Performance Profiling in Primary Care: Does the Choice of Statistical Model Matter?

Institute of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, the Netherlands.
Medical Decision Making (Impact Factor: 3.24). 08/2013; 34(2). DOI: 10.1177/0272989X13498825
Source: PubMed


Background. Profiling is increasingly being used to generate input for improvement efforts in health care. For these efforts to be successful, profiles must reflect true provider performance, requiring an appropriate statistical model. Sophisticated models are available to account for the specific features of performance data, but they may be difficult to use and explain to providers. Objective. To assess the influence of the statistical model on the performance profiles of primary care providers. Data Source. Administrative data (2006-2008) on 2.8 million members of a Dutch health insurer who were registered with 1 of 4396 general practitioners. Methods. Profiles are constructed for 6 quality measures and 5 resource use measures, controlling for differences in case mix. Models include ordinary least squares, generalized linear models, and multilevel models. Separately for each model, providers are ranked on z scores and classified as outlier if belonging to the 10% with the worst or best performance. The impact of the model is evaluated using the weighted kappa for rankings overall, percentage agreement on outlier designation, and changes in rankings over time. Results. Agreement among models was relatively high overall (kappa typically >0.85). Agreement on outlier designation was more variable and often below 80%, especially for high outliers. Rankings were more similar for processes than for outcomes and expenses. Agreement among annual rankings per model was low for all models. Conclusions. Differences among models were relatively small, but the choice of statistical model did affect the rankings. In addition, most measures appear to be driven largely by chance, regardless of the model that is used. Profilers should pay careful attention to the choice of both the statistical model and the performance measures.

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    • "Ieva and Paganoni successfully used mixed effect models and funnel plots in hospital readmission rates [30]. Most recently, Eijkenaar and van Vliet compared rankings of quality, not of LTC facilities but of primary care providers, using many different statistical models to identify outliers [31]. They observed similar results from the models but very varied outliers and rankings, notably that the models better detected high-performing providers than low-performing providers. "
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