Clinically relevant quality measures for risk factor control in primary care: a retrospective cohort study
1 Department of General Internal Medicine, University of Bern, Bern, Switzerland
2 Department of Clinical Research, Clinical Trials Unit, University of Bern, Bern, Switzerland
3 Department of Health Sciences and Health Policy, University of Lucerne, Lucerne, Switzerland
4 Swiss Paraplegic Research, Nottwil, Switzerland
5 Department of Ambulatory Care and Community Medicine, University of Lausanne, Lausanne, Switzerland
6 Service of Endocrinology, Diabetes, and Metabolism, Lausanne University Hospital, Lausanne, Switzerland
7 Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, USA
8 Department of Medicine, University of California San Francisco, San Francisco, CA, USA
9 Division of Internal Medicine, University Hospital of Zurich, Zurich, Switzerland
10 Medical Outpatient Department/Ambulatory Internal Medicine, University Hospital Basel, Basel, Switzerland
11 Department of Community Medicine and Primary Care, University Hospitals of Geneva and Faculty of Medicine, Geneva, Switzerland
12 Veterans Affairs Center for Clinical Management Research, HSR&D Center of Excellence; Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
BMC Health Services Research 2014, 14:306 doi:10.1186/1472-6963-14-306Published: 15 July 2014
Assessment of the proportion of patients with well controlled cardiovascular risk factors underestimates the proportion of patients receiving high quality of care. Evaluating whether physicians respond appropriately to poor risk factor control gives a different picture of quality of care. We assessed physician response to control cardiovascular risk factors, as well as markers of potential overtreatment in Switzerland, a country with universal healthcare coverage but without systematic quality monitoring, annual report cards on quality of care or financial incentives to improve quality.
We performed a retrospective cohort study of 1002 randomly selected patients aged 50–80 years from four university primary care settings in Switzerland. For hypertension, dyslipidemia and diabetes mellitus, we first measured proportions in control, then assessed therapy modifications among those in poor control. “Appropriate clinical action” was defined as a therapy modification or return to control without therapy modification within 12 months among patients with baseline poor control. Potential overtreatment of these conditions was defined as intensive treatment among low-risk patients with optimal target values.
20% of patients with hypertension, 41% with dyslipidemia and 36% with diabetes mellitus were in control at baseline. When appropriate clinical action in response to poor control was integrated into measuring quality of care, 52 to 55% had appropriate quality of care. Over 12 months, therapy of 61% of patients with baseline poor control was modified for hypertension, 33% for dyslipidemia, and 85% for diabetes mellitus. Increases in number of drug classes (28-51%) and in drug doses (10-61%) were the most common therapy modifications. Patients with target organ damage and higher baseline values were more likely to have appropriate clinical action. We found low rates of potential overtreatment with 2% for hypertension, 3% for diabetes mellitus and 3-6% for dyslipidemia.
In primary care, evaluating whether physicians respond appropriately to poor risk factor control, in addition to assessing proportions in control, provide a broader view of the quality of care than relying solely on measures of proportions in control. Such measures could be more clinically relevant and acceptable to physicians than simply reporting levels of control.