Rapidity and modality of imaging for acute low back pain in elderly patients.

BACKGROUND: Most quality metrics focus on underuse of services, leaving unclear what factors are associated with potential overuse. METHODS: We analyzed Medicare claims from 2000-2002 and 2004-2006 for 35 039 fee-for-service Medicare beneficiaries with acute low back pain (LBP) who were treated by 1 of 4567 primary care physicians responding to the 2000-2001 or 2004-2005 Community Tracking Study Physician Surveys. We modified a measure of inappropriate imaging developed by the National Committee on Quality Assurance. We characterized the rapidity (<28 days, 29-180 days, none within 180 days) and modality of imaging (computed tomography or magnetic resonance imaging [CT/MRI], only radiograph, or no imaging). We used ordered logit models to assess relationships between imaging and patient demographics and physician/practice characteristics including exposure to financial incentives based on patient satisfaction, clinical quality, cost profiling, or productivity. RESULTS: Of 35 039 beneficiaries with LBP, 28.8% underwent imaging within 28 days and an additional 4.6% between 28 and 180 days. Among patients who received imaging, 88.2% received radiography, while 11.8% received CT/MRI as their initial study. White patients received higher levels of imaging than black patients or those of other races. Medicaid patients received less rapid or advanced imaging than other patients. Patients had higher levels of imaging if their primary care physician worked in large practices. Compared with no incentives, clinical quality-based incentives were associated with less advanced imaging (10.5% vs 1.4% for within 28 days; P < .001), whereas incentive combinations including satisfaction measures were associated with more rapid and advanced imaging. Results persisted in multivariate analyses and when the outcome was redefined as the number of imaging studies performed. CONCLUSIONS: Rapidity and modality of imaging for LBP is associated with patient and physician characteristics but the directionality of associations with desirable care processes is opposite of associations for measures targeting underuse. Metrics that encompass overuse may suggest new areas of focus for quality improvement.

Potentially avoidable hospitalizations for COPD and pneumonia: the role of physician and practice characteristics.

BACKGROUND: Hospitalizations for bacterial pneumonia and chronic obstructive pulmonary disease (COPD) occur frequently, but many are potentially avoidable. OBJECTIVE: To examine associations between elderly patients' usual physician and practice characteristics, and the risk of hospitalization for bacterial pneumonia and COPD. RESEARCH DESIGN: Time-to-event analysis of Medicare claims from 2000 (baseline year) through 2001-2002 (follow-up years) for beneficiaries whose usual physician participated in the 2000-2001 Community Tracking Study Physician Survey. SUBJECTS: A total of 509,613 patients and 5764 physicians for pneumonia hospitalizations; subset of 91,318 beneficiaries with an antecedent diagnosis of COPD and 5074 physicians for COPD hospitalizations. MEASURES: Hospitalizations for bacterial pneumonia or COPD occurring in 2001-2002. RESULTS: Beneficiaries whose usual physician had been in practice for >10 years (vs. 5% Medicaid revenue (vs. 0-5%, P < 0.0001), or reported more (vs. less) difficulty securing ancillary services (P < 0.01 for bacterial pneumonia and P = 0.05 for COPD). Patient socioeconomic status, previous respiratory hospitalizations, and comorbidities had the strongest associations with hospitalization. CONCLUSIONS: Given that physicians who report limited access to ancillary services and high Medicaid case volume have patients who experience higher rates of admission for COPD and pneumonia, additional resources and quality improvement interventions targeting these providers should be priorities.

Care patterns in Medicare and their implications for pay for performance.

BACKGROUND: Two assumptions underpin the implementation of pay for performance in Medicare: that with the use of claims data, patients can be assigned to a physician or to a practice that will have primary responsibility for their care, and that a meaningful fraction of the care physicians deliver is for patients for whom they have primary responsibility. METHODS: We analyzed Medicare claims from 2000 through 2002 for 1.79 million fee-for-service beneficiaries treated by 8604 respondents to the Community Tracking Study Physician Survey in 2000 and 2001. In separate analyses, we assigned each patient to the physician or primary care physician with whom the patient had had the most visits. We determined the number of physicians and practices seen annually, the percentage of care received from the assigned physician or practice, the stability of assignments over time, and the percentage of physicians' Medicare patients who were their assigned patients. RESULTS: Beneficiaries saw a median of two primary care physicians and five specialists working in four different practices. A median of 35% of beneficiaries' visits each year were with their assigned physicians; for 33% of beneficiaries, the assigned physician changed from one year to another. On the basis of all visits to any physician, a primary care physician's assigned patients accounted for a median of 39% of the physician's Medicare patients and 62% of Medicare visits. For medical specialists, the respective percentages were 6% and 10%. On the basis of visits to primary care physicians only, 79% of beneficiaries could be assigned to a physician, and a median of 31% of beneficiaries' visits were with that assigned primary care physician. CONCLUSIONS: In fee-for-service Medicare, the dispersion of patients' care among multiple physicians will limit the effectiveness of pay-for-performance initiatives that rely on a single retrospective method of assigning responsibility for patient care.