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Barbara Starfield, MD, MPH; Neil R. Powe, MD, MPH, MBA; Jonathan R. Weiner, DrPH; Mary Stuart, ScD; Donald Steinwachs, PhD; Sarah Hudson Scholle, DrPH; Andrea Gerstenberger, ScD

JAMA. 1994;272(24):1903-1908.

Abstract
Objective.
—To determine the relationship between efficiency in use of resources and quality of care provided by physicians serving as the usual source of care for patients in a state Medicaid program.

Design.
—Retrospective quality-of-care review of 2024 outpatient medical records of 135 providers sampled from system-wide Medicaid claims data in Maryland.

Subjects.
—Providers in three types of practice settings (hospital outpatient clinic, community health center, and physician's office) were stratified into three case mix—adjusted resource use groups (high, medium, and low). A sample of patients with the diagnoses of diabetes, hypertension, asthma, well-child care, or otitis media were identified from Medicaid claims forms from visits during 1988. Case mix was controlled by the application of the ambulatory care groups, a method that characterizes populations according to their burden of morbidity.

Main Outcome Measures.
—Nurses from the local peer review organization audited medical records using explicit criteria for quality of care in several categories: evidence of impaired access, evidence of compromised technical quality, evidence of inappropriate care, outcome of care, and several generic indicators of quality. Well-adult care was assessed for patients with the adult diagnoses.

Results.
—Although there were some systematic differences by type of facility in some aspects of quality of care (more access problems for patients in hospital clinics and more technical quality problems for patients in office-based practice), there were no consistent differences in quality of care overall for patients in different types of settings and no consistent relationships between cost-efficiency and quality of care. However, patients in medium-cost community health centers had the best or second best scores for most of the 21 comparisons of type of quality assessed.

Conclusions.
—Quality of care provided for common conditions in primary care is not associated with costs generated by providers. Policies directed toward the choice of low-cost vs high-cost providers will not necessarily lead to a deterioration in the quality of care. States can both improve quality and lower costs by consistent monitoring of programs over time. The finding of generally higher quality of care for patients in medium-cost community health centers deserves further study.

(JAMA. 1994;272:1903-1908)

Author Affiliations
From the Department of Health Policy and Management, School of Hygiene and Public Health (Drs Starfield, Powe, Weiner, and Steinwachs), and Department of Medicine, School of Medicine, (Drs Scholle and Gerstenberger), The Johns Hopkins University, and the State of Maryland, Department of Health and Mental Hygiene, Baltimore, Md (Dr Stuart). Dr Scholle is now with the Department of Pediatrics, University of Arkansas School of Medicine, Little Rock. Dr Gerstenberger is now with The Robert Wood Johnson Foundation, Princeton, NJ. Dr Powe was an American College of Physicians teaching and research scholar during the course of this study.

Footnotes
Reprint requests to Division of Health Policy, The Johns Hopkins University, 624 N Broadway, Fourth Floor, Baltimore, MD 21205-1996 (Dr Starfield).

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