Patient Complexity and Diabetes Quality of Care in Rural Settings

• Published in: Journal of the National Medical Association Vol. 103; no. 3; pp. 234 - 240
• Main Authors: Salanitro, Amanda H., MD, MSPH, Safford, Monika M., MD, Houston, Thomas K., MD, MPH, Williams, Jessica H., MPH, Ovalle, Fernando, MD, Payne-Foster, Pamela, MD, Allison, Jeroan J., MD, MSc, Estrada, Carlos A., MD, MS
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01-03-2011; Elsevier Limited
• Subjects: Age Factors; Aged; Alabama; Data Interpretation, Statistical; diabetes; Diabetes Mellitus - therapy; Female; Glycated Hemoglobin A - analysis; Humans; Hypoglycemic Agents - therapeutic use; Insulin - therapeutic use; Internal Medicine; Male; Middle Aged; Practice Patterns, Physicians' - statistics & numerical data; primary care; Primary Health Care - standards; quality of care; Quality of Health Care; Randomized Controlled Trials as Topic; Risk Factors; Rural Health Services - standards; Rural Population; United States; primary care; diabetes; quality of care
• ISSN: 0027-9684; 1943-4693
• DOI: 10.1016/S0027-9684(15)30297-2

Purpose Even though pay-for-performance programs are being rapidly implemented, little is known about how patient complexity affects practice-level performance assessment in rural settings. We sought to determine the association between patient complexity and practice-level performance in the rural United States. Basic procedures: Using baseline data from a trial aimed at improving diabetes care, we determined factors associated with a practice's proportion of patients having controlled diabetes (hemoglobin A1c < 7%): patient socioeconomic factors, clinical factors, difficulty with self-testing of blood glucose, and difficulty with keeping appointments. We used linear regression to adjust the practice-level proportion with A1c controlled for these factors. We compared practice rankings using observed and expected performance and classified practices into hypothetical pay-for-performance categories. Main Findings: Rural primary care practices (n = 135) in 11 southeastern states provided information for 1641 patients with diabetes. For practices in the best quartile of observed control, 76.1% of patients had controlled diabetes vs 19.3% of patients in the worst quartile. After controlling for other variables, proportions of diabetes control were 10% lower in those practices whose patients had the greatest difficulty with either self testing or appointment keeping (p <.05 for both). Practice rankings based on observed and expected proportion of A1c control showed only moderate agreement in pay-for-performance categories (K = 0.47; 95% confidence interval, 0.32-0.56; p <.001). Principal Conclusions: Basing public reporting and resource allocation on quality assessment that does not account for patient characteristics may further harm this vulnerable group of patients and physicians.