The Case for Case-Mix Adjustment in Practice Profiling

Abstract

Failure to adjust for case mix in physician practice profiles may lead to overestimates of variation and misidentification of outliers. To the extent that unadjusted practice profiles are used for decisions about education, sanctions, or employment, physicians may be subject to inequitable decisions and actions. Misinformation about the causes and extent of practice variation may also lead to misdirection of scarce resources for quality improvement efforts.

Can Resident Physicians Be Profiled?

“…However, the amount of interaction or effect one plays on the other is controversial. [1][2][3]6,7 Historically, the professional judgment of a peer group has been at the core of systems monitoring quality of care and attempting quality improvement. The variance from accepted practice is determined relative to expert opinion, published guidelines, or as a result of a poor patient outcome.…”

“…1 Individual physician report cards have been criticized for lacking adequate control for casemix variations, for ignoring nursing and ancillary staff variations, and for being in conflict with the best interests of the individual patient. [1][2][3] In addition to the lack of a reliable instrument, there remains the challenge of how to use the information to produce an improvement in quality of care. Most profiling assessments of physician performance have measured process data rather than patient outcomes.…”

“…6,7 Attempts at generalizing physician data from one hospital or system to another have been staunchly criticized as hospitals possess different staffing schemes, triage coding schemes, admission and resource-utilization patterns, local managed care penetrations, and levels of technology. [1][2][3][6][7][8] Productivity and efficiency are examples of process functions. To be valid, however, they must be very carefully measured.…”

“…More concerning is the possibility that the process could infringe on the patient-physician relationship. [1][2][3]7 Resident physicians differ in many ways from independent practicing physicians. First and foremost is that they are students in an educational system.…”

“…Health plan administrators and physician group directors have come to rely on the objective information supplied by a wide variety of productivity measuring tools to evaluate clinical performance. [1][2][3][4] These report cards are then used to affect physician and nonphysician performance. Physician performance parameters have included those actions or processes leading to the desired outcome, i.e., competent medical care of the patient, or data on the outcome itself.…”