Physician and patient influences on provider performance: β-blockers in postmyocardial infarction management in the MI-Plus study.
Physician and patient influences on provider performance: β-blockers in postmyocardial infarction management in the MI-Plus study.
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DOI：
10.1161/circoutcomes.110.942318
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发表时间：
2011-01-01
期刊：
影响因子：
--
通讯作者：
Kiefe CI
中科院分区：
文献类型：
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作者：
Funkhouser E;Houston TK;Levine DA;Richman J;Allison JJ;Kiefe CI
Efforts to improve the quality of care for patients with cardiovascular disease frequently target the decrease of physician-level performance variability. We assessed how variability in providing beta-blockers to ambulatory post-myocardial infarction (MI) patients was influenced by physician and patient level characteristics. Beta-blocker prescription and patient characteristics were abstracted from charts of post-MI patients treated by 133 primary care physicians between 2003 and 2007, and linked to physician and practice characteristics. Associations of beta-blocker prescription with physician and patient level characteristics were examined using mixed-effects models, with physician level effects as random. Mean physician specific predicted probabilities, and the intra-class correlations, which assessed the proportion of variance explainable at the physician level, were estimated. Of 1,901 patients without major contraindication, 69.1% (range across physicians: 20%–100%) were prescribed beta-blockers. Prescription varied with co-morbidity from 78.3% in patients with chronic kidney disease to 54.7% for patients with stroke. Although physician characteristics such as older physician age, group practice, and rural location were each positively associated with beta-blocker prescription, physician factors accounted for only 5% to 8% of the variance in beta-blocker prescription; the preponderance of the variance, 92–95%, was at the patient level. The mean physician-specific probability of beta-blocker prescription (95% confidence interval) in the fully adjusted model was 63% (61%–65%). Beta-blocker prescription rates were surprisingly low. The contribution of physician factors to overall variability in beta-blocker prescription, however, was limited. Increasing evidence-based use of beta-blockers may not be accomplished by focusing mostly on differential performance across physicians.
