Associations Between Structural Capabilities of Primary Care Practices and Performance on Selected Quality Measures

  1. Mark W. Friedberg, MD, MPP;
  2. Kathryn L. Coltin, MPH;
  3. Dana Gelb Safran, ScD;
  4. Marguerite Dresser, MS;
  5. Alan M. Zaslavsky, PhD; and
  6. Eric C. Schneider, MD, MSc
  1. From Brigham and Women's Hospital, Harvard Medical School, and Blue Cross/Blue Shield of Massachusetts, Boston; Harvard Pilgrim Health Care, Wellesley; and Massachusetts Health Quality Partners, Watertown, Massachusetts.

    Abstract

    Background: Recent proposals to reform primary care have encouraged physician practices to adopt such structural capabilities as performance feedback and electronic health records. Whether practices with these capabilities have higher performance on measures of primary care quality is unknown.

    Objective: To measure associations between structural capabilities of primary care practices and performance on commonly used quality measures.

    Design: Cross-sectional analysis.

    Setting: Massachusetts.

    Participants: 412 primary care practices.

    Measurements: During 2007, 1 physician from each participating primary care practice (median size, 4 physicians) was surveyed about structural capabilities of the practice (responses representing 308 practices were obtained). Data on practice structural capabilities were linked to multipayer performance data on 13 Healthcare Effectiveness Data and Information Set (HEDIS) process measures in 4 clinical areas: screening, diabetes, depression, and overuse.

    Results: Frequently used multifunctional electronic health records were associated with higher performance on 5 HEDIS measures (3 in screening and 2 in diabetes), with statistically significant differences in performance ranging from 3.1 to 7.6 percentage points. Frequent meetings to discuss quality were associated with higher performance on 3 measures of diabetes care (differences ranging from 2.3 to 3.1 percentage points). Physician awareness of patient experience ratings was associated with higher performance on screening for breast cancer and cervical cancer (1.9 and 2.2 percentage points, respectively). No other structural capabilities were associated with performance on more than 1 measure. No capabilities were associated with performance on depression care or overuse.

    Limitation: Structural capabilities of primary care practices were assessed by physician survey.

    Conclusion: Among the investigated structural capabilities of primary care practices, electronic health records were associated with higher performance across multiple HEDIS measures. Overall, the modest magnitude and limited number of associations between structural capabilities and clinical performance suggest the importance of continuing to measure the processes and outcomes of care for patients.

    Primary Funding Source: The Commonwealth Fund.

    Article and Author Information

    • Acknowledgment: The authors thank Katherine Howitt, MA, for invaluable assistance in fielding the survey; Elaine Kirshenbaum of the Massachusetts Medical Society, for advice regarding development of the physician survey; and Arnold Epstein, MD, MA, for helpful comments on an earlier draft of this paper.

    • Grant Support: By The Commonwealth Fund. Dr. Friedberg was supported by a National Research Service Award from the Health Resources and Services Administration (5 T32 HP11001 20).

    • Potential Conflicts of Interest: None disclosed.

    • Reproducible Research Statement: Study protocol: Physician practice survey instrument available from Dr. Friedberg (e-mail, mfriedbe{at}rand.org). Statistical code: Available from Dr. Friedberg (e-mail, mfriedbe{at}rand.org). Data set: Not available.

    • Requests for Single Reprints: Eric C. Schneider, MD, MSc, RAND Boston, 20 Park Plaza, 7th Floor, Suite 720, Boston, MA 02116; e-mail, eschneid{at}rand.org.

    • Current Author Addresses: Dr. Friedberg: RAND, 1776 Main Street, PO Box 2138, Santa Monica, CA 90407-2138.

    • Ms. Coltin: Harvard Pilgrim Health Care, 93 Worcester Street, Wellesley, MA 02481.

    • Dr. Safran: Blue Cross Blue Shield of Massachusetts, 401 Park Drive, Boston, MA 02215.

    • Ms. Dresser: Massachusetts Health Quality Partners, 100 Talcott Avenue, Watertown, MA 02472.

    • Dr. Zaslavsky: Harvard Medical School, Department of Health Care Policy, 180 Longwood Avenue, Boston, MA 02115.

    • Dr. Schneider: RAND Boston, 20 Park Plaza, 7th Floor, Suite 720, Boston, MA 02116.

    • Author Contributions: Conception and design: M.W. Friedberg, K.L. Coltin, D.G. Safran, E.C. Schneider.

    • Analysis and interpretation of the data: M.W. Friedberg, K.L. Coltin, D.G. Safran, M. Dresser, A.M. Zaslavsky, E.C. Schneider.

    • Drafting of the article: M.W. Friedberg, D.G. Safran, M. Dresser, A.M. Zaslavsky, E.C. Schneider.

    • Critical revision of the article for important intellectual content: K.L. Coltin, D.G. Safran, A.M. Zaslavsky, E.C. Schneider.

    • Final approval of the article: D.G. Safran, A.M. Zaslavsky, E.C. Schneider.

    • Statistical expertise: A.M. Zaslavsky.

    • Obtaining of funding: E.C. Schneider.

    • Administrative, technical, or logistic support: K.L. Coltin, E.C. Schneider.

    • Collection and assembly of data: M.W. Friedberg, M. Dresser, E.C. Schneider.

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    1. Ann Intern Med October 6, 2009 vol. 151 no. 7 456-463
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