Influence of patient characteristics on preventive service delivery and general practitioners’ preventive performance indicators: A study in patients with hypertension or diabetes mellitus from Hungary

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Abstract

Background: Regular primary healthcare (PHC) performance monitoring to produce a set of performance indicators for provider effectiveness is a fundamental method for improving guideline adherence but there are potential negative impacts of the inadequate application of this approach. Since performance indicators can reflect patient characteristics and working environments, as well as PHC team contributions, inadequate monitoring practices can reduce their effectiveness in the prevention of cardiometabolic disorders.

Objectives: To describe the influence of patients’ characteristics on performance indicators of PHC preventive practices in patients with hypertension or diabetes mellitus.

Methods: This cross-sectional analysis was based on a network of 165 collaborating GPs. A random sample of 4320 adults was selected from GP’s patient lists. The response rate was 97.3% in this survey. Sociodemographic status, lifestyle, health attitudes and the use of recommended preventive PHC services were surveyed by questionnaire. The relationship between the use of preventive services and patient characteristics were analysed using hierarchical regression models in a subsample of 1659 survey participants with a known diagnosis of hypertension or diabetes mellitus.

Results: Rates of PHC service utilization varied from 18.0% to 97.9%, and less than half (median: 44.4%; IQR: 30.8–62.5) of necessary services were used by patients. Patient attitude was as strong of an influencing factor as demographic properties but was remarkably weaker than patient socioeconomic status.

Conclusion: These findings emphasize that PHC performance indicators have to be evaluated concerning patient characteristics.

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Most cited references 22

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The strength of primary care in Europe: an international comparative study.

Dionne Sofia Kringos, Wienke Boerma, Yann Bourgueil … (2013)

A suitable definition of primary care to capture the variety of prevailing international organisation and service-delivery models is lacking. Evaluation of strength of primary care in Europe. International comparative cross-sectional study performed in 2009-2010, involving 27 EU member states, plus Iceland, Norway, Switzerland, and Turkey. Outcome measures covered three dimensions of primary care structure: primary care governance, economic conditions of primary care, and primary care workforce development; and four dimensions of primary care service-delivery process: accessibility, comprehensiveness, continuity, and coordination of primary care. The primary care dimensions were operationalised by a total of 77 indicators for which data were collected in 31 countries. Data sources included national and international literature, governmental publications, statistical databases, and experts' consultations. Countries with relatively strong primary care are Belgium, Denmark, Estonia, Finland, Lithuania, the Netherlands, Portugal, Slovenia, Spain, and the UK. Countries either have many primary care policies and regulations in place, combined with good financial coverage and resources, and adequate primary care workforce conditions, or have consistently only few of these primary care structures in place. There is no correlation between the access, continuity, coordination, and comprehensiveness of primary care of countries. Variation is shown in the strength of primary care across Europe, indicating a discrepancy in the responsibility given to primary care in national and international policy initiatives and the needed investments in primary care to solve, for example, future shortages of workforce. Countries are consistent in their primary care focus on all important structure dimensions. Countries need to improve their primary care information infrastructure to facilitate primary care performance management.

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The unintended consequences of publicly reporting quality information.

David Asch, M. Werner (2005)

Health care report cards publicly report information about physician, hospital, and health plan quality in an attempt to improve that quality. Reporting quality information publicly is presumed to motivate quality improvement through 2 main mechanisms. First, public quality information allows patients, referring physicians, and health care purchasers to preferentially select high-quality physicians. Second, public report cards may motivate physicians to compete on quality and, by providing feedback and by identifying areas for quality improvement initiatives, help physicians to do so. Despite these plausible mechanisms of quality improvement, the value of publicly reporting quality information is largely undemonstrated and public reporting may have unintended and negative consequences on health care. These unintended consequences include causing physicians to avoid sick patients in an attempt to improve their quality ranking, encouraging physicians to achieve "target rates" for health care interventions even when it may be inappropriate among some patients, and discounting patient preferences and clinical judgment. Public reporting of quality information promotes a spirit of openness that may be valuable for enhancing trust of the health professions, but its ability to improve health remains undemonstrated, and public reporting may inadvertently reduce, rather than improve, quality. Given these limitations, it may be necessary to reassess the role of public quality reporting in quality improvement.

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The unreliability of individual physician "report cards" for assessing the costs and quality of care of a chronic disease.

S Greenfield, T Hofer, Matthew Hayward … (1999)

Physician profiling is widely used by many health care systems, but little is known about the reliability of commonly used profiling systems. To determine the reliability of a set of physician performance measures for diabetes care, one of the most common conditions in medical practice, and to examine whether physicians could substantially improve their profiles by preferential patient selection. Cohort study performed from 1990 to 1993 at 3 geographically and organizationally diverse sites, including a large staff-model health maintenance organization, an urban university teaching clinic, and a group of private-practice physicians in an urban area. A total of 3642 patients with type 2 diabetes cared for by 232 different physicians. Physician profiles for their patients' hospitalization and clinic visit rates, total laboratory resource utilization rate and level of glycemic control by average hemoglobin A1c level with and without detailed case-mix adjustment. For profiles based on hospitalization rates, visit rates, laboratory utilization rates, and glycemic control, 4% or less of the overall variance was attributable to differences in physician practice and the reliability of the median physician's case-mix-adjusted profile was never better than 0.40. At this low level of physician effect, a physician would need to have more than 100 patients with diabetes in a panel for profiles to have a reliability of 0.80 or better (while more than 90% of all primary care physicians at the health maintenance organization had fewer than 60 patients with diabetes). For profiles of glycemic control, high outlier physicians could dramatically improve their physician profile simply by pruning from their panel the 1 to 3 patients with the highest hemoglobin A1c levels during the prior year. This advantage from gaming could not be prevented by even detailed case-mix adjustment. Physician "report cards" for diabetes, one of the highest-prevalence conditions in medical practice, were unable to detect reliably true practice differences within the 3 sites studied. Use of individual physician profiles may foster an environment in which physicians can most easily avoid being penalized by avoiding or deselecting patients with high prior cost, poor adherence, or response to treatments.

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Author and article information

Journal

Journal ID (nlm-ta): Eur J Gen Pract

Journal ID (iso-abbrev): Eur J Gen Pract

Journal ID (publisher-id): IGEN

Journal ID (publisher-id): igen20

Title: The European Journal of General Practice

Publisher: Taylor & Francis

ISSN (Print): 1381-4788

ISSN (Electronic): 1751-1402

Publication date Collection: 2018

Publication date (Electronic): 02 August 2018

Volume: 24

Issue: 1

Pages: 183-191

Affiliations

[a ]Department of Preventive Medicine, Faculty of Public Health, University of Debrecen , Debrecen, Hungary;

[b ]National Institute on Health Development, Department of Primary Health Care , Budapest, Hungary;

[c ]WHO Collaborating Centre on Vulnerability and Health, Department of Preventive Medicine, Faculty of Public Health, University of Debrecen , Debrecen, Hungary;

[d ]MTA-DE-Public Health Research Group, University of Debrecen , Debrecen, Hungary

Author notes

CONTACT János Sándor sandor.janos@ 123456sph.unideb.hu H-4012 Debrecen, Kassai26, Hungary

Article

Publisher ID: 1491545

DOI: 10.1080/13814788.2018.1491545

PMC ID: 6084504

PubMed ID: 30070151

SO-VID: 4e27dc39-a16a-4b8e-99fe-b67f55d068c4

License:

This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

History

Date received : 25 May 2016

Date revision received : 18 May 2018

Date accepted : 05 June 2018

Page count

Pages: 9, Words: 5467

Funding

This study was funded by the Swiss Contribution Programme (SH/8/1), and by the TÁMOP-4.2.2.AA-11/1/KONV-2012-0031 (IGEN-HUNGARIAN) project, which was co-financed by the European Union and the European Social Fund, and by the Hungarian Academy of Sciences (MTA 11003, 2006TKI227).

Influence of patient characteristics on preventive service delivery and general practitioners’ preventive performance indicators: A study in patients with hypertension or diabetes mellitus from Hungary

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Chinese Journal of General Practice

Most cited references 22

The strength of primary care in Europe: an international comparative study.

The unintended consequences of publicly reporting quality information.

The unreliability of individual physician "report cards" for assessing the costs and quality of care of a chronic disease.

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