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Patient complexity and diabetes quality of care in rural settings.

Salanitro AH, Safford MM, Houston TK, Williams JH, Ovalle F, Payne-Foster P, Allison JJ, Estrada CA. Patient complexity and diabetes quality of care in rural settings. Journal of the National Medical Association. 2011 Mar 1; 103(3):234-40.

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PURPOSE: Even though pay-for-performance programs are being rapidly implemented, little is known about how patient complexity affects practice-level performance assessment in rural settings. We sought to determine the association between patient complexity and practice-level performance in the rural United States. BASIC PROCEDURES: Using baseline data from a trial aimed at improving diabetes care, we determined factors associated with a practice's proportion of patients having controlled diabetes (hemoglobin A1c < or = 7%): patient socioeconomic factors, clinical factors, difficulty with self-testing of blood glucose, and difficulty with keeping appointments. We used linear regression to adjust the practice-level proportion with A1c controlled for these factors. We compared practice rankings using observed and expected performance and classified practices into hypothetical pay-for-performance categories. MAIN FINDINGS: Rural primary care practices (n = 135) in 11 southeastern states provided information for 1641 patients with diabetes. For practices in the best quartile of observed control, 76.1% of patients had controlled diabetes vs 19.3% of patients in the worst quartile. After controlling for other variables, proportions of diabetes control were 10% lower in those practices whose patients had the greatest difficulty with either self testing or appointment keeping (p < .05 for both). Practice rankings based on observed and expected proportion of A1c control showed only moderate agreement in pay-for-performance categories (kappa = 0.47; 95% confidence interval, 0.32-0.56; p < 001). PRINCIPAL CONCLUSIONS: Basing public reporting and resource allocation on quality assessment that does not account for patient characteristics may further harm this vulnerable group of patients and physicians.

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