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Primary Care Physician Resource Use Changes Associated With Feedback Reports
Eva Chang, PhD, MPH; Diana S.M. Buist, PhD, MPH; Matt Handley, MD; Eric Johnson, MS; Sharon Fuller, BA; Roy Pardee, JD, MA; Gabrielle Gundersen, MPH; and Robert J. Reid, MD, PhD
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Primary Care Physician Resource Use Changes Associated With Feedback Reports

Eva Chang, PhD, MPH; Diana S.M. Buist, PhD, MPH; Matt Handley, MD; Eric Johnson, MS; Sharon Fuller, BA; Roy Pardee, JD, MA; Gabrielle Gundersen, MPH; and Robert J. Reid, MD, PhD
Implementing systemwide dissemination of feedback reports to primary care physicians in an integrated delivery system may be associated with changes in medical resource use.
ABSTRACT

Objectives: To measure changes in primary care physician (PCP) ordering rates for 4 global resource use measures before and after dissemination of physician feedback reports that provided peer-comparison resource use rates. We also explored whether physician practice characteristics (panel size, clinic size, and years of experience) were associated with resource use changes.

Study Design: Pre-post implementation study measuring physician resource use in an integrated healthcare system (2011-2014).

Methods: Kaiser Permanente Washington PCPs (N = 210) were provided annual feedback reports showing their personal ordering rates compared with those of their peers. Monthly physician ordering was measured from November 2011 to September 2014 (including prereport and postreport periods). We examined 4 physician ordering rates (specialty referrals, high-end imaging, laboratory tests, and 30-day prescriptions) per 1000 patients, adjusted for patient age, gender, and clinical complexity.

Results: After accounting for physician practice characteristics, monthly PCP ordering rates for high-end imaging significantly decreased by 0.8 images per 1000 patients (P <.01). In contrast, orders for laboratory tests and 30-day prescriptions significantly increased by 15.0 tests and 84.7 prescriptions per 1000 patients (both P <.01). We observed greater changes following feedback in physicians with fewer years of experience (≤10 years), who had 4.2 fewer specialty referrals (P = .01) and 101.3 more 30-day prescriptions (P <.01) compared with those with more experience (>20 years).

Conclusions: Physician feedback reports may be associated with changes in physician resource use, and physicians with fewer years of experience may be more responsive to feedback reports. Better understanding of factors associated with changes in resource use is necessary for future targeted development of physician interventions.

Am J Manag Care. 2018;24(10):455-461
Takeaway Points

Healthcare systems use feedback reports to document physician practice patterns and increase physician accountability for resource use, but there are few reports of whether personalized resource use feedback affects provider performance. We evaluated the association between distribution of feedback reports to primary care physicians in an integrated delivery system and changes in 4 global measures of physician resource use.
  • Feedback reports were associated with varied changes in resource use.
  • Physicians with fewer years of experience may be more responsive to feedback reports.
  • Better understanding of factors associated with changes in resource use is necessary for future targeted development of physician interventions.
Fueled by concerns of rising healthcare costs and the national dialogue on overuse and misuse, healthcare systems are increasingly interested in developing better tools for measuring and reporting healthcare quality and efficiency.1 Reducing variability in physician practice patterns is an opportunity for healthcare systems to improve quality and reduce costs.2 Healthcare organizations are addressing variability in care with increased internal transparency in organizations to create a culture of high-value care.3-5 Numerous organizations, from Medicare and Medicaid to small practices, use audit and feedback reports to support physician behavior change and performance improvement.6,7 Although feedback reports have been shown to effectively increase accountability,8-10 the literature on implementing feedback reports and their impact on physician practice patterns in healthcare systems is inconclusive.8,11-16

In 2012, Kaiser Permanente Washington (KPWA; formerly Group Health Cooperative) implemented a Resource Stewardship quality improvement (QI) initiative to reduce low-value care, or care that does not improve patient outcomes and can harm patients. The initiative focused on helping KPWA physicians become better stewards of healthcare resources. Recognizing that daily decisions drive quality and cost, an internally transparent peer-comparison feedback report was developed to bring personalized information to physicians that informed their clinical decision making and facilitated internal conversations about medical resource use.

The annual resource stewardship report showed individual physician-, clinic-, and system-level ordering rates for specialty referrals, high-end imaging, laboratory tests, and 30-day prescriptions. It was designed to show variations in global service use, because improving a few specific areas was deemed unlikely to be sufficient for reducing low-value care at the healthcare-system level. Feedback was combined across multiple services to help identify areas of greater overall resource use rather than targeting single areas of utilization that may result in unintended shifts in resource utilization (eg, reducing specialty referrals may cause increases in high-end imaging).

We evaluated whether distribution of internally transparent peer-comparison feedback reports within an integrated delivery system was associated with changes in individual physician resource use. We also explored whether physician practice characteristics (panel size, clinic size, and years of experience) were associated with changes in resource use. Although evidence for the link between practice characteristics and resource use is mixed,17-22 better understanding of these characteristics could be used to target feedback reports to those who would benefit most.

METHODS

Setting and Data

KPWA is a mixed-model delivery system providing insurance and healthcare to approximately 710,000 patients in Washington state. Approximately 370,000 KPWA patients are cared for within the integrated delivery system (group practice); the remainder receive care through a network of contracted physicians and other healthcare providers across the state. Within the group practice, approximately 1000 salaried multispecialty clinicians practice in 25 medical clinics; approximately 300 are primary care physicians (PCPs). We included KPWA PCPs specializing in family medicine or internal medicine with a panel size of 250 or more patients during each month of the study period. This QI initiative and subsequent analyses were determined to be exempt from human subjects review in compliance with the Office for Human Research Protections (45 CFR Part 46). We followed healthcare QI reporting guidelines.23

We extracted data on physician orders and characteristics from KPWA’s automated clinical and administrative data systems. We used physician orders to accurately attribute and assess physicians’ intended resource use. We created monthly measures of physician ordering from November 2011 to September 2014, including the 11 months before distribution of the reports (prereport period, November 2011-September 2012) and the 11 months after distribution (postreport period, November 2013-September 2014). We included a 13-month implementation period (October 2012-October 2013) during which 2 reports were distributed to each PCP.

Feedback (Resource Stewardship) Reports

Resource stewardship reports were designed to identify practice pattern variations and make resource use visible to KPWA’s PCPs. Physicians were given clinic-specific reports that included ordering rates and physician names for all PCPs in their clinic. Bar graphs of annual, physician-level, comorbidity-adjusted ordering rates in the prior calendar year for specialty referrals, high-end imaging, laboratory tests, and 30-day prescriptions per 1000 patients were displayed for all PCPs within the clinic (see eAppendix A [eAppendices available at ajmc.com] for a sample 2015 report; some reported ordering rates changed since the 2013 report). The graphs included lines to indicate the system or clinic average and 1 SD above and below the average. Bar graphs in the second-year report (September 2013) also showed physicians’ ordering rates in the prior year to allow physicians to see personal changes over time. Reports included physician names to promote within-system transparency and give physicians the opportunity to learn from the practice patterns of other physicians within their clinic.

Feedback reports were disseminated in November 2012 and September 2013 through monthly within-clinic physician meetings and individual meetings between physicians and their local clinic chiefs. The Medical Director for Quality (M.H.) and clinic chiefs explained the Resource Stewardship initiative and the report’s purpose, presented the data, and gave physicians opportunities to discuss intraclinic variability as a group. Clinic chiefs were trained to present the reports as a chance for physicians to learn from each other rather than as a punitive tool.


 
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