1. The Usual Source of Care and Delivery of Preventive Services to Medicare Beneficiaries Academy Health, June 2005 Hoangmai Pham, MD, MPH Deborah Schrag, MD, MPH* J. Lee Hargraves, PhD Peter B Bach, MD, MAPP** *Memorial Sloan Kettering Cancer Center ** Centers for Medicare and Medicaid Services

2. Does quality vary with physician characteristics?  Quality of care is suboptimal – across demographics, SES, conditions, communities  Evidence suggesting the influence of: Physician sex, specialty, practice type for specific services or conditions  Definitively established associations can: Direct quality assurance, quality improvement efforts Affect patient or payer choice of physician

3. Study Objective  Assess associations between physician and practice characteristics, and the quality of preventive care their patients receive Physician characteristics Practice characteristics Preventive services

4. Methods – Data sources  2000-01 Community Tracking Study Physician Survey 12,406 respondents, 59% response rate Clinically active physicians, PCPs oversampled Nationally representative Demographics, care setting, attitudes, practice behavior Linked through performing UPINs, to  Medicare beneficiaries they treated in 2001, as captured by the 5% 2001 Carrier File

5. Methods – Populations  Physicians: Assigning the usual source of care (USOC) physician - Physician billing for the plurality of a beneficiary’s evaluation and management visits - Ties broken by comparing total amount of paid claims Limited to USOCs who were general internists or family/general pracitioners also responding to the CTS  Beneficiaries: 65 years or older as of January 1, 2001 Clinically eligible for at least one of six preventive services

6. Methods – Independent variables Physician characteristics - Medical school site, Specialty, Board certification, Number of years in practice, Sex Practice setting characteristics - Practice type, Urban vs. rural location - % revenue from Medicare, Medicaid, managed care - HIT to access treatment guidelines or to generate reminders

7. Methods – Outcome variables  Whether clinically eligible beneficiaries received each preventive services once Diabetic care – Eye exams and Hemoglobin A1c testing Cancer screening – Mammography and Colonoscopy/sigmoidoscopy Vaccinations – Influenza and Pneumococcal

8. Methods – Analysis  Unit of analysis: Individual beneficiary  Logistic regression, applied CTS survey weights  Adjusted for All other independent variables Beneficiary age, sex, race, comorbidity score (Klabunde) Median income in beneficiary’s zip code % of county adult population with 12+ yrs education % of beneficiary’s visits with USOC physician Number of clinical radiologists per capita in MSA

9. Results – Physicians and Beneficiaries PhysiciansBeneficiaries 5,914 diabetics eligible for eye exams and HbA1c 6,928 women for mammograms 17,525 eligible for colon cancer screening 24,581 eligible for vaccinations

10. Results – Receipt of services Eye ExamsHbA1cMammograms Colon cancer screening Influenza vaccination Pneumococcal vaccination Expected proportion 100% 10%, 20%100%10% Observed proportion 47.955.946.79.046.58.0 Proportion in lowest income tercile 44.950.939.88.041.57.3 Proportion in highest income tercile 53.259.550.810.350.88.7

11. Results – Physician characteristics and Proportion of beneficiaries receiving preventive services Diabetic Eye ExamHbA1cMammogram Colon cancer screening Influenza vaccination Pneumococcal vaccination General IM 50.056.950.57.846.78.5 FP/GP 44.9*54.542.4***9.9***46.47.4* Certified 48.757.148.59.547.48.3 Not certified 43.448.8*36.5**6.5*41.7*6.5** N Amer med grad 49.056.848.29.347.98.4 Other FMG 43.0**52.339.7**7.7*40.0***6.3** *p<0.05, **p<0.01, ***p<0.001

12. Results – Practice characteristics and Proportion of beneficiaries receiving services Diabetic Eye ExamHbA1cMammogram Colon cancer screening Influenza vaccination Pneumococcal vaccination Solo/2 46.9*52.3***42.5***8.4**44.6**7.0** Small group53.468.649.29.348.19.1 Med/large group46.570.160.511.452.68.6 Other practice45.144.045.68.845.88.7 Lowest Medicaid tercile 48.961.252.110.050.28.2 Middle Medicaid tercile 49.252.0**43.3***7.8***44.4**6.8*** Highest Medicaid tercile 43.0*48.4***38.9***8.539.2***6.4*** Have HIT49.557.048.35.847.08.6 No HIT45.4**54.646.05.946.07.2** *p<0.05, **p<0.01, ***p<0.001

13. Results – Physician characteristics and delivery of services, adjusted OR’s (95% CI) Diabetic Eye Exam HbA1cMammogram Colon cancer screening Influenza vaccination Pneumococcal vaccination Female 1.19 (0.93-1.51) 0.96 (0.73-1.28) 1.33 (1.05-1.68) * 0.90 (0.74-1.09 0.82 (0.72-0.93) ** 0.98 (0.83-1.17) FP/GP 0.81 (0.67-0.97) * 1.11 (0.90-1.37) 0.83 (0.72-0.97) * 0.86 (0.75-0.99) ** 1.08 (0.95-1.21) 0.95 (0.82-1.10) Board certified 1.12 (0.90-1.40) 1.22 (0.89-1.68) 1.34 (1.04-1.71) * 1.27 (1.04-1.57) * 1.08 (0.92-1.26) 1.06 (0.86-1.32) Other FMG 0.82 (0.68-0.99) * 0.91 (0.70-1.18) 0.78 (0.63-0.98) * 0.92 (0.76-1.12) 0.82 (0.71-0.94) ** 0.74 (0.59-0.93) *

14. Results – Practice characteristics and delivery of services, adjusted OR’s (95% CI) Diabetic Eye Exam HbA1cMammogram Colon cancer screening Influenza vaccination Pneumococcal vaccination Small group 1.12 (0.84-1.49) 1.90 (1.45-2.48) ** 1.13 (0.89-1.44) 0.97 (0.78-1.22) 1.01 (0.89-1.15) 1.19 (0.99-1.44) Med/large group 0.81 (0.59-1.10) 1.91 (1.40-2.60) ** 1.40 (1.10-1.77) ** 1.12 (0.90-1.38) 1.22 (0.98-1.50) 1.16 (0.95-1.42) Other practice 0.84 (0.73-0.96) * 0.68 (0.51-0.90) * 1.03 (0.86-1.23) 0.91 (0.75-1.10) 1.03 (0.90-1.18) 1.21 (1.02-1.45) * Middle Medicaid tercile 1.12 (0.97-1.29) 0.74 (0.60-0.92) ** 0.81 (0.71-0.92) ** 0.87 (0.75-1.00) ** 0.85 (0.75-0.95) ** 0.76 (0.65-0.89) *** Highest Medicaid tercile 1.04 (0.83-1.29) 0.73 (0.57-0.95) ** 0.76 (0.62-0.94) ** 1.09 (0.91-1.31) 0.77 (0.68-0.87) *** 0.73 (0.60-0.89) ** Have HIT 1.21 (1.08-1.35) *** 1.13 (0.97-1.33) 1.07 (0.96-1.20) 0.96 (0.84-1.09) 1.02 (0.93-1.13) 1.21 (1.06-1.38) **

15. Summary  Quality of preventive care is suboptimal across the board  Physician and practice characteristics associated with delivery of preventive services Strongest associations were with practice level factors – revenue from Medicaid and practice type, less so availability of HIT Medical school site, specialty, and board certification

16. Conclusions and Implications  Physician and practice factors account for a meaningful degree of the variation in quality of preventive care  Practice level factors appear particularly influential and should be considered, in addition to individual physician factors, in designing quality improvement interventions

18. Results – Physician characteristics and Proportion of beneficiaries receiving preventive services Diabetic Eye ExamHbA1cMammogram Colon cancer screening Influenza vaccination Pneumococcal vaccination Male47.756.646.19.147.67.9 Female49.051.950.0*8.743.0***8.0 General IM50.056.950.57.846.78.5 FP/GP44.9*54.542.4***9.9***46.47.4* Certified48.757.148.59.547.48.3 Not certified 43.448.8*36.5**6.5*41.7*6.5** N Amer med grad 49.056.848.29.347.98.4 Other FMG43.0**52.339.7**7.7*40.0***6.3** *p<0.05, **p<0.01, ***p<0.001