Primary care physicians with high outpatient volume linked to lower-quality diabetes care

1. Primary care physicians with higher overall patient volume were associated with lower quality care for diabetes.

2. In contrast, primary care physicians with higher diabetes-specific volume were linked to higher quality diabetes care for all six indicators analyzed.

Evidence Rating Level: 2 (Good)

Study Rundown: The quality of patient care can be affected by a physician’s patient volume. Although volume-quality studies have been completed for many conditions of acute care, it is uncertain if such a relationship is present for chronic diseases managed in the primary care outpatient setting. Using information from health care administrative databases in Ontario, Canada, this cohort study of 1 018 647 patients with diabetes found that higher patient volume was linked to decreased rates of medicine prescription and suitable disease monitoring. However, higher diabetes-specific volume was linked to better care quality for all six indicators measured. Health policies supporting physicians with low diabetes-specific volume may aid in improving care.

Strengths of the study include a population-based design, a broad patient and physician sample, use of routinely collected health care data to strongly limit missing data or loss to follow-up, and patient-level analysis of quality indicators. One of the limitations of the study was the inability to determine drug indicators in patients younger than age 65 or to adjust analyses for factors such as body mass index because the databases used did not contain this information. In addition, using administrative databases prevented the determination of certain other quality indicators.

Click to read the study in Annals of Internal Medicine

Relevant Reading: Quality of care and volume for patients with diabetes mellitus in the primary care setting: A population based retrospective cohort study

In-Depth [retrospective cohort]: This population-based cohort study analyzed 1 018 647 patients between 20 and 104 years of age who were diagnosed with diabetes as of March 31^st 2011. These patients received care from 9014 primary care physicians. Data from health care administrative databases in Ontario, Canada was used. These databases document nearly all care received by provincial residents. Diabetes care quality was measured over the course of two years using six indicators, including appropriate disease monitoring and testing, appropriate medication prescriptions, and adverse clinical outcomes. Overall ambulatory volume and diabetes-specific volume were calculated. In comparison to patients of physicians with the smallest overall volume, patients of physicians with higher volume had lower marginal rates of hemoglobin A_1c testing, LDL cholesterol testing, and appropriate eye examination. In addition, prescription rates for ACEIs, ARBs, or statins were lower. However, patients of physicians who had higher diabetes-specific volume had higher rates for these four measurements. In addition, emergency department visits for hypoglycemia or hyperglycemia were lower. The authors suggest that doctors with high patient volume may be too rushed during patient appointments to deliver proper chronic disease management. The authors also propose that physicians with high diabetes-specific volume may acquire specialized knowledge for diabetes, which could enhance care quality.

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