Quality of Care in Patients with Diabetes
Authors: Parthiv J. Mahadevia, Seth Himelhoch, Joel Braunstein
Journal: Annals of Internal Medicine (2002)

Letters2 July 2002Quality of Care in Patients with DiabetesParthiv J. Mahadevia, MD, Seth Himelhoch, MD, and Joel Braunstein, MDParthiv J. Mahadevia, MDJohns Hopkins Hospital; Baltimore, MD 21287 (Mahadevia, Himelhoch, Braunstein)Search for more papers by this author, Seth Himelhoch, MDJohns Hopkins Hospital; Baltimore, MD 21287 (Mahadevia, Himelhoch, Braunstein)Search for more papers by this author, and Joel Braunstein, MDJohns Hopkins Hospital; Baltimore, MD 21287 (Mahadevia, Himelhoch, Braunstein)Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-137-1-200207020-00019 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail TO THE EDITOR:We applaud Greenfield and colleagues for demonstrating the confounding effects of physician-level clustering on quality assessments across provider groups (1). We disagree, however, with one of the study's major inferences: that endocrinologists and generalists do not significantly differ in the quality of patient diabetes care after adjustment for case mix and physician-level clustering.Physician-level clustering limited the power of this study to detect major differences in care between endocrinologists and generalists. Still, the maximal likelihood estimations for most of the process and outcome measures suggested that endocrinologists offered favorable care. Physician-level clustering did not qualitatively change maximal likelihood estimates on any of the measures; it simply widened the confidence intervals. The failure to achieve “statistical significance” due to high variances should not necessarily minimize the importance of a consistent point estimate that suggests meaningful differences in care quality.There is face validity to the notion that endocrinologists assess hemoglobin A1c levels, screen for urine proteinuria, and ask patients for self-measured blood glucose levels more frequently than generalists. Greenfield and colleagues' Figure, which displays the proportion of patients achieving hemoglobin A1c levels less than 0.10 (10%), further supports meaningful specialty differences. Seven endocrinology sites compared with only two generalist sites statistically performed above the mean.Despite advancements in case-mix and physician-clustering techniques, we question the rationale for comparisons between specialists and generalists. In the end, aren't we comparing apples and oranges? Generalists and specialists operate under different contexts in our health care system. In our opinion, the most enlightening aspect of Greenfield and colleagues' analysis was the observed within-specialty variation in care quality. Why do some endocrinologists' practices achieve 90% success in reducing patients' hemoglobin A1c levels to less than 0.10 (10 %) while others achieve only 50% success? We look forward to future evaluations that address this question, particularly those that appropriately adjust for physician-level clustering.Reference1. Greenfield S, Kaplan SH, Kahn R, Ninomiya J, Griffith JL. Profiling care provided by different groups of physicians: effects of patient case-mix (bias) and physician-level clustering on quality assessment results. Ann Intern Med. 2002;136:111-21. [PMID: 11790062] LinkGoogle Scholar Comments0 CommentsSign In to Submit A Comment Author, Article, and Disclosure InformationAffiliations: Johns Hopkins Hospital; Baltimore, MD 21287 (Mahadevia, Himelhoch, Braunstein) PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoProfiling Care Provided by Different Groups of Physicians: Effects of Patient Case-Mix (Bias) and Physician-Level Clustering on Quality Assessment Results Sheldon Greenfield , Sherrie H. Kaplan , Richard Kahn , John Ninomiya , and John L. Griffith Quality of Care in Patients with Diabetes Rhoda H. Cobin and Helena W. Rodbard Quality of Care in Patients with Diabetes Sam Weir , Robert Stone , Philip Levy , Stephen F. Hodgson , and Barbara Fleming Quality of Care in Patients with Diabetes Sheldon Greenfield , Sherrie H. Kaplan , and Richard Kahn Quality of Care in Patients with Diabetes Metrics Cited bySubspecialist Care Improves Diabetes Outcomes 2 July 2002Volume 137, Issue 1Page: 70KeywordsForecastingGlucoseHealth careHealth care qualityHealth care quality assessmentHemoglobinPatientsProteinuriaReproducibilityUrine ePublished: 2 July 2002 Issue Published: 2 July 2002 Copyright & PermissionsCopyright © 2002 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...