Profiling performance in primary care in the United States

We agree with Goldfield, Gnani and Majeed(1) that it is important to
measure physician performance in a way that will improve the effectiveness
and efficiency of primary health care delivery. As primary care physicians
we have a responsibility to ensure such measurements of our performance
will actually drive our care in a positive direction, although the
generalist, longitudinal and team based nature of primary health care
makes this a complex exercise.(2) In addition, different patient disease,
socioeconomic and cultural profiles make comparisons difficult to
interpret and release of this information to the general public of this
information is potentially unfair.

In Canada, there is much discussion about Family Physician
performance at a national level, but little action to date. At a local and
regional level, however researchers from the University of Ottawa have had
considerable success. Our model(3)is practice-based rather than physician
profiling and run by the University, independent of government, payers and
medical organizations. Clinical performance measurement is confidential
and not released to the public at any level that could identify individual
practices or physicians. Performance results of detailed repeated chart
audit and patient survey are supported by feedback from facilitators.
Such feedback is emotional, complicated and takes skilled people several
visits before it is integrated fully and accepted by physicians.(4) The
practices are helped to use the information to set targets and create a
plan to improve service delivery. Physician and practice patterns do
change.(2) Currently we are funded to implement this research program at a
provincial level in Ontario.

Other developments in Canada are noteworthy. The current Primary
Health Care Transition Fund (PHCTF) program is shifting the emphasis from
physician performance to the performance of an interdisciplinary team or
practice. PHCTF is mostly about promoting improved team performance in its
goals of access, comprehensiveness, quality and accountability with less
focus on individual physician performance. This is appropriate and fair;
however, completely ignoring the primary care physician leadership role in
responsibility for clinical care outcomes will not best serve the
population either. We should not shy away from true physician
accountability that is based on fair and scientifically valid appraisal,
but recognizes different roles and responsibilities in the complexity of
primary health care delivery in different populations. There is an urgent
need to collaborate internationally on how to measure such performance
with well validated indicators and to improve care delivery. Such
measurement should be conducted at arms length from the payers whether
they are private or public in a way that is empowering and formative and
not punitive.

Carmel Martin and William Hogg, Department of Family Medicine,
University of Ottawa, Ontario, Canada

1. Goldfield N, Gnani S and Majeed A. Primary care in the United
States - Profiling performance in primary care in the United States, BMJ
2003;326:744-747 5

2. Martin C, Douglas R. "Getting Value for Money". Measuring the
outcome and quality of general practice care. MJA, Vol 159, 16 August,
1993.

3. Lemelin J, Hogg W, Baskerville N. Evidence to action: a tailored
multifaceted approach to changing family physician practice patterns and
improving preventive care. CMAJ 2001; 164(6):757-763

4. Baskerville NB, Hogg W, Lemelin J. Process evaluation of a
tailored multifaceted approach to changing family physician practice
patterns improving preventive care. J Fam Pract 2001; 50(3):W242-W249.

Competing interests:  
None declared