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      Hemodialysis Patient Outcomes: Provider Characteristics

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          Abstract

          Background/Aims: Physician characteristics are associated with differential performance on quality measures and patient outcomes in several medical fields. We aimed to determine whether characteristics of physicians who provide care to dialysis patients were associated with patient outcomes. Methods: This cohort study used United States Renal Data System data for patients who initiated in-center hemodialysis between October 1, 2003, and September 30, 2006 (n = 91,276). Patient characteristics were defined and physicians identified from Part B Medicare claims for outpatient dialysis services submitted during months 4-6 of hemodialysis. Physician characteristics were obtained from the American Medical Association Physician Master File. Associations of physician characteristics with 1-year patient mortality and first hospitalization were determined using Cox proportional hazards analysis; associations with quality of care (defined by influenza vaccination and waitlisting for kidney transplant) were determined using logistic regression. Results: Physician characteristics were not associated with patient mortality. After adjustment for patient and other provider characteristics, patients whose physicians had practiced longer or were in administrative, research, or teaching practices were more likely to be hospitalized; patients whose providers practiced in smaller metropolitan statistical areas (MSAs) were less likely. More years since training was associated with greater chance of waitlisting, and practicing in smaller MSAs with less chance. Graduation from a foreign medical school, practicing in smaller MSAs, and travelling farther from office to dialysis unit were associated with greater odds of influenza vaccination. Conclusions: Several characteristics of physicians seeing incident outpatient hemodialysis patients were associated with hospitalization and quality of care, but none with mortality.

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          Most cited references 16

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          Systematic review: the relationship between clinical experience and quality of health care.

          Physicians with more experience are generally believed to have accumulated knowledge and skills during years in practice and therefore to deliver high-quality care. However, evidence suggests that there is an inverse relationship between the number of years that a physician has been in practice and the quality of care that the physician provides. To systematically review studies relating medical knowledge and health care quality to years in practice and physician age. English-language articles in MEDLINE from 1966 to June 2004 and reference lists of retrieved articles. Studies that provided empirical results about knowledge or a quality-of-care outcome and included years since graduation or physician age as explanatory variables. We categorized studies on the basis of the nature of the association between years in practice or age and performance. Overall, 32 of the 62 (52%) evaluations reported decreasing performance with increasing years in practice for all outcomes assessed; 13 (21%) reported decreasing performance with increasing experience for some outcomes but no association for others; 2 (3%) reported that performance initially increased with increasing experience, peaked, and then decreased (concave relationship); 13 (21%) reported no association; 1 (2%) reported increasing performance with increasing years in practice for some outcomes but no association for others; and 1 (2%) reported increasing performance with increasing years in practice for all outcomes. Results did not change substantially when the analysis was restricted to studies that used the most objective outcome measures. Because of the lack of reliable search terms for physician experience, reports that provided relevant data may have been missed. Physicians who have been in practice longer may be at risk for providing lower-quality care. Therefore, this subgroup of physicians may need quality improvement interventions.
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            Delivery of preventive services to older adults by primary care physicians.

            Rates of preventive services remain below national goals. To identify characteristics of physicians and their practices that are associated with the quality of preventive care their patients receive. Cross-sectional analysis of data on US physician respondents to the 2000-2001 Community Tracking Study Physician Survey linked to claims data on Medicare beneficiaries they treated in 2001. Physician variables included training and qualifications and sex. Practice setting variables included practice type, size, sources of revenue, and access to information technology. Analyses were adjusted for patient demographics and comorbidity, as well as community characteristics. Primary care delivered by 3660 physicians providing usual care to 24 581 Medicare beneficiaries aged 65 years and older. Proportion of eligible beneficiaries receiving each of 6 preventive services: diabetic monitoring with hemoglobin A(1c) measurement or eye examinations, screening for colon or breast cancer, and vaccination for influenza or pneumococcus in 2001. Overall, the proportion of beneficiaries receiving services was below national goals. Physician and, more consistently, practice-level characteristics were both associated with differences in the delivery of services. The strongest associations were with practice type and the percentage of practice revenue derived from Medicaid. For instance, beneficiaries receiving usual care in practices with less than 6% of revenue from Medicaid were more likely than those with more than 15% of revenue derived from Medicaid to receive diabetic eye examinations (48.9% vs 43%; P = .02), hemoglobin A1c monitoring (61.2% vs 48.4%; P<.001), mammograms (52.1% vs 38.9%; P<.001), colon cancer screening (10.0% vs 8.5%; P = .60), and influenza (50.2% vs 39.2%; P<.001) and pneumococcal (8.2% vs 6.4%; P<.001) vaccinations. Other variables associated with delivery of preventive services after adjustment for patient and geographic factors included obtaining usual health care from a physician who worked in group practices of 3 or more, who was a graduate of a US or Canadian medical school, or who reported availability of information technology to generate preventive care reminders or access treatment guidelines. Delivery of routine preventive services is suboptimal for Medicare beneficiaries. However, patients treated within particular practice settings and by particular subgroups of physicians are at particular risk of low-quality care. Profiling these practices may help develop tailored interventions that can be directed to sites where the opportunities for quality improvement are greatest.
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              Associations between physician characteristics and quality of care.

              Information on physicians' performance on measures of clinical quality is rarely available to patients. Instead, patients are encouraged to select physicians on the basis of characteristics such as education, board certification, and malpractice history. In a large sample of Massachusetts physicians, we examined the relationship between physician characteristics and performance on a broad range of quality measures. We calculated overall performance scores on 124 quality measures from RAND's Quality Assessment Tools for each of 10,408 Massachusetts physicians using claims generated by 1.13 million adult patients. The patients were continuously enrolled in 1 of 4 Massachusetts commercial health plans from 2004 to 2005. Physician characteristics were obtained from the Massachusetts Board of Registration in Medicine. Associations between physician characteristics and overall performance scores were assessed using multivariate linear regression. The mean overall performance score was 62.5% (5th to 95th percentile range, 48.2%-74.9%). Three physician characteristics were independently associated with significantly higher overall performance: female sex (1.6 percentage points higher than male sex; P < .001), board certification (3.3 percentage points higher than noncertified; P < .001), and graduation from a domestic medical school (1.0 percentage points higher than international; P < .001). There was no significant association between performance and malpractice claims (P = .26). Few characteristics of individual physicians were associated with higher performance on measures of quality, and observed associations were small in magnitude. Publicly available characteristics of individual physicians are poor proxies for performance on clinical quality measures.
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                Author and article information

                Journal
                AJN
                Am J Nephrol
                10.1159/issn.0250-8095
                American Journal of Nephrology
                S. Karger AG
                0250-8095
                1421-9670
                2014
                June 2014
                23 April 2014
                : 39
                : 5
                : 367-375
                Affiliations
                aVeterans Administration Health Care System, bDepartment of Medicine, University of Minnesota, and cChronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, Minn., USA
                Author notes
                *Yelena Slinin, MD, MS, VA Medical Center (111J), One Veteran's Drive, Minneapolis, MN 55417 (USA), E-Mail slini001@umn.edu
                Article
                362286 PMC4901871 Am J Nephrol 2014;39:367-375
                10.1159/000362286
                PMC4901871
                24776789
                © 2014 S. Karger AG, Basel

                Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher. Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug. Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

                Page count
                Tables: 4, Pages: 9
                Categories
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