Cottrell Erika K, O'Malley Jean P, Dambrun Katie, Park Brian, Hendricks Michelle A, Xu Hongzhi, Charlson Mary, Bazemore Andrew, Shenkman Elizabeth Ann, Sears Abby, DeVoe Jennifer E
From OCHIN, Inc, Portland, OR (EKC, JPO, KD, MAH, AS); Department of Family Medicine. Oregon Health and Science University, Portland (EKC, JPO, BP, JED); University of Florida, Gainesville (HX, EAS); Cornell University School of Medicine, Ithaca, NY (MC); American Board of Family Medicine, Lexington, KY (AB).
J Am Board Fam Med. 2020 Jul-Aug;33(4):600-610. doi: 10.3122/jabfm.2020.04.190367.
In an age of value-based payment, primary care providers are increasingly scrutinized on performance metrics that assess quality of care, including the outcomes of their patient population in key areas such as diabetes control. Although such measures often adjust for patient clinical risk factors or clinical complexity, most do not account for the social complexity of patient populations, despite research demonstrating the strong association between social factors and health.
Using patient electronic health record data from 2 large community health center networks serving safety net patients, we assessed the effect of both clinical and social risk factors on poor glucose control among diabetics. Logistic regression results were used to estimate the impact of adjusting for both clinical and social complexity on provider performance metrics. Clinical complexity was measured at the patient-level using the Charlson Comorbidity Index. Social complexity was measured at the community-level using the Social Deprivation Index.
Clinical complexity alone was not consistently associated with poor diabetes control (ie, HbA1c > 9%) in diabetic patients with HbA1c testing during the study period. However, increasing social complexity was significantly associated with higher rates of poor diabetic control in both cohorts. After adding adjustment for social complexity down to the national median score, our models suggest that approximately 25% of providers would have 1 to 2% improvement in the assessment of their diabetes control measures, with 45% showing a 2 to 5% improvement, and 5% showing more than a 5% improvement.
Providers caring for patients with greater social risk factors may benefit from having their performance metrics adjusted for the social complexity of their patient populations.
在基于价值的支付时代，初级保健提供者越来越受到针对评估医疗质量的绩效指标的严格审查，这些指标包括他们在糖尿病控制等关键领域的患者群体的治疗结果。尽管此类措施通常会对患者的临床风险因素或临床复杂性进行调整，但大多数措施并未考虑患者群体的社会复杂性，尽管研究表明社会因素与健康之间存在密切关联。
利用来自两个为安全网患者服务的大型社区卫生中心网络的患者电子健康记录数据，我们评估了临床和社会风险因素对糖尿病患者血糖控制不佳的影响。逻辑回归结果用于估计针对临床和社会复杂性进行调整对提供者绩效指标的影响。临床复杂性在患者层面使用查尔森合并症指数进行衡量。社会复杂性在社区层面使用社会剥夺指数进行衡量。
在研究期间进行糖化血红蛋白（HbA1c）检测的糖尿病患者中，仅临床复杂性与糖尿病控制不佳（即HbA1c>9%）之间并无一致关联。然而，在两个队列中，社会复杂性的增加均与糖尿病控制不佳的较高发生率显著相关。在将社会复杂性调整至全国中位数得分后，我们的模型表明，约25%的提供者在其糖尿病控制措施评估方面将有1%至2%的改善，45%的提供者将有2%至5%的改善，5%的提供者将有超过5%的改善。
照顾具有较高社会风险因素患者的提供者可能会受益于根据其患者群体的社会复杂性对其绩效指标进行调整。
