Using Consistently Low Performance to Identify Low-Quality Physician Groups

Importance

There has been a growth in the use of performance-based payment models in the past decade, but inherently noisy and stochastic quality measures complicate the assessment of the quality of physician groups. Examining consistently low performance across multiple measures or multiple years could potentially identify a subset of low-quality physician groups.

Objective

To identify low-performing physician groups based on consistently low performance after adjusting for patient characteristics across multiple measures or multiple years for 10 commonly used quality measures for diabetes and cardiovascular disease (CVD).

Design, Setting, and Participants

This cross-sectional study used medical and pharmacy claims and laboratory data for enrollees ages 18 to 65 years with diabetes or CVD in an Aetna health insurance plan between 2016 and 2019. Each physician group's risk-adjusted performance for a given year was estimated using mixed-effects linear probability regression models. Performance was correlated across measures and time, and the proportion of physician groups that performed in the bottom quartile was examined across multiple measures or multiple years. Data analysis was conducted between September 2020 and May 2021.

Exposures

Primary care physician groups.

Main Outcomes and Measures

Performance scores of 6 quality measures for diabetes and 4 for CVD, including hemoglobin A1c (HbA1c) testing, low-density lipoprotein testing, statin use, HbA1c control, low-density lipoprotein control, and hospital-based utilization.

Results

A total of 786 641 unique enrollees treated by 890 physician groups were included; 414 655 (52.7%) of the enrollees were men and the mean (SD) age was 53 (9.5) years. After adjusting for age, sex, and clinical and social risk variables, correlations among individual measures were weak (eg, performance-adjusted correlation between any statin use and LDL testing for patients with diabetes, r = -0.10) to moderate (correlation between LDL testing for diabetes and LDL testing for CVD, r = .43), but year-to-year correlations for all measures were moderate to strong. One percent or fewer of physician groups performed in the bottom quartile for all 6 diabetes measures or all 4 cardiovascular disease measures in any given year, while 14 (4.0%) to 39 groups (11.1%) were in the bottom quartile in all 4 years for any given measure other than hospital-based utilization for CVD (1.1%).

Conclusions and Relevance

A subset of physician groups that was consistently low performing could be identified by considering performance measures across multiple years. Considering the consistency of group performance could contribute a novel method to identify physician groups most likely to benefit from limited resources.

Health system affiliation of physician organizations and quality of care for Medicare beneficiaries who have high needs

OBJECTIVE

To test the hypothesis that health systems provide better care to patients with high needs by comparing differences in quality between system-affiliated and nonaffiliated physician organizations (POs) and to examine variability in quality across health systems.

DATA SOURCES

2015 Medicare Data on Provider Practice and Specialty linked physicians to POs. Medicare Provider Enrollment, Chain, and Ownership System (PECOS) and IRS Form 990 data identified health system affiliations. Fee-for-service Medicare enrollment and claims data were used to examine quality.

STUDY DESIGN

This cross-sectional analysis of beneficiaries with high needs, defined as having more than twice the expected spending of an average beneficiary, examined six quality measures: continuity of care, follow-up visits after hospitalizations and emergency department (ED) visits, ED visits, all-cause readmissions, and ambulatory care-sensitive hospitalizations. Using a matched-pair design, we estimated beneficiary-level regression models with PO random effects to compare quality of care in system-affiliated and nonaffiliated POs. We then limited the sample to system-affiliated POs and estimated models with system random effects to examine variability in quality across systems.

PRINCIPAL FINDINGS

Among 2 323 301 beneficiaries with high needs, 52.3% received care from system-affiliated POs. Rates of ED visits were statistically significantly different in system-affiliated POs (117.5 per 100) and nonaffiliated POs (106.8 per 100, P < .0001). Small differences in the other five quality measures were observed across a range of sensitivity analyses. Among systems, substantial variation was observed for rates of continuity of care (90% of systems had rates between 70.8% and 89.4%) and follow-up after ED visits (90% of systems had rates between 56.9% and 73.5%).

CONCLUSIONS

Small differences in quality of care were observed among beneficiaries with high needs receiving care from system POs and nonsystem POs. Health systems may not confer hypothesized quality advantages to patients with high needs.

General practitioners' income and activity: the impact of multi-professional group practice in France

France has first experimented, in 2009, and then generalized a practice level add-on payment to promote Multi-Professional Primary Care Groups (MPCGs). Team-based practices are intended to improve both the efficiency of outpatient care supply and the attractiveness of medically underserved areas for healthcare professionals. To evaluate its financial attractiveness and thus the sustainability of MPCGs, we analyzed the evolution of incomes (self-employed income and wages) of General Practitioners (GPs) enrolled in a MPCG, compared with other GPs. We also studied the impacts of working in a MPCG on GPs' activity through both the quantity of medical services provided and the number of patients encountered. Our analyses were based on a quasi-experimental design, with a panel dataset over the period 2008-2014. We accounted for the selection into MPCG by using together coarsened exact matching and difference-in-differences (DID) design with panel-data regression models to account for unobserved heterogeneity. We show that GPs enrolled in MPCGs during the period exhibited an increase in income 2.5% higher than that of other GPs; there was a greater increase in the number of patients seen by the GPs' (88 more) without involving a greater increase in the quantity of medical services provided. A complementary cross-sectional analysis for 2014 showed that these changes were not detrimental to quality in terms of bonuses related to the French pay-for-performance program for the year 2014. Hence, our results suggest that labor and income concerns should not be a barrier to the development of MPCGs, and that MPCGs may improve patient access to primary care services.

Practice composition and sex differences in physician income: observational study

OBJECTIVE

To assess whether differences in income between male and female physicians vary according to the sex composition of physician practices.

DESIGN

Retrospective observational study.

SETTING

US national survey of physician salaries, 2014-18.

PARTICIPANTS

18 802 physicians from 9848 group practices (categorized according to proportion of male physicians ≤50%, >50-75%, >75-90%, and >90%).

MAIN OUTCOME MEASURES

Sex differences in physician income in relation to the sex composition of physician practices after multivariable adjustment for physician specialty, years of experience, hours worked, measures of clinical workload, practice type, and geography.

RESULTS

Among 11 490 non-surgical specialists, the absolute adjusted sex difference in annual income (men versus women) was $36 604 (£29 663; €32 621) (95% confidence interval $24 903 to $48 306; 11.7% relative difference) for practices with 50% or less of male physicians compared with $91 669 ($56 587 to $126 571; 19.9% relative difference) for practices with at least 90% of male physicians (P=0.03 for difference). Similar findings were observed among surgical specialists (n=3483), with absolute adjusted sex difference in annual income of $46 503 ($42 198 to $135 205; 10.2% relative difference) for practices with 50% or less of male physicians compared with $149 460 ($86 040 to $212 880; 26.9% relative difference) for practices with at least 90% of male physicians (P=0.06 for difference). Among primary care physicians (n=3829), sex differences in income were not related to the proportion of male physicians in a practice.

CONCLUSIONS

Among both non-surgical and surgical specialists, sex differences in income were largest in practices with the highest proportion of male physicians, even after detailed adjustment for factors that might explain sex differences in income.

Opioid prescription patterns among radiation oncologists in the United States

BACKGROUND

Radiation oncologists (ROs) play an important role in managing cancer pain; however, their opioid prescribing patterns remain poorly described.

METHODS

The 2016 Medicare Physician Compare National Downloadable and the 2016 Medicare Part D Prescriber Data files were cross-linked to identify RO-written opioid prescriptions.

RESULTS

Of 4,627 identified ROs, 1,360 (29.3%) wrote >10 opioid prescriptions. The average number of opioid prescriptions written was significantly (P ≤ .05) associated with the following RO characteristics: sex [13.1 ± 36.5 male vs 7.5 ± 16.9 female]; years since medical school graduation [4.5 ± 11.5 1-10 years vs 12.6 ± 26.0 11-24 years vs 13.3 ± 40.9 ≥25 years]; practice size [15.5 ± 44.6 size ≤10 vs 13.3 ± 25.9 size 11-49 vs 8.5 ± 12.7 size 50-99 vs 8.8 ± 26.9 size ≥100]; Medicare Physician Quality Reporting System (PQRS) participation [12.6 ± 31.8 yes vs 7.0 ± 35.4 no]; and practice location [17.4 ± 47.0 South vs 10.6 ± 29.4 Midwest vs 8.1 ± 13.9 West vs 6.9 ± 15.2 Northeast]. On multivariable regression modeling, male sex (RR 1.29, 95% CI 1.22-1.35, P < .001), ≥25 years since graduation (RR 0.78, 95% CI 0.64-0.70, 1-10 years vs ≥25 years; RR 1.00, 95% CI 0.96 - 1.04, 11-24 years vs ≥25 years; P < .001), practice size <10 members (RR 1.51, CI 1.44-1.59, ≤10 vs ≥100 members, RR 1.27, CI 1.20-1.34, 10-49 vs ≥100 members, RR 0.86, CI 0.80-0.92, 50-99 vs ≥100 members, P < .001), PQRS participation (RR 1.12, CI 1.04-1.19, P < .002), and Southern location (RR 0.67, CI 0.64-0.70, Midwest vs South; RR 0.39, CI 0.37-0.41, Northeast vs South; RR 0.43, CI 0.41-0.46, West vs South; P < .001) were predictive of higher opioid prescription rates.

CONCLUSIONS

Factors associated with increased number of RO-written opioid prescriptions were male sex, ≥25 years since graduation, group practice <10, PQRS participation, and Southern location. Additional research is required to establish optimal opioid prescribing practices for ROs.

Residency Program Characteristics and Individual Physician Practice Characteristics Associated With Family Physician Scope of Practice

PURPOSE

A family physician's ability to provide continuous, comprehensive care begins in residency. Previous studies show that patterns developed during residency may be imprinted upon physicians, guiding future practice. The objective was to determine family medicine residency characteristics associated with graduates' scope of practice (SCoP).

METHOD

The authors used (1) residency program data from the 2012 Accreditation Council for Graduate Medicine Education Accreditation Data System and (2) self-reported data supplied by family physicians when they registered for the first recertification examination with the American Board of Family Medicine (2013-2016)-7 to 10 years after completing residency. The authors used linear regression analyses to examine the relationship between individual physician SCoP (measured by the SCoP for primary care [SP4PC] score [scale of 0-30; low = small scope]) and individual, practice, and residency program characteristics.

RESULTS

The authors sampled 8,261 physicians from 423 residencies. The average SP4PC score was 15.4 (standard deviation, 3.2). Models showed that SCoP broadened with increasing rurality. Physicians from unopposed (single) programs had higher SCoP (0.26 increase in SP4PC); those from major teaching hospitals had lower SCoP (0.18 decrease in SP4PC).

CONCLUSIONS

Residency program characteristics may influence family physicians' SCoP, although less than individual characteristics do. Broad SCoP may imply more comprehensive care, which is the foundation of a strong primary care system to increase quality, decrease cost, and reduce physician burnout. Some residency program characteristics can be altered so that programs graduate physicians with broader SCoP, thereby meeting patient needs and improving the health system.

Association Between Clinical Practice Group Adherence to Quality Measures and Adverse Outcomes Among Adult Patients With Diabetes

IMPORTANCE

Clinical practice group performance on quality measures associated with chronic disease management has become central to reimbursement. Therefore, it is important to determine whether commonly used process and disease control measures for chronic conditions correlate with utilization-based outcomes, as they do in acute disease.

OBJECTIVE

To examine the associations among clinical practice group performance on diabetes quality measures, including process measures, disease control measures, and utilization-based outcomes.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective, cross-sectional analysis examined commercial claims data from a national health insurance plan. A cohort of eligible beneficiaries with diabetes aged 18 to 65 years who were enrolled for at least 12 months from January 1, 2010, through December 31, 2014, was defined. Eligible beneficiaries were attributed to a clinical practice group based on the plurality of their primary care or endocrinology office visits. Data were analyzed from October 1, 2018, through April 30, 2019.

MAIN OUTCOMES AND MEASURES

For each clinical practice group, performance on current diabetes quality measures included 3 process measures (2 testing measures [hemoglobin A1c {HbA1c} and low-density lipoprotein {LDL} testing] and 1 drug use measure [statin use]) and 2 disease control measures (HbA1c <8% and LDL level <100 mg/dL). The rates of utilization-based outcomes, including hospitalization for diabetes and major adverse cardiovascular events (MACEs), were also measured.

RESULTS

In this cohort of 652 258 beneficiaries with diabetes from 886 clinical practice groups, 42.9% were aged 51 to 60 years, and 52.6% were men. Beneficiaries lived in areas that were predominantly white (68.1%). At the clinical practice group level, except for high correlation between the 2 testing measures, correlations among different quality measures were weak (r range, 0.010-0.244). Rate of HbA1c of less than 8% had the strongest correlation with hospitalization for MACE (r = -0.046; P = .03) and diabetes (r = -0.109; P < .001). Rates of HbA1c control at the clinical practice group level were not significantly associated with likelihood of hospitalization at the individual level. Performance on the process and disease control measures together explained 3.9% of the variation in the likelihood of hospitalization for a MACE or diabetes at the individual level.

CONCLUSIONS AND RELEVANCE

In this study, performance on utilization-based measures-intended to reflect the quality of chronic disease management-was only weakly associated with direct measures of chronic disease management, namely, disease control measures. This correlation should be considered when determining the degree of financial emphasis to place on hospitalization rates as a measure of quality in treatment of chronic diseases.

Prevalence of burnout among German general practitioners: Comparison of physicians working in solo and group practices

Background

Studies from general practitioner (GP) populations from various European countries show a high prevalence of burnout, yet data from Germany are scarce and there are no data comparing GPs from solo versus group practices.

Methods

This cross-sectional survey addressed all GPs from a German network of family medicine practices comprising 185 practices. Participants were asked to fill in a self-administered questionnaire addressing socio-demographic and job-related characteristics. The German version of the Maslach Burnout Inventory was used to measure the dimensions emotional exhaustion (EE), depersonalization (DP), and personal accomplishment (PA). Each participant was categorized as having high EE, high DP and low PA following pre-defined cut-offs.

Results

A total of 214 GPs from 129 practices participated: 65.9% male, 24.8% solo practice. Of all GPs, 34.1% (n = 73) scored high for EE, 29.0% (n = 62) high for DP, 21.5% (n = 46) low for PA and 7.5% (n = 16) for all three dimensions. A higher risk for EE was found among female physicians, those unsatisfied with their job, those using few stress-regulating measures regularly and those reporting bad work-life balance. Burnout prevalence was higher in GPs in group than in solo practices (37.9% vs. 28.8% had high EE, 33.1% vs. 18.9% had high DP and 22.8% vs. 18.9% had low PA). A significantly higher prevalence of burnout symptoms was found in group practice employees compared to group practice owners.

Conclusion

Burnout prevalence was higher among physicians in group practices compared to solo practices. In group practices, employed, young, female and part-time working physicians showed a higher burnout risk.

A New Multisource Feedback Tool for Evaluating the Performance of Specialty-Specific Physician Groups: Validity of the Group Monitor Instrument

INTRODUCTION

Since clinical practice is a group-oriented process, it is crucial to evaluate performance on the group level. The Group Monitor (GM) is a multisource feedback tool that evaluates the performance of specialty-specific physician groups in hospital settings, as perceived by four different rater classes. In this study, we explored the validity of this tool.

METHODS

We explored three sources of validity evidence: (1) content, (2) response process, and (3) internal structure. Participants were 254 physicians, 407 staff, 621 peers, and 282 managers of 57 physician groups (in total 479 physicians) from 11 hospitals.

RESULTS

Content was supported by the fact that the items were based on a review of an existing instrument. Pilot rounds resulted in reformulation and reduction of items. Four subscales were identified for all rater classes: Medical practice, Organizational involvement, Professionalism, and Coordination. Physicians and staff had an extra subscale, Communication. However, the results of the generalizability analyses showed that variance in GM scores could mainly be explained by the specific hospital context and the physician group specialty. Optimization studies showed that for reliable GM scores, 3 to 15 evaluations were needed, depending on rater class, hospital context, and specialty.

DISCUSSION

The GM provides valid and reliable feedback on the performance of specialty-specific physician groups. When interpreting feedback, physician groups should be aware that rater classes' perceptions of their group performance are colored by the hospitals' professional culture and/or the specialty.

Directing Improvements in Primary Care Patient Experience through Analysis of Service Quality

OBJECTIVE

To examine the influence of dimensions of service quality on patient experience of primary care.

DATA SOURCES/STUDY SETTING

Data from the national GP Patient Survey in England 2014/15, with responses from 858,351 patients registered at 7,918 practices.

STUDY DESIGN

Expert panel and principal component analysis helped identify relevant dimensions of service quality. Regression was then used to examine the relationships between these dimensions and reported patient experience.

DATA COLLECTION/EXTRACTION METHODS

Aggregated scores for each practice were used, comprising the proportion of positive responses to each element of the study.

PRINCIPAL FINDINGS

Of eight service quality dimensions identified, six have statistically significant impacts on patient experience but only two have large effects. Patient experience is highly influenced by practice responsiveness and the interactions with the physician. Other dimensions have small or even slightly negative influence. Service quality provided by nurses has negligible effect on patient experience.

CONCLUSIONS

To improve patient experience in primary health care, efforts should focus on practice responsiveness and interactions with the physician. Other areas have little influence over patient experience. This suggests a gap in patients' perspectives on health care, which has policy implications for patient education.

Medical Group Characteristics and the Cost and Quality of Care for Medicare Beneficiaries

OBJECTIVE

To estimate the relationship between outcomes of care and medical practices' structure and use of organized care improvement processes.

DATA SOURCES/STUDY SETTING

We linked Medicare claims data to our national survey of physician practices (2012-2013). Fifty percent response rate; 1,040 responding practices; 31,888 physicians; 868,213 attributed Medicare beneficiaries.

STUDY DESIGN

Cross-sectional observational analysis of the relationship between practice characteristics and total spending, readmissions, and ambulatory care-sensitive admissions (ACSAs), for all beneficiaries and five categories of beneficiary defined by predicted need for care.

PRINCIPAL FINDINGS

Practices with 100+ physicians and 50-99 physicians had, respectively, annual spending per high-need beneficiary that was $1,870 (12.5 percent) and $1,824 higher than practices with 1-2 physicians, and readmission rates 1.64 and 1.71 higher. ACSA rates did not vary significantly by practice size. Outcomes did not vary significantly by ownership or by practices' use of organized processes to improve care.

CONCLUSIONS

Large practices had higher spending and readmission rates than the smallest practices, especially for high-need beneficiaries. There were no significant performance differences between physician-owned and hospital-owned practices. Policy makers should consider the effects of specific policies on provider organization, pending further research to learn which types of practice provide better care.

Patient centred medical home (PCMH) and patient-practitioner orientation: Is there a relationship?

BACKGROUND

The patient-centred medical home (PCMH) and utilisation of a patient-centred care approach have been promoted as opportunities to improve healthcare quality while controlling expenditures.

OBJECTIVES

To determine the penetration of PCMH within physician practices, and to evaluate physician attitudes towards patient-practitioner orientation. The ultimate objective was to explore relationships between the patient-practitioner orientation of respondents and the presence of PCMH elements within their practice.

METHODS

A survey instrument was developed following a comprehensive literature review. Lead physicians practicing in four states were surveyed.

RESULTS

The adjusted response rate was 26.7%. Responses indicated increased utilisation of PCMH elements (electronic medical records, e-mail and telephone consultations, and physician performance monitoring and feedback) compared with previous research. Within a logistic regression model, medical school graduation year (1990 or later >prior to 1990), practice size (group >solo), and percentage of time allocated to patient care (less >more) were significant predictors of working in a high PCMH alignment setting. Physician and practice characteristics did not predict the level of patient-practitioner orientation, though rural physicians were more patient-centred than urban physicians. A non-linear correlation between patient-practitioner orientation and the likelihood of practicing in a low or high PCMH-aligned practice was observed.

CONCLUSIONS

There is a non-linear correlation between patient-practitioner orientation and the likelihood of a physician practicing in a low or high PCMH-aligned practice. The ability of a physician to work in a PCMH setting or practicing patient-centred care can go beyond a physician's aspirations to work and practice in that manner.

The Association of Changing Practice Settings on Maintenance of Certification Exam Outcomes: A Comparative Study of General Internists Over Time

PURPOSE

To investigate how changing to or from solo practice settings relates to maintenance of certification (MOC) exam performance.

METHOD

The authors conducted a retrospective analysis of exam pass/fail outcomes for 7,112 physicians who successfully completed their initial MOC cycle from 2000 to 2004. Initial physician MOC practice characteristics records, demographic information, and exam performance were linked with exam pass/fail outcomes from their second MOC cycle from 2006 to 2014 (5,215 physicians after attrition). Exam pass/fail outcomes for physicians' second MOC cycle were compared among four groups: those who remained in group practice across both MOC cycles, those who changed from group to solo practice, those who changed from solo to group practice, and those who remained in solo practice across both MOC cycles.

RESULTS

Physicians who changed from solo to group practice performed significantly better than those who remained in solo practice (odds ratio [OR] = 1.67; 95% confidence interval [CI] = 1.11, 2.51; P = .027). Conversely, physicians changing from group to solo practice performed significantly worse than physicians staying in group practice (OR = 0.60; 95% CI = 0.45, 0.80; P = .002). Meanwhile, physicians who changed from solo to group practice performed similarly to physicians remaining in group practice (OR = 0.95; 95% CI = 0.67, 1.35; P = 0.76).

CONCLUSIONS

Changes in solo/group practice status were associated with second-cycle MOC exam performance. This study provides evidence that the context in which a physician practices may have an impact on their MOC exam performance.

The relationships of physician practice characteristics to quality of care and costs

BACKGROUND

Medical group practices are central to many of the proposals for health care reform, but little is known about the relationship between practice-level characteristics and the quality and cost of care.

METHODS

Practice characteristics from a 2009 national survey of 211 group practices were linked to Medicare claims data for beneficiaries attributed to the practices. Multivariate regression was used to examine the relationship between practice characteristics and claims-computable measures of screening and monitoring, avoidable utilization, risk-adjusted per-beneficiary per-year (PBPY) costs, and the practice's net revenue.

RESULTS

Several characteristics of group practices are predictive of screening and monitoring measures. Those measures, in turn, are predictive of lower values of avoidable utilization measures that contribute to higher PBPY costs. The effects of group practice characteristics on avoidable utilization, cost, and practice net revenue appear to work primarily through improved screening and monitoring.

CONCLUSIONS

Practice characteristics influence costs indirectly through a set of statistically significant relationships among screening and monitoring measures and avoidable utilization. However, these relationships are not the only pathways connecting practice characteristics to cost and those additional pathways contain substantial "noise" adding uncertainty to the estimated direct effects. Some of the attributes thought to be important characteristics of accountable care organizations and medical homes appear to be associated with lower quality and no improvement in cost.

Case studies in clinical transformation

Keys to success in undertaking clinical transformation initiatives include: Payer alignment. Robust technology (e.g., tools that can migrate patient data into disease registries). Commitment to making the investments and process changes needed to support population health management. Partnerships with local employers. Small steps toward greater value.

The road to high performance is paved with data

Data is a necessary component of any organization's move toward accountability. This commentary describes Wilmington Health's use of high-tech and low-tech data sources in its journey to succeed as an accountable care organization. This commentary also discusses shortcomings in the availability of data and the lack of transparency regarding cost and quality.

Practice improvement, part II: trends in employment versus private practice

A growing percentage of physicians are selecting employment over solo practice, and fewer family physicians have hospital admission privileges. Results from surveys of recent medical school graduates indicate a high value placed on free time. Factors to consider when choosing a practice opportunity include desire for independence, decision-making authority, work-life balance, administrative responsibilities, financial risk, and access to resources. Compensation models are evolving from the simple fee-for-service model to include metrics that reward panel size, patient access, coordination of care, chronic disease management, achievement of patient-centered medical home status, and supervision of midlevel clinicians. When a practice is sold, tangible personal property and assets in excess of liabilities, patient accounts receivable, office building, and goodwill (ie, expected earnings) determine its value. The sale of a practice includes a broad legal review, addressing billing and coding deficiencies, noncompliant contractual arrangements, and potential litigations as well as ensuring that all employment agreements, leases, service agreements, and contracts are current, have been executed appropriately, and meet regulatory requirements.

Effect of pay-for-performance incentives on quality of care in small practices with electronic health records: a randomized trial

IMPORTANCE

Most evaluations of pay-for-performance (P4P) incentives have focused on large-group practices. Thus, the effect of P4P in small practices, where many US residents receive care, is largely unknown. Furthermore, whether electronic health records (EHRs) with chronic disease management capabilities support small-practice response to P4P has not been studied.

OBJECTIVE

To assess the effect of P4P incentives on quality in EHR-enabled small practices in the context of an established quality improvement initiative.

DESIGN, SETTING, AND PARTICIPANTS

A cluster-randomized trial of small (<10 clinicians) primary care clinics in New York City from April 2009 through March 2010. A city program provided all participating clinics with the same EHR software with decision support and patient registry functionalities and quality improvement specialists offering technical assistance.

INTERVENTIONS

Incentivized clinics were paid for each patient whose care met the performance criteria, but they received higher payments for patients with comorbidities, who had Medicaid insurance, or who were uninsured (maximum payments: $200/patient; $100,000/clinic). Quality reports were given quarterly to both the intervention and control groups.

MAIN OUTCOMES AND MEASURES

Comparison of differences in performance improvement, from the beginning to the end of the study, between control and intervention clinics for aspirin or antithrombotic prescription, blood pressure control, cholesterol control, and smoking cessation interventions. Mixed-effects logistic regression was used to account for clustering of patients within clinics, with a treatment by time interaction term assessing the statistical significance of the effect of the intervention.

RESULTS

Participating clinics (n = 42 for each group) had similar baseline characteristics, with a mean of 4592 (median, 2500) patients at the intervention group clinics and 3042 (median, 2000) at the control group clinics. Intervention clinics had greater adjusted absolute improvement in rates of appropriate antithrombotic prescription (12.0% vs 6.1%, difference: 6.0% [95% CI, 2.2% to 9.7%], P = .001 for interaction term), blood pressure control (no comorbidities: 9.7% vs 4.3%, difference: 5.5% [95% CI, 1.6% to 9.3%], P = .01 for interaction term; with diabetes mellitus: 9.0% vs 1.2%, difference: 7.8% [95% CI, 3.2% to 12.4%], P = .007 for interaction term; with diabetes mellitus or ischemic vascular disease: 9.5% vs 1.7%, difference: 7.8% [95% CI, 3.0% to 12.6%], P = .01 for interaction term), and in smoking cessation interventions (12.4% vs 7.7%, difference: 4.7% [95% CI, -0.3% to 9.6%], P = .02 for interaction term). Intervention clinics performed better on all measures for Medicaid and uninsured patients except cholesterol control, but no differences were statistically significant.

CONCLUSIONS AND RELEVANCE

Among small EHR-enabled clinics, a P4P incentive program compared with usual care resulted in modest improvements in cardiovascular care processes and outcomes. Because most proposed P4P programs are intended to remain in place more than a year, further research is needed to determine whether this effect increases or decreases over time.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00884013.

Use of electronic medical records differs by specialty and office settings

OBJECTIVE

To assess differences in the use of electronic medical records (EMRs) among medical specialties and practice settings.

METHODS

A cross-sectional retrospective study using nationally representative data from the National Ambulatory Medical Care Survey for the period 2003-2010 was performed. Bivariate and multivariate analyzes compared EMR use among physicians of 14 specialties and assessed variation by practice setting. Differences in EMR use by geographic region, patient characteristics, and physician office settings were also assessed.

RESULTS

Bivariate and multivariate analysis demonstrated increased EMR use from 2003 to 2010, with 16% reporting at least partial use in 2003, rising to 52% in 2010 (p<0.001). Cardiologists, orthopedic surgeons, urologists, and family/general practitioners had higher frequencies of EMR use whereas psychiatrists, ophthalmologists, and dermatologists had the lowest EMR use. Employed physicians had higher EMR uptake than physicians who owned their practice (48% vs 31%, p<0.001). EMR uptake was lower among solo practitioners (23%) than non-solo practitioners (42%, p<0.001). Practices owned by Health Maintenance Organizations had higher frequencies of EMR use (83%) than practices owned by physicians, community health centers, or academic centers (all <45%, p<0.001). Patient demographics did not affect EMR use (p>0.05).

CONCLUSIONS

Uptake of EMR is increasing, although it is significantly slower in dermatology, ophthalmology, and psychiatry. Solo practitioners and owners of a practice have low frequencies of EMR use compared with non-solo practitioners and those who do not own their practice. Despite incentives for EMR adoption, physicians should carefully weigh which, if any, EMR to adopt in their practices.

Patient medical group continuity and healthcare utilization

OBJECTIVES

To measure continuity among medical groups of insured patients over a 5-year period and to test whether group continuity of care is associated with healthcare utilization and costs.

STUDY DESIGN

Retrospective observational study.

METHODS

We studied natural patient behavior by using insurance claims data in the absence of any medical group or health plan incentives for continuity. We conducted the study through a retrospective analysis of administrative data of 121,780 patients enrolled from 2005 to 2009 in HealthPartners, a large nonprofit Minnesota health plan. Each year, patients were attributed to the medical group where they received the greatest number of primary care visits. Multilevel multiple regression models were used to estimate the association of annualized medical cost and utilization with attribution and continuity categories.

RESULTS

Although patients with high medical group continuity were older and had more comorbidities than patients with medium or low continuity of care, they had a consistently lower probability of any inpatient expenditure or any emergency department (ED) utilization and lower total medical costs.

CONCLUSIONS

Although a small proportion, health plan members who visited a primary care provider but had low or medium continuity among medical groups had higher inpatient and ED use than those with high continuity. Improved coordination and integration has potential to lower utilization and costs in this group.

Creating a culture of patient safety in a primary-care physician group

Typically risk-management strategies have been applied to the inpatient setting. In 2003, a comprehensive risk-management program was introduced to ProHealth Physicians, one of the largest primary-care practice groups in Connecticut. The program included strategies for education, practice change, incentive and compliance. Performance metrics for clinician participation and compliance were prespecified. Clinicians' attitudes and behavior change were assessed after introduction of the program. Audits were conducted by external reviewers to assess compliance. Financial data from before-to-after program implementation were compared. Results showed fewer claims and substantial cost savings. A strong commitment to the implementation of a comprehensive risk-management program can create a culture of safety in an outpatient setting.

Determinants of diagnostic imaging utilization in primary care

OBJECTIVES

To examine patient and physician factors affecting utilization of diagnostic imaging in primary care.

DATA SOURCES/STUDY SETTING

Patient-level data from a large academic group practice over the period July 1, 2007, through June 30, 2009.

STUDY DESIGN

This is a retrospective cohort study of 85,277 patients cared for by 148 primary care physicians (PCPs). The dependent variable is the number of outpatient imaging exams ordered by each patient's PCP over the study period. Independent variables include 17 patient factors describing both clinical need and demographic characteristics and 7 physician factors.

DATA COLLECTION

Data were collected from the electronic medical record and associated administrative databases.

PRINCIPAL FINDINGS

Patient factors having a statistically significant effect on both the probability race, more than 10 medications, congestive heart failure, diabetes, hypertension, other problems, visits to the PCP, visits to specialists, and imaging exams ordered by specialists. For physician factors, experience, gender, and having another degree were statistically significant in both portions of the model.

CONCLUSIONS

Both patient and physician factors have a substantial effect on primary care outpatient diagnostic imaging utilization. Several of these significantly influence both the probability that any images will be ordered and the intensity (number) of imaging.

Reduction in downstream test utilization following introduction of coronary computed tomography in a cardiology practice

To compare utilization of non-invasive ischemic testing, invasive coronary angiography (ICA), and percutaneous coronary intervention (PCI) procedures before and after introduction of 64-slice multi-detector row coronary computed tomographic angiography (CCTA) in a large urban primary and consultative cardiology practice. We utilized a review of electronic medical records (NotesMD) and the electronic practice management system (Megawest) encompassing a 4-year period from 2004 to 2007 to determine the number of exercise treadmill (TME), supine bicycle exercise echocardiography (SBE), single photon emission computed tomography (SPECT) myocardial perfusion stress imaging (MPI), coronary calcium score (CCS), CCTA, ICA, and PCI procedures performed annually. Test utilization in the 2 years prior to and 2 years following availability of CCTA were compared. Over the 4-year period reviewed, the annual utilization of ICA decreased 45% (2,083 procedures in 2004 vs. 1,150 procedures in 2007, P < 0.01) and the percentage of ICA cases requiring PCI increased (19% in 2004 vs. 28% in 2007, P < 0.001). SPECT MPI decreased 19% (3,223 in 2004 vs. 2,614 in 2007 P < 0.02) and exercise stress treadmill testing decreased 49% (471 in 2004 vs. 241 in 2007 P < 0.02). Over the same period, there were no significant changes in measures of practice volume (office and hospital) or the annual incidence of PCI (405 cases in 2004 vs. 326 cases in 2007) but a higher percentage of patients with significant disease undergoing PCI 19% in 2004 vs. 29% in 2007 P < 0.01. Implementation of CCTA resulted in a significant decrease in ICA and a corresponding significant increase in the percentage of ICA cases requiring PCI, indicating that CCTA resulted in more accurate referral for ICA. The reduction in unnecessary ICA is associated with avoidance of potential morbidity and mortality associated with invasive diagnostic testing, reduction of downstream SPECT MPI and TME as well as substantial savings in health care dollars.

Electronic health records in ambulatory care--a national survey of physicians

BACKGROUND

Electronic health records have the potential to improve the delivery of health care services. However, in the United States, physicians have been slow to adopt such systems. This study assessed physicians' adoption of outpatient electronic health records, their satisfaction with such systems, the perceived effect of the systems on the quality of care, and the perceived barriers to adoption.

METHODS

In late 2007 and early 2008, we conducted a national survey of 2758 physicians, which represented a response rate of 62%. Using a definition for electronic health records that was based on expert consensus, we determined the proportion of physicians who were using such records in an office setting and the relationship between adoption and the characteristics of individual physicians and their practices.

RESULTS

Four percent of physicians reported having an extensive, fully functional electronic-records system, and 13% reported having a basic system. In multivariate analyses, primary care physicians and those practicing in large groups, in hospitals or medical centers, and in the western region of the United States were more likely to use electronic health records. Physicians reported positive effects of these systems on several dimensions of quality of care and high levels of satisfaction. Financial barriers were viewed as having the greatest effect on decisions about the adoption of electronic health records.

CONCLUSIONS

Physicians who use electronic health records believe such systems improve the quality of care and are generally satisfied with the systems. However, as of early 2008, electronic systems had been adopted by only a small minority of U.S. physicians, who may differ from later adopters of these systems.

Attitudes toward pay-for-performance initiatives among primary care osteopathic physicians in small group practices

CONTEXT

Pay-for-performance (P4P) programs reward physicians who meet-and electronically document-specific healthcare standards during patient encounters, incentivizing certain aspects of medical care. Although such documentation can be time consuming and technology intensive, noncompliance can result in decreased physician reimbursement.

OBJECTIVE

To assess the attitudes of primary care osteopathic physicians toward P4P initiatives.

METHODS

In 2006, a 20-item questionnaire was mailed to 1000 osteopathic physicians randomly pulled from the American Osteopathic Association database for this cross-sectional, survey-based study. Distinctions were not made between physician practice type or group size when the mailing list was compiled.

RESULTS

Two hundred thirty responses were received for a response rate of 23%. Of these respondents, 123 physicians (54%) were in primary care practices comprising fewer than five physicians. Of these practitioners, 94% felt unprepared for P4P initiatives, 81% did not have the resources for appropriate technological investments, and 75% required additional P4P education and training to respond to P4P initiatives. In addition, the 28% of respondents who used electronic medical records were almost five times more likely (odds ratio, 4.80; 95% confidence interval, 1.91-12.06) to report that they could meet P4P reporting requirements. The majority of survey respondents were skeptical that P4P would appropriately capture the quality of their work and did not believe that health outcomes should influence their reimbursement.

CONCLUSIONS

Although the current study's sample size may limit generalizability, small group primary care osteopathic physicians will need assistance-both technological and educational-to meet P4P measures.

Evaluation of the relationship between a chronic disease care management program and california pay-for-performance diabetes care cholesterol measures in one medical group

BACKGROUND

Pay for performance (P4P) is a business model in which health plans pay provider organizations (medical groups) financial incentives based on attainment of clinical quality, patient experience, and use of information technology. The California P4P program is the largest P4P program in the united states and represents a potential revenue source for all participating medical groups. The clinical specifications for the California P4P program are based on the national Committee for Quality assurance (NCQA), Health Plan Employer Data, and information set (HEDIS), and each clinical measure has its own benchmark. in 2005, participating medical groups were paid on the basis of 9 clinical measures that were evaluated in the 2004 measurement year. The cholesterol testing measure represented 4.44%-7.14% of the total P4P dollars available to participating medical groups from the health plans.

OBJECTIVES

To (1) compare the percentage of medical group members aged 18 to 75 years with diabetes (type 1 or type 2) who received a low-density lipoprotein cholesterol (LDL-C) test and attained LDL-C control (<130 mg per dl) after enrolling in a chronic disease care management (CDCM) program with similar members managed by routine care, and to (2) assess the potential effect of CDCM on the quality performance ranking and financial reimbursement of a medical group reporting these measures in the 2004 California P4P measurement year.

METHODS

This is a retrospective database review of electronic laboratory (lab) values, medical and hospital claims, and encounter data collected between january 1, 2003 and December 31, 2004 at 1 California medical group comprising 160 multispecialty providers. Requirements were continuous patient enrollment in 1 of the 7 health plans participating in P4P during the measurement year (2004) with no more than 1 gap in enrollment of up to 45 days. Patients aged 18 to 75 years were included in the diabetes cholesterol measure (denominator) if they had at least 2 outpatient encounters coded for a primary, secondary, or tertiary diagnosis of diabetes (International Classification of Diseases, Ninth Revision, Clinical Modification code 250.xx, 357.2, 362.0, 366.41, 648.0) or 1 acute inpatient (Diagnosis Related Group code 294 or 295) or emergency room visit for diabetes. Lab values were obtained from multiple sources, including archived lab databases during the same measurement period (numerator). The CDCM program provided education and recommendations for diet, lifestyle, and medication modification delivered by a multidisciplinary team of nurses, pharmacists, and dieticians, and this intervention was compared with routine care for patients not enrolled in the CDCM program.

RESULTS

Of the 54,000 health plan members enrolled in this medical group under capitated reimbursement, 1,859 patients (3.4%) met the California P4P specifications for eligibility for the diabetes cholesterol measures and were evaluated. Of these, 8.9% (165/1,859) were followed by the CDCM program and 91.1% (1,694/1,859) by routine care. The LDL-C lab testing rate for patients in the CDCM program was 91.5% (151/165), and the LDL-C goal rate was 78.2% (129/165) compared with 67.8% (1,148/1,694) and 55.7%, respectively, for routine care (P < 0.001 for both comparisons). if the LDL-C lab testing and goal attainment rates for the CDCM group were compared with rates for peer medical groups, this medical group would have scored in the 75th and 90th percentiles, respectively, corresponding to an annual revenue potential of $28,512 for this medical group if the total incentive payment from the health plan was $1 per member per month (PMPM), or $57,024 if the total incentive P4P payment was $2 PMPM.

CONCLUSIONS

Preliminary data from 165 patients with diabetes managed in a CDCM program in a medical group operating under a small P4P financial incentive showed higher rates of LDL-C lab testing and goal attainment than from patients managed by routine care. Had these rates of LDL-C testing and goal attainment achieved in the CDCM program been extended to the entire P4P population with diabetes, this medical group would have generated incentive payments under the P4P program and ranked higher in publicly available quality scores.

Gender shift in realisation of preferred type of GP practice: longitudinal survey over the last 25 years

Background

An increasing number of newly trained Dutch GPs prefer to work in a group practice and as a non-principal rather than in a single-handed practice. In view of the greater number of female doctors, changing practice preferences, and discussions on future workforce problems, the question is whether male and female GPs were able to realise their initial preferences in the past and will be able to do so in the future.

Methods

We have conducted longitudinal cohort study of all GPs in the Netherlands seeking a practice between 1980 and 2004. The Netherlands Institute of Health Services Research (NIVEL) in Utrecht collected the data used in this study by means of a postal questionnaire. The overall mean response rate was 94%.

Results

Over the past 20 years, an increasing proportion of GPs, both male and female, were able to achieve their preference for working in a group practice and/or in a non-principal position. Relatively more women than men have settled in group practices, and more men than women in single-handed practices; however, the practice preference of men and women is beginning to converge. Dropout was highest among the GPs without any specific practice preference.

Conclusion

The overwhelming preference of male and female GPs for working in group practices is apparently being met by the number of positions (principal or non-principal) available in group practices. The preference of male and female GPs regarding the type of practice and job conditions is expected to converge further in the near future.

Colonoscopy completion and complication rates in a community gastroenterology practice

BACKGROUND

In the United States, colonoscopy completion and complication rates are rarely reported outside academic institutions. Increased transparency of quality measures and outcomes is being driven by professional societies, government agencies, and private enterprise.

OBJECTIVE

To collect and report the completion and complication rates of colonoscopy in a community gastroenterology practice.

DESIGN

Single-center study, prospective for completion, retrospective for complications.

SETTING

Community gastroenterology group practice, conducted from August 2002 through December 2004.

PATIENTS

A total of 12,407 consecutive patients referred for colonoscopy; mean age, 59.7 years; 5925 men.

INTERVENTIONS

Polypectomy and cautery were completed as indicated.

MAIN OUTCOME MEASURES

Completion of colonoscopy to cecum or ileocolonic anastomosis. Complications of hemorrhage and perforation.

RESULTS

A colonoscopy was completed in 98.4% of patients. Polypectomy was accomplished in 5074 (40.9%). Polyps occurred more often in men (46.4% vs 35.8%, P < .001). Causes for failure included difficult anatomy (55.9%), inadequate preparation (20.8%), obstructing malignancy (8.6%), discomfort (8.1%), and severe inflammation (6.1%). Failure from difficult anatomy was more likely in women (1.19% vs 0.56%, P < .001). Hemorrhage requiring hospitalization occurred after 25 cases (0.20%). Twenty-three episodes of bleeding occurred after polypectomy (0.46%) and 2 after treatment of arteriovenous malformations. Two perforations occurred (0.016%). One patient developed a posterior circulation stroke. No deaths occurred.

LIMITATIONS

Completion not independently verifiable. Complications were collected retrospectively.

CONCLUSIONS

Colonoscopy completion and complication rates in this community gastroenterology practice compared favorably with U.S. academic centers. Endoscopic quality in community practices can meet published outcomes.

Determinants of Radiologists’ Productivity in Private Group Practices in California

PURPOSE

The purpose of this study was to determine factors that would affect radiologists' productivity in private group practices in California.

METHODS

Individual productivity data were collected for 236 private practice radiologists from 6 private radiology groups in California. The data included information on physician characteristics, facility indicators, and group practice factors that were hypothesized to affect providers' productivity. Statistical tests including chi-square testing and multivariate linear regression were used to analyze the effect of the 3 groupings of factors on the productivity of the radiologists.

RESULTS

With increases in age, the number of years in practice, and the number of years in affiliation with the group practice, productivity seemed to decrease. On the other hand, productivity tended to increase if a radiologist was a shareholder, with an increase in the number of facilities served by the radiologist per day, in the proportion of imaging examinations and interventional procedures conducted, and in the proportion of those examinations stored in picture archiving and communication systems.

CONCLUSIONS

To improve radiologists' productivity, group practices must invest in data-reporting infrastructure for tracking productivity, contract with outpatient imaging centers, and review group practice partnership composition and incentive models to ensure higher productivity. Future studies might consider examining the effect of other factors, such as time spent on nonclinical duties and the use of paramedical assistants in the practice.

Drivers of electronic medical record adoption among medical groups

BACKGROUND

Use of electronic medical records (EMRs) in health care organizations can reduce medical errors and improve quality of care through physicians' increased use of evidence-based patient care processes. However, only 20%-25% of physician organizations have adopted EMRs. A study was undertaken to determine the characteristics of primary care medical groups that distinguish EMR adopter from nonadopter organizations.

METHODS

A quantitative nationwide survey was undertaken of all primary care medical groups in the United States with 20 or more physicians; data were collected on 738 medical groups (70% response rate).

RESULTS

Fewer than one-third of the medical groups reported having either patients' medical records or progress notes in an EMR. Large organizations with relatively fewer practice locations were more likely to adopt an EMR.

DISCUSSION

Large medical groups are more likely to have the financial and human resources necessary to overcome barriers to the adoption of an EMR. Knowing the influence of the other organizational characteristics on EMR adoption will help prepare organizational leaders for the complicated process of achieving consensus among physicians and others in medical groups on the expenditure of funds and other resources to acquire an EMR. Financial incentives for all medical groups will help drive EMR adoption, but financial and technical assistance aimed specifically at smaller groups is particularly warranted. Widespread adoption of EMR among medical groups will take time.

Practice systems for chronic care: frequency and dependence on an electronic medical record

OBJECTIVES

To document the presence and functioning of different practice systems in a small sample of medical groups in Minnesota and to examine the relationship between the presence of practice systems and prior adoption of an electronic medical record (EMR).

STUDY DESIGN

Descriptive study of the frequency of practice systems in 11 medical groups.

METHODS

We recruited 11 medical groups for the study. Four groups had an EMR; the other groups used paper medical records, often supplemented by electronic ordering or data systems. Using an on-site audit team, we validated the presence of practice systems organized under 8 categories.

RESULTS

All of the medical groups had implemented a substantial number of practice systems for care management of patients with chronic conditions. Although the medical groups with an EMR tended to have more comprehensive practice systems in place, the medical groups without an EMR also had most of the practice systems.

CONCLUSIONS

Although required in some functions, an EMR may not be necessary in facilitating practice systems that support consistent management of patients with chronic illness. Approaches are needed that will encourage the implementation of practice systems in medical groups with and without an EMR.

The routine use of health risk appraisals: results from a national study of physician organizations

PURPOSE

To document use of health risk appraisals (HRAs) by U.S. physician organizations as part of their overall approach to health promotion and to identify associated organizational characteristics.

METHODS

Telephone survey of 1590 physician organizations in the United States; surveys were conducted in organizations comprising 20 or more physicians and were conducted between September 2000 and September 2001 (70% response rate). Chi-square tests and logistic regression analysis were used to examine the association between organizational characteristics and routine administration of HRAs.

RESULTS

Only 22.5% of physician organizations in the United States routinely administer HRAs. External quality incentives, information technology capabilities, and status as a medical group vs. an independent practice association are associated with greater odds of the routine use of HRA.

DISCUSSION

Increased use of external quality incentives and information technology in physician organizations may be important in supporting the use of HRAs.

Imputation of SF-12 health scores for respondents with partially missing data

OBJECTIVE

To create an efficient imputation algorithm for imputing the SF-12 physical component summary (PCS) and mental component summary (MCS) scores when patients have one to eleven SF-12 items missing.

STUDY SETTING

Primary data collection was performed between 1996 and 1998.

STUDY DESIGN

Multi-pattern regression was conducted to impute the scores using only available SF-12 items (simple model), and then supplemented by demographics, smoking status and comorbidity (enhanced model) to increase the accuracy. A cut point of missing SF-12 items was determined for using the simple or the enhanced model. The algorithm was validated through simulation.

DATA COLLECTION

Thirty-thousand-three-hundred and eight patients from 63 physician groups were surveyed for a quality of care study in 1996, which collected the SF-12 and other information. The patients were classified as "chronic" patients if they reported that they had diabetes, heart disease, asthma/chronic obstructive pulmonary disease, or low back pain. A follow-up survey was conducted in 1998.

PRINCIPAL FINDINGS

Thirty-one percent of the patients missed at least one SF-12 item. Means of variance of prediction and standard errors of the mean imputed scores increased with the number of missing SF-12 items. Correlations between the observed and the imputed scores derived from the enhanced models were consistently higher than those derived from the simple model and the increments were significant for patients with > or =6 missing SF-12 items (p<.03).

CONCLUSION

Missing SF-12 items are prevalent and lead to reduced analytical power. Regression-based multi-pattern imputation using the available SF-12 items is efficient and can produce good estimates of the scores. The enhancement from the additional patient information can significantly improve the accuracy of the imputed scores for patients with > or =6 items missing, leading to estimated scores that are as accurate as that of patients with <6 missing items.

Gender-related differences in general practice preferences: longitudinal evidence from the Netherlands 1982-2001

The proportion of female doctors is increasing. Yet, there is little evidence that demonstrates changing career preferences over a long period, nor do we know the long-term impact of changing male-female ratios in medicine. We explored this within the GP profession. By means of a longitudinal cohort study (postal questionnaires) among all graduated GPs in the Netherlands between 1982 and 2001 we explored trends in career preferences and investigated whether practice preferences of men and women differ over the years. Preference of becoming a GP has significantly decreased among men. GPs prefer group practice more than solo practice. Female doctors were more likely to prefer a small practice and to associate. Men prefer to take over an established practice. Main reasons to abstain from practicing as a GP for men were having found another job or not having found a practice according to their preferences. Main reasons for women were having decided for another job and family life. We conclude that male and female GPs select differently on practice setting. Preferences change through the years but tend to converge. Gender differences are likely due to the circumstance that career choices for men are more influenced by fluctuating labour markets, while female choices are more based on family circumstances. We expect that as more women will become a GP the demand for small group practices will increase. Also, as many female GPs abstain from practicing after having finished a vocational GP training program it will be essential to create work facilities to keep them available for the GP labour market.