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Profiling Care Provided by Different Groups of Physicians: Effects of Patient Case-Mix (Bias) and Physician-Level Clustering on Quality Assessment Results

Sheldon Greenfield, MD; Sherrie H. Kaplan, PhD, MPH; Richard Kahn, PhD; John Ninomiya, MS; and John L. Griffith, PhD
[+] Article and Author Information

From New England Medical Center and Tufts University School of Medicine, Boston, Massachusetts; American Diabetes Association National Office, Alexandria, Virginia; and University of California, San Diego, California.


Disclaimer: The views expressed in this manuscript are those of the authors and do not necessarily reflect those of the American Diabetes Association.

Grant Support: By the American Diabetes Association, Alexandria, Virginia.

Acknowledgments: The authors thank the American Diabetes Association Provider Recognition Steering Committee for guidance and leadership in facilitating this study; the Health Outcomes Institute, particularly David Radosevich, PhD, and Michael Huber, for invaluable assistance and support; Grace A. Connolly, JD, for editorial input; and Elaine Ackerson for help with preparation of the manuscript.

Requests for Single Reprints: Sheldon Greenfield, MD, Primary Care Outcomes Research Institute, Tufts University School of Medicine, M&V 1, 136 Harrison Avenue, Boston, MA 02111; e-mail, sheldon.greenfield@tufts.edu.

Current Author Addresses: Drs. Greenfield and Kaplan: Primary Care Outcomes Research Institute, Tufts University School of Medicine, M&V 1, 136 Harrison Avenue, Boston, MA 02111.

Dr. Kahn: American Diabetes Association, 1701 North Beauregard Street, Alexandria, VA 22311.

Mr. Ninomiya: 351 Longden Lane, Solana Beach, CA 92075.

Dr. Griffith: Biostatistics Research Center, New England Medical Center, 750 Washington Street, NEMC 063, Boston, MA 02111.

Author Contributions: Conception and design: S. Greenfield, S.H. Kaplan, R. Kahn, J.L. Griffith.

Analysis and interpretation of the data: S. Greenfield, S.H. Kaplan, R. Kahn, J. Ninomiya, J.L. Griffith.

Drafting of the article: S. Greenfield, S.H. Kaplan, R. Kahn.

Critical revision of the article for important intellectual content: S. Greenfield, S.H. Kaplan, R. Kahn, J.L. Griffith.

Final approval of the article: S. Greenfield, S.H. Kaplan, R. Kahn.

Provision of study materials or patients: R. Kahn.

Statistical expertise: S.H. Kaplan, J. Ninomiya, J.L. Griffith.

Obtaining of funding: S. Greenfield, R. Kahn.

Administrative, technical, or logistic support: R. Kahn, J. Ninomiya.

Collection and assembly of data: R. Kahn, J. Ninomiya.


Ann Intern Med. 2002;136(2):111-121. doi:10.7326/0003-4819-136-2-200201150-00008
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Identification of physician characteristics associated with optimal management of chronic disease could serve as the basis for designing quality improvement initiatives. However, assessment of the quality of care provided by physicians with different characteristics (for example, generalists vs. specialists, male vs. female, or those in health maintenance organizations vs. those with fee-for-service arrangements) presents a unique set of methodologic problems that stem from the nature of outpatient medicine. First, if older or sicker patients with multiple diseases have different needs for health care services and different health outcomes independent of the quality of care they receive, physicians who see such patients may appear to provide lower quality of care than do those who see younger patients with less comorbid disease. Accounting for these patient characteristics (that is, avoiding case-mix bias) is therefore an essential feature of fair and accurate comparisons of physicians' quality of care.

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Proportion of patients with unadjusted hemoglobin A1c values less than 0.10 (10%) for each practice site within specialty.
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Summary for Patients

Comparing the Quality of Diabetes Care by Generalists and Specialists

The summary below is from the full report titled “Profiling Care Provided by Different Groups of Physicians: Effects of Patient Case-Mix (Bias) and Physician-Level Clustering on Quality Assessment Results.” It is in the 1 January 2002 issue of Annals of Internal Medicine (volume 136, pages 111-121). The authors are S Greenfield, SH Kaplan, R Kahn, J Ninomiya, and JL Griffith.

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