promote healthcare quality. To identify characteristics of PQRI participants and examine their beliefs about its impact. National survey of 4934 U.S. physicians, conducted June through October 2009. All practice settings. Randomly selected physicians categorized as primary care, medical specialists, surgeons, other specialists. Beliefs about impact of PQRI reporting on quality. The response rate was 49.8%. There were no significant differences between respondents and non-respondents by age, gender, specialty, and region. Thirty-eight percent participated in the PQRI, and were more likely than non-participants to be practice owners (69.0% vs. 57.1%, p<.0001) and to receive performance bonuses through their employer or practice (50.4% vs. 37.0%, p<.0001). Half of PQRI participants believed it had no impact on quality. Medical specialists (57.0%) and surgeons (55.1%) were more likely than primary care (40.4%) and other physicians (45.7%) to say that PQRI has no impact on quality (p=.004). Most PQRI participants believed it had little if any impact on quality. Medicare should identify the reasons behind physicians' negative views while it works to expand the Physicians Quality Reporting System.
    Health Policy 05/2011; 102(2-3):229-34. DOI:10.1016/j.healthpol.2011.05.003 · 1.91 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Purpose: The medical home has gained national attention as a model to reorganize primary care to improve health outcomes. Pennsylvania has undertaken one of the largest state-based, multipayer medical home pilot projects. We used a positive deviance approach to identify and compare factors driving the care models of practices showing the greatest and least improvement in diabetes care in a sample of 25 primary care practices in southeast Pennsylvania. Methods: We ranked practices into improvement quintiles on the basis of the average absolute percentage point improvement from baseline to 18 months in 3 registry-based measures of performance related to diabetes care: glycated hemoglobin concentration, blood pressure, and low-density lipoprotein cholesterol level. We then conducted surveys and key informant interviews with leaders and staff in the 5 most and least improved practices, and compared their responses. Results: The most improved/higher-performing practices tended to have greater structural capabilities (eg, electronic health records) than the least improved/lower-performing practices at baseline. Interviews revealed striking differences between the groups in terms of leadership styles and shared vision; sense, use, and development of teams; processes for monitoring progress and obtaining feedback; and presence of technologic and financial distractions. Conclusions: Positive deviance analysis suggests that primary care practices' baseline structural capabilities and abilities to buffer the stresses of change may be key facilitators of performance improvement in medical home transformations. Attention to the practices' structural capabilities and factors shaping successful change, especially early in the process, will be necessary to improve the likelihood of successful medical home transformation and better care.
    The Annals of Family Medicine 05/2013; 11 Suppl 1(Suppl 1):S99-S107. DOI:10.1370/afm.1473 · 5.43 Impact Factor
Show more