Primary care physician volume associated with quality of diabetes care
medwireNews: There is a “consistent, graded, and independent” relationship between the number of patients seen by a primary care physician (PCP) and the quality of diabetes care, Canadian researchers report.
In a study of 1,018,647 patients with diabetes under the care of 9014 primary care physicians, Baiju Shah (Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada) and fellow researchers found that PCPs seeing a higher overall number of patients provided poorer quality of care, whereas those with a higher proportion of patients with diabetes delivered better care.
After adjustment for patient- and physician-level confounders, the authors examined several indicators to assess the quality of diabetes care, including disease monitoring, prescriptions of appropriate medications, and emergency department visits. Each patient volume measure was split into five groups.
PCPs who saw the highest volume of patients overall (>40 per day) recorded that 67.1% of patients received an eye examination within 2 years of the index date, compared with 72.0% of patients under the care of physicians who saw the lowest overall number of patients (<20 per day).
To be successful at managing chronic disease we will need to move from a system driven by quantity of care to quality of care.
“If all primary care physicians had achieved the same rate of eye examinations as those with the lowest overall ambulatory volume, more than 25 000 additional patients would have had an examination,” explain the researchers.
Similarly, patients under the care of physicians with higher overall volumes had lower rates of glycated hemoglobin and low-density lipoprotein (LDL) cholesterol testing, and were less likely to receive prescriptions for ACE inhibitors or angiotensin-receptor blockers and statins, compared with patients of physicians with the lowest patient volumes. There was no significant relationship between overall physician volume and diabetes-related emergency department visits.
By contrast, PCPs with higher diabetes-specific volumes scored better on care quality indicators. A total of 69.8% of patients who were under the care of a physician with 301 or more patients with diabetes received an eye examination within 2 years, compared with 67.0% of patients under the care of PCPs with 100 or fewer patients with diabetes.
Patients of physicians with higher diabetes-specific volume also had higher rates of glycated hemoglobin and LDL cholesterol testing, higher prescription rates for appropriate medications, and were less likely to visit the emergency department for hypoglycemia or hyperglycemia.
These findings suggest that “relationships between physician volume and quality can be extended from acute care to outpatient chronic disease care,” says the team in the Annals of Internal Medicine.
However, the author of an accompanying editorial, Kevin Peterson (University of Minnesota, Minneapolis, USA), cautions that the findings may not be applicable to diabetes care in the USA, noting that although almost 13% of PCPs in the Canadian study saw more than 40 patients per day, “U.S. PCPs are estimated to be able to provide high-quality care to only about 24 patients per day,” highlighting “important differences between U.S. and Canadian care models.”
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