Practice list size, workforce composition and performance in English general practice: a latent profile analysis.

BACKGROUND: Following government calls for General Practices in England to work at scale, some practices have grown in size from traditionally small, General Practitioner (GP)-led organisations to large multidisciplinary enterprises. We assessed the effect of practice list size and workforce composition on practice performance in clinical outcomes and patient experience. METHODS: We linked five practice-level datasets in England to obtain a single dataset of practice workforce, list size, proportion of registered patients ≥ 65 years of age, female-male sex ratio, deprivation, rurality, GP contract type, patient experience of care, and Quality and Outcomes Framework (QOF) and non-QOF clinical processes and outcomes. Latent Profile Analysis (LPA) was used to cluster general practices into groups based on practice list size and workforce composition. Bayesian Information Criterion, Akaike Information Criterion and deliberation within the research team were used to determine the most informative number of groups. One-way ANOVA was used to assess how groups differed on indicator variables and other variables of interest. Linear regression was used to assess the association between practice group and practice performance. RESULTS: A total of 6024 practices were available for class assignment. We determined that a 3-class grouping provided the most meaningful interpretation; 4494 (74.6%) were classified as 'Small GP-reliant practices', 1400 (23.2%) were labelled 'Medium-size GP-led practices with a multidisciplinary team (MDT) input' and 131 (2.2%) practices were named 'Large multidisciplinary practices'. Small GP-reliant practices outperformed larger multidisciplinary practices on all patient-reported indicators except on confidence and trust where medium-size GP-led practices with MDT input appeared to do better. There was no difference in performance between small GP-reliant practices and larger multidisciplinary practices on QOF incentivised indicators except on asthma reviews where medium-size GP-led practices with MDT input performed worse than smaller GP-reliant practices and immunisation coverage where the same group performed better than smaller GP-reliant practices. For non-incentivised indicators, larger multidisciplinary practices had higher cancer detection rates than small GP-reliant practices. CONCLUSION: Small GP-reliant practices were found to provide better patient reported access, continuity of care, experience and satisfaction with care. Larger multidisciplinary practices appeared to have better cancer detection rates but had no effect on other clinical processes and outcomes. As England moves towards larger multidisciplinary practices efforts should be made to preserve good patient experience.

Optimization of laboratory procedures for intrauterine insemination: survey of methods in relation to clinical outcome.

BACKGROUND: There is a wide practice variation of used methods and outcomes in IUI in fertility laboratories. Standardization of the IUI procedure is important for reducing inconsistency among laboratories in counseling infertile couples and in pregnancy results. The aim of the study was to evaluate the currently used laboratory procedures of IUI in Dutch fertility laboratories and their effect on IUI pregnancy results. Additionally, the methods for semen analysis (SA) were evaluated, as SA is related to IUI in terms of inseminated sperm number and IUI counseling. MATERIAL AND METHODS: This questionnaire survey study was sent to laboratories participating in the Dutch external quality control program for semen analysis (SKML) and consisted of 46 questions concerning laboratory management, methods for semen analysis and IUI, and clinical results. The results were analyzed using univariable and multivariable logistic regression models. RESULTS: A total of 52 laboratories (out of 99) provided information on used methodologies for SA or laboratory procedures of IUI and the organization of the laboratory. A wide variability was confirmed in used methods for both SA and IUI. Evaluation of pregnancy results obtained during 3 years (2013-2015) showed that specific used laboratory methods have a significant effect on the probability of becoming pregnant. DISCUSSION AND CONCLUSION: Important to remark is that in this survey study cycle-specific data, including variables of the individual couples (age, stimulation protocol, etc), were not included and may have effects on the results. The reported results provide an overview of the current practice performance; however, the organization of fertility laboratories is changing rapidly. The use of standardized methods in IUI is important for optimizing the performance of care and improving pregnancy results. The knowledge on used procedures, however, is limited, and further research on factors involving SA and the IUI procedure is necessary.

A Multifaceted Organizational Physician Assessment Program: Validity Evidence and Implications for the Use of Performance Data.

OBJECTIVE: To provide validity evidence for a multifaceted organizational program for assessing physician performance and evaluate the practical and psychometric consequences of 2 approaches to scoring (mean vs top box scores). PARTICIPANTS AND METHODS: Participants included physicians with a predominantly outpatient practice in general internal medicine (n=95), neurology (n=99), and psychiatry (n=39) at Mayo Clinic from January 1, 2013, through December 31, 2014. Study measures included hire year, patient complaint and compliment rates, note-signing timeliness, cost per episode of care, and Likert-scaled surveys from patients, learners, and colleagues (scored using mean ratings and top box percentages). RESULTS: Physicians had a mean ± SD of 0.32±1.78 complaints and 0.12±0.76 compliments per 100 outpatient visits. Most notes were signed on time (mean ± SD, 96%±6.6%). Mean ± SD cost was 0.56±0.59 SDs above the institutional average. Mean ± SD scores were 3.77±0.25 on 4-point and 4.06±0.31 to 4.94±0.08 on 5-point Likert-scaled surveys. Mean ± SD top box scores ranged from 18.6%±16.8% to 90.7%±10.5%. Learner survey scores were positively associated with patient survey scores (r=0.26; P=.003) and negatively associated with years in practice (r=-0.20; P=.02). CONCLUSION: This study provides validity evidence for 7 assessments commonly used by medical centers to measure physician performance and reports that top box scores amplify differences among high-performing physicians. These findings inform the most appropriate uses of physician performance data and provide practical guidance to organizations seeking to implement similar assessment programs or use existing performance data in more meaningful ways.

Patient experiences with family medicine: a longitudinal study after the Dutch health care reforms in 2006.

BACKGROUND: In 2006 The Dutch Health Care system changed to a market oriented system. The GP remuneration changed from ± 2/3 capitation patients and 1/3 private patients before 2006 to a mixed payment scheme. From 2006 onward every patient was insured and the GP received partly capitation, partly fees for consultations and for specific services. This change coincided with many other organisational changes in General Practice care. Our research question was if during the years after 2006 patient experiences of Dutch family practice had changed. We also wanted to explore the influence of patient and practice characteristics on patient experiences. Data on patient experiences were available from 2007 to 2012. METHOD: In a series of annual cross sectional patient surveys the performance of GPs and practices was measured. Patient sampling took place as a part of the Dutch accreditation program in 1657 practices involving 2966 GPs. Patients' experiences, gender, age, health status, and number of annual consultations were documented as well as the type and location of practices. Linear regression analysis was used to examine time trends in patient experiences and the impact of patient and practice characteristics. RESULTS: 78,985 patients assessed the performance of 2966 GPs, and 45,773 patients assessed the organisation of 1657 practices. The number of patients with positive experiences increased significantly between 2007 and 2012; respectively 4.8 % for GPs (beta 0.20 and p < 0.0001) and 6.6 % for practices (beta 0.10, p < 0.004). Higher age, having no chronic illness, more frequent consultations and attending single-handed practices, predicted better patient experiences. CONCLUSIONS: In our evaluation of patient experiences with general practice care from 2007 to 2012 we found an increase of 4.8 % for GPs and 6.6 % for practices respectively. This improvement is significant. While no direct causation can be made, possible explanations may be found in the various reforms in Dutch family practice since 2006. More insight is needed into key determinants of this improvement before policymakers and care providers can attribute the improvement to these reforms.

Effect of Physician IT Use on Practice Performance.

The role of information technology (IT) remains important within the medical community. However, little is known about the extent to which practicing physicians improve practice performance by having and utilizing IT at the national level. The present study, analyzing a national physician survey (n = 4,720), seeks to explore associations of IT availability and utilization with practice performance at the national level. The multivariate regression analysis results suggest that patient information IT functionality upholds physician advantages in annual income but prescription drug IT functionality was reversely linked to annual income. We also found a negative association of patient information IT functionality with patient visit volume. Our study results revealed mixed findings. Not all IT functionalities would offer benefits to practicing physicians. Our data suggest that patient information IT functionality can moderate cost concerns related to IT investment among providers.

Sources of apical defects on a high-sensitivity cardiac camera: experiences from a practice performance assessment.

UNLABELLED: Apical perfusion artifacts seen on a high-sensitivity camera warranted a practice performance assessment to evaluate contributions from soft-tissue attenuation, patient positioning, and image processing techniques. METHODS: Cardiac perfusion studies (n = 534) spanning 5 mo were retrospectively reviewed. Images were acquired with the patient in the upright position, and attenuation correction was used. Regression analysis and contingency tables correlated clinical data to the presence of apical artifacts. RESULTS: There was a positive correlation of with female sex (χ(2) = 32, P < 0.001), degree of overlying soft tissues (χ(2) = 20, P < 0.002), and breast cleavage (χ(2) = 7, P < 0.008) and a negative correlation with angiography-confirmed disease (χ(2) = 6, P < 0.02). There was moderate interobserver agreement between 2 observers in determining the presence of apical defects (κ= 0.44, 95% confidence interval = 0.19-0.69), and there was a perceived improvement of apical defects using fewer iterative updates (χ(2) = 8, P < 0.003). CONCLUSION: An understanding of sources contributing to imaging artifacts is a crucial portion of quality assessment in radiology and nuclear medicine. A practice performance assessment study at our institution showed that apical artifacts on a new-generation cardiac camera can be partially attributed to overlying soft-tissue attenuation and ameliorated by altering the reconstruction.