California provider group report cards: what do they tell us?

The objective of this study was to perform a practical assessment of publicly reported data from 4 reports on California provider groups through the eyes of the consumer. The study compared performance indicator content and rating methodologies, examined the degree of correlation in provider group performance on indicators common to 2 or more reports, and assessed the level of concordance among summary ratings of performance. Comparative analyses revealed significant variation in performance indicator content, data sources, and rating methodologies. Spearman correlation analysis revealed highly correlated group performance on patient satisfaction and member-requested group transfers, poorly correlated performance on breast and cervical cancer screening, and moderately correlated performance on state and regional average scores. Summary ratings applied to these data were only moderately correlated. These findings suggest that competing California provider group report cards produce inconsistent messages about provider quality and may create barriers to use, comprehension, and reliance upon quality information among consumers and other potential users.

Organizational systems used by California capitated medical groups and independent practice associations to increase cancer screening.

BACKGROUND: Patients in health maintenance organizations (HMOs) appear to have higher utilization of cancer screening tests than patients with fee-for-service insurance. METHODS: The authors surveyed the medical directors of 174 physician organizations in a California network model HMO to obtain information regarding their organizational structure, implementation of guidelines, and use of systems to increase cancer screening. RESULTS: The majority of independent practice associations (IPAs) and medical groups (IMGs) in this California HMO had guidelines and office systems aimed at improving cancer screening. These activities were reported more frequently for mammography and Papanicolaou (Pap) smears than for colorectal carcinoma screening. IMGs reported using flow sheets more often than IPAs. Chart audits were performed more frequently for mammography (48% for IMGs and 40% for IPAs) and Pap smears (45% and 40%, respectively) than for colorectal carcinoma screening (38% and 30%, respectively). Approximately 50% of IPAs and IMGs reported mailing reminders to patients for mammography and Pap smears, but only a few did so for colorectal carcinoma screening. Annual fecal occult blood testing was believed by most medical directors to be a reasonable strategy for managed care patients (86% of IPAs and 96% of IMGs); however, fewer believed that screening sigmoidoscopy for patients ages 50-70 years was a reasonable expectation (71% and 78%, respectively). CONCLUSIONS: The majority of IPAs and IMGs in this California HMO reported using both guidelines and office systems to improve cancer screening rates. Further research is needed to understand the effect of these systems, as well their complex interactions with competing incentives, on cancer screening in managed care patients.

Provider group characteristics & quality report card performance: a cross-sectional study in a managed care setting.

We describe 1 health plan's annual, incentive-based, provider group quality report card (Scorecard) and identify trends in Scorecard performance among 142 California provider groups. We explore variation in Scorecard performance by provider group characteristics. Scorecard evaluates provider groups on standardized measures of performance including preventive screening, patient satisfaction, and quality management operations and infrastructure. In a cross-sectional study, we use linear regression to measure associations between provider group characteristics and performance on the 1997 Scorecard. Provider group performance trends (1996-1997) revealed improvement on 6 Scorecard indicators. Regional differences in performance were also shown. Multivariate results indicate that group location in northern California (P = .01), IPA (independent practice association) status (P = .02), older group age (P = .02), and higher mean patient age (P < .01) were independently associated with higher 1997 Scorecard total scores. Member education was marginally associated with performance. Group size, member income, and gender distributions were not independently associated with Scorecard performance. Results of this study suggest that (among Blue Cross of California's contracted provider groups) older, more established groups; groups located in northern California; IPAs; and groups with a patient demographic mix characterized by higher than network average mean age and a lower than network average proportion of members with a college education or greater were more likely to perform well on Scorecard.

Risk and protective factors associated with screening for complications of diabetes in a health maintenance organization setting.

OBJECTIVE: To identify risk and protective factors associated with screening for complications of diabetes, we performed a cross-sectional study of 3,612 diabetic members enrolled in CaliforniaCare, a large network-model health maintenance organization (HMO). RESEARCH DESIGN AND METHODS: We used the Health Plan and Employer Data Information Set (HEDIS) 3.0 technical definition to identify all members (aged > or = 31 years) receiving any diabetes medication(s) during a 12-month period. Using a telephone survey instrument, identified members were interviewed about their diabetes care and screening, patient, and provider history. Survey data were supplemented with HMO claims and demographic information. Multivariate analysis was performed to identify demographic, clinical, and utilization characteristics that affect the odds of diabetic members receiving annual retinal examination, foot examination, and HbA1c testing. RESULTS: While results varied by screening category, the odds of obtaining screening were higher for diabetic members who were older, spoke English, received diabetes nutrition counseling, visited a diabetes specialist physician, belonged to a diabetes association or support group, used insulin, performed glycemic level self-examination at least once a day, and had higher overall prescription drug use (suggesting higher comorbidity). Since this study is a cross-sectional review, these results do not imply a cause-and-effect relationship between dependent and independent variables. CONCLUSIONS: Results of this study suggest barriers, risks, and protective factors associated with screening for complications of diabetes. Diabetic members who do not possess these characteristics may be at increased risk.

Change in paternity: a risk factor for preeclampsia in multiparas.

Preeclampsia, a hypertensive disorder of pregnancy, is hypothesized to be a maternal immunologic response to foreign fetal antigen derived from the father's sperm. This response may be reduced by prolonged exposure to father's antigen, such as through a prior pregnancy, which may explain why multiparas are typically at lower risk for preeclampsia than nulliparas. Since multiparas with new partners are presented with a new set of paternal antigen, we hypothesize that they would have the same elevated risk for preeclampsia and gestational hypertension as nulliparas, compared with multiparas with no change in partner. We studied 5,068 nulliparas and 5,800 multiparas, 573 of whom had new partners, selected from the Child Health and Development Studies cohort (Oakland, CA, 1959-1967). Preeclampsia was diagnosed in 3.2% of nulliparas, 3.0% of multiparas with changed paternity, and 1.9% of multiparas with no change. Compared with multiparas with no change, the adjusted odds ratio for preeclampsia among nulliparas was 2.5 [95% confidence interval (CI) = 1.8-3.5]; among multiparas with new partners, the adjusted odds ratio for preeclampsia was 1.4 (95% CI = 0.8-2.4). There was a similar pattern of results for gestational hypertension. The adjusted attributable risk of preeclampsia in multiparas associated with a change in paternity was 29%. Although these findings in part support the immunologic theory of preeclampsia, they also suggest that a subsequent pregnancy with any partner is associated with a reduced risk for preeclampsia.