Benchmarking & Clinician Profiles

Introduction

This section introduces you to benchmarking.  Benchmarking is the process of profiling clinicians by comparing their observed outcomes against expected outcomes.

Objectives

The objectives of the session are:

• Describe how you should provide feedback to clinicians
• Describe the literature on what works in changing clinicians practice patterns

Performance Reports

Epstein, A.  Performance Reports on Quality -- Prototypes, Problems, and Prospects.  New England Journal of Medicine, Volume 333(1), 6 Jul 1995,  pp 57-61. Please logoff after seeing the article.  For updates on this article click here. 

Author discusses the prospect of a national reporting system on the quality of care that covers all patients.

Analysis of Practice Patterns

Welch, Gilbert H.; Miller, Mark E.; Welch, W. Pete.  Physician Profiling -- An Analysis of Inpatient Practice Patterns in Florida and Oregon.  New England Journal of Medicine, Volume 330(9) 3 Mar 1994 pp 607-612.  Please logoff after seeing the article.  For updates on this article click here. 

Background: Physician profiling is a method of cost control that focuses on patterns of care instead of case by case reviews. It is a cost-control method that takes into account physicians' desire to avoid administrators' intrusion in their practice patterns.  Authors analyze the inpatient practice patterns of physicians in Florida and Oregon.  They found that Florida physicians used markedly more resource than their colleagues in Oregon.

Changing Physicians' Practices

Greco, Peter J.; Eisenberg, John M.  Changing Physicians' Practices.  New England Journal of Medicine, Volume 329(17), 21 Oct 1993, pp 1271-1274.  Please logoff after seeing the article.  For updates on this article click here. 

What causes physicians to change the way they practice? This question is especially important today because physicians' decisions influence not only the health of their patients but also the cost of care. Thus, the ability to change physicians' practices could improve the quality of health care while controlling expenditures.

What Do You Know?

Advanced learners like you, often need different ways of understanding a topic. Reading is just one way of understanding. Another way is through writing. When you write you not only recall what you have written but also may need to make inferences about what you have read. The following questions are designed to get you to think more about the concepts taught in this session.

1. List factors known to affect physician's practice patterns (please rely on the reading and not your own intuitions)

2. Are physicians in Florida more efficient than physicians in Oregon.  Explain your answer.  Give your reservations about your conclusions.

Please send an email to your instructor with your responses to the above questions.    Make sure that the email subject line includes the course number, topic name and your name, otherwise it will not get to the right place.  If you wish to receive a delivery receipt, you may request the receipt from your email program.  Please respond to all of the questions within the same email.  Be kind to your instructor and do not attach a file so there will be no need to check for viruses.  Keep a copy of all your emails to the instructor till the end of the semester.

Slides and Narrated Lecture

To assist you in reviewing how to provide feedback to clinicians, please see slides or listen to narrated lecture. 

Narrated lecture requires use of Flash.

Recently Asked Questions

Ask a question and we will answer it within the next 48 hours.  If you have no questions, please review the answer to the questions asked by others: 

Question: Are RVUs the same in all states or are there differences from state to state? For example, are RVUs in New York, where prices are generally higher, equal to RVUs in Maryland, where prices may be lower? Answer: Relative Value Scales are the same across the nation but a local price difference is used to adjust these values before setting visit prices. In this sense, the doctor in NY and the doctor in MD are not paid the same amount for the same visit.  This question was asked on 4/14/2008 3:44:28 AM and answered on 4/14/2008 7:06:55 AM.

Question: What is a good link on the internet for benchmarking data? Answer: I would encourage you to look at CMS and Agency for health care Quality web sites.  This question was asked on 4/8/2008 7:43:57 PM and answered on 4/9/2008 8:29:50 AM.

Question: If you are having trouble opening up the link to the articles on this page what do you suggest the students do? And the homework assignment is due tomorrow. Answer: Email me and I will send you a copy of the paper.   This question was asked on 4/7/2008 5:34:00 PM and answered on 4/7/2008 6:51:59 PM.

Question: The lecture on risk adjusted physician profiling talked about event trees, are these readily used for profiling? Answer: No, most physician profiling is done using the calculation of event trees but without the visual display of trees. We have added these to the lecture in order to provide clinicians and students with more insight about what is behind the numbers used in risk profiling.   This question was asked on 4/6/2008 9:16:35 AM and answered on 4/6/2008 1:31:00 PM.

Question: Do you feel that implementing a peer-review process is enough alone to improve the quality and efficiency of physician practices? Answer: No research data show that traditional peer review process is not effective in bringing about quality improvement. The focus of the traditional peer review process was on finding the bad apple in the basket, finding the clinician that is not performing well. This is not very productive and causes a great deal of defensive letter writing back and forth. In contrast, continuous quality improvement attempts to make system changes that improve every one's performance.   This question was asked on 4/1/2008 7:46:00 AM and answered on 4/1/2008 7:58:45 AM.

Question: How commonly used is RVUs as a metric in evaluating the deliver yo healthcare. Answer: I do not have a lot of expertise in this area. But from my reading of the literature, relative value scales are used often in reimbursement of office visits.   This question was asked on 3/31/2008 2:37:32 PM and answered on 3/31/2008 4:55:06 PM.

Question: Could you give a simple example of a "just before reminder?" I listened to the lecture but I seemed to miss the essence of what you were saying regarding this stategy. Answer: Several years ago we had a computer interview patients prior to their visits on the phone and assess whether they were using excessive alcohol. The computer printed a report that was put into the client's file. When patients visited the physician would notice the reminder and as a consequence the percentage of diagnoses of alcohol abuse went up from 2% to 17%.  This question was asked on 11/17/2007 12:00:37 PM and answered on 11/17/2007 9:00:19 PM.

Question:  How can i find the SF- 36 questionaire itself? Answer: Unfortunately, this questionnaire is no longer freely available on the web but you can purchase access to it if you searcg for it under google.  This question was asked on 7/18/2006 10:18:06 AM and answered on 7/24/2006 9:53:53 AM.

Question: HOW DO WE MEASURE VALIDITY AND RELIABILITY IN SF-36 Answer: Validity of all instruments including SF36 is measured by seeing if it predicts a gold standard, e.g. mortality or morbidity. Reliability is measured by seeing in test re-test the same person is scored the same or alternatively by seeing if two rater would score the same person the same. Sometimes reliability is measured by asking the person to complete a self reported instrument such as SF36 twice and see if the resulting scores are the same.  This question was asked on 12/5/2005 5:45:57 PM and answered on 12/6/2005 5:10:39 PM.

Question: A couple of the values I calculated for the UCL and LCL are off from the values you posted by .01. Is this something that will significantly affect the overall value of the p-chart? Answer: No, this is just rounding error  This question was asked on 10/16/2005 3:29:50 PM and answered on 10/17/2005 9:01:37 PM.

Suggestions for Improving Lecture on "Health Status"

Add your own suggestions or read below suggestions made by others regarding how to improve this session:

Suggestion: Lecture was good, but more examples of scenarios and use cases would have been helpful.  This comment was left on 10/11/2009 4:56:51 PM.

Suggestion: This lecture is a little confusing. I think more examples would be helpful for those that do not have experience with use case and scenarios.  This comment was left on 9/13/2009 10:00:27 PM.

Suggestion: liked this one better than the last. was more engaging because the presenter went well beyond the slides. felt more like a dialogue, if that is possible.  This comment was left on 9/12/2009 9:43:28 PM.

Suggestion: Great lecture. I have written several use cases in the past, but never been taught a structured way to do them. This combination of experience and education is very beneficial.  This comment was left on 9/12/2009 3:14:12 PM.

Suggestion: The scenario tool worked well, but the use case tool kept erroring out. Another example within the text might have been helpful in outlining the flow from the decision to the scenario to the use case.  This comment was left on 9/14/2008 10:09:15 PM.

Suggestion: Good lecture. I liked the examples that were used to illustrate how the different steps.   This comment was left on 9/12/2008 8:53:24 AM.

Suggestion: The lectures helped as well as the updated slides. I liked the details in the slides.  This comment was left on 9/9/2008 8:35:32 PM.

Suggestion: Overall the lecture was okay. I think if there were better examples of scenarios and use cases I would have grasped the concepts better.  This comment was left on 9/2/2008 9:03:40 PM.

Suggestion: It was nice to have experiences with vistA.   This comment was left on 7/28/2008 9:57:07 AM.

Suggestion: Read and learned alot about the VA in undergrad and they are a leader in providing and coordinating care, much is attributed to their implementation of VistA.  This comment was left on 7/8/2008 8:15:05 AM.

More

1. For a detailed instruction on how to do risk adjusted practice profiling, click here. 
2. For a Medline search on practice profiling click here. 
3. For importance of risk adjustment in measuring performance in primary care, click here.
4. For a web search of articles on practice profiling, click here. 
5. Achievable Benchmarks of Care user manual.