Search

Background: Although previous research has demonstrated high rates of inappropriate diagnostic imaging, the potential influence of several physician-level characteristics is not well established., Objective: To examine the influence of three types of physician characteristics on inappropriate imaging: experience, specialty training, and self-referral., Design: A retrospective analysis of over 70,000 MRI claims submitted for commercially insured individuals. Physician characteristics were identified through a combination of administrative records and primary data collection. Multi-level modeling was used to assess relationships between physician characteristics and inappropriate MRIs., Setting: Massachusetts PARTICIPANTS: Commercially insured individuals who received an MRI between 2010 and 2013 for one of three conditions: low back pain, knee pain, and shoulder pain., Measurements: Guidelines from the American College of Radiology were used to classify MRI referrals as appropriate/inappropriate. Experience was measured from the date of medical school graduation. Specialty training comprised three principal groups: general internal medicine, family medicine, and orthopedics. Two forms of self-referral were examined: (a) the same physician who ordered the procedure also performed it, and (b) the physicians who ordered and performed the procedure were members of the same group practice and the procedure was performed outside the hospital setting., Results: Approximately 23% of claims were classified as inappropriate. Physicians with 10 or less years of experience had significantly higher odds of ordering inappropriate MRIs. Primary care physicians were almost twice as likely to order an inappropriate MRI as orthopedists. Self-referral was not associated with higher rates of inappropriate MRIs., Limitations: Classification of MRIs was conducted with claims data. Not all self-referred MRIs could be detected., Conclusions: Inappropriate imaging continues to be a driver of wasteful health care spending. Both physician experience and specialty training were highly associated with inappropriate imaging.

Background: Although pay-for-performance (P4P) has become a central strategy for improving quality in US healthcare, questions persist about the effectiveness of these programs. A key question is whether quality improvement that occurs as a result of P4P programs is sustainable, particularly if incentives are removed., Objective: To investigate sustainability of performance levels following removal of performance-based incentives., Design, Setting, and Participants: Observational cohort study that capitalized on a P4P program within the Veterans Health Administration (VA) that included adoption and subsequent removal of performance-based incentives for selected inpatient quality measures. The study sample comprised 128 acute care VA hospitals where performance was assessed between 2004 and 2010., Intervention: VA system managers set annual performance goals in consultation with clinical leaders, and report performance scores to medical centers on a quarterly basis. These scores inform performance-based incentives for facilities and their managers. Bonuses are distributed based on the attainment of these performance goals., Measurements: Seven quality of care measures for acute coronary syndrome, heart failure, and pneumonia linked to performance-based incentives., Results: Significant improvements in performance were observed for six of seven quality of care measures following adoption of performance-based incentives and were maintained up to the removal of the incentive; subsequently, the observed performance levels were sustained., Limitations: This is a quasi-experimental study without a comparison group; causal conclusions are limited., Conclusion: The maintenance of performance levels after removal of a performance-based incentive has implications for the implementation of Medicare's value-based purchasing initiative and other P4P programs. Additional research is needed to better understand human and system-level factors that mediate sustainability of performance-based incentives.

Background: Studies examining the effectiveness of pay-for-performance programs to improve quality of care primarily have been confined to bonus-type arrangements that reward providers for performance above a predetermined threshold. No studies to date have evaluated programs placing providers at financial risk for performance relative to other participants in the program., Objective: The objective of the study is to evaluate the impact of an incentive program conferring limited financial risk to primary care physicians., Participants: There were 334 participating primary care physicians in Rochester, New York., Design: The design of the study is a retrospective cohort study using pre/post analysis., Measurements: The measurements adhere to 4 diabetes performance measures between 1999 and 2004., Results: While absolute performance levels increased across all measures immediately following implementation, there was no difference between the post- and pre-intervention trends indicating that the overall increase in performance was largely a result of secular trends. However, there was evidence of a modest 1-time improvement in physician adherence for eye examination that appeared attributable to the incentive program. For this measure, physicians improved their adherence rate on average by 7 percentage points in the year after implementation of the program., Conclusions: This study demonstrates a modest effect in improving provider adherence to quality standards for a single measure of diabetes care during the early phase of a pay-for-performance program that placed physicians under limited financial risk. Further research is needed to determine the most effective incentive structures for achieving substantial gains in quality of care.

Objective: Little is known about how care is coordinated for patients with diseases requiring multidisciplinary treatments. How complex care is coordinated may affect a patient's chance of receiving the full complement of care provided by multiple physicians. We sought to describe approaches used to coordinate care for women with early-stage breast cancer, a disease often treated by multiple different disciplines in the outpatient setting., Design: Case studies of 6 hospitals with in-depth semi-structured interviews with providers of breast cancer care and their support staff., Setting: Five hospitals in downstate New York and 1 hospital in upstate New York., Participants: Sixty-seven interviews were conducted including 35 physicians, 9 nurses, 4 senior clinical or quality directors, 10 administrative assistants, and 9 patient educators and navigators., Measurements and Main Results: Content analysis of interviews revealed 7 different coordination mechanisms including tracking of referrals, patient support, regularly-scheduled multidisciplinary meetings, feedback of performance data, use of protocols, computerized systems, and a single physical location. No site had any systematic mechanism to track results of referrals or receipt of care provided by other physicians. All physicians used follow-up appointments to check on patients' receipt of care, but only half of the physicians had an approach to follow up missed appointments. Real-time multidisciplinary meetings with a patient management focus and systematic use of patient support programs, such as patient educators and navigators, were perceived to be valuable., Conclusions: Numerous coordination mechanisms exist. No site has the ability to systematically track care provided by multiple different specialists. The most valued mechanisms are under the hospital's aegis. Hospitals should consider implementing coordination mechanisms to improve delivery of multidisciplinary care.