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Where Is the Emphasis?

Eve A. Kerr, MD, MPH; Brian S. Mittman, PhD; Ron D. Hays, PhD; Barbara Leake, PhD; Robert H. Brook, MD, ScD

JAMA. 1996;276(15):1236-1239.

Abstract
Objective.
—To describe quality assurance (QA) programs implemented by capitated physician groups; to measure their relative emphasis on monitoring of overuse compared with underuse and monitoring and improving preventive services compared with chronic disease care; and to examine how group characteristics influence QA activity.

Design.
—Cross-sectional questionnaire.

Setting.
—A large network-model health maintenance organization in California (133 contracting physician groups).

Participants.
—Ninety-four physician groups (71%) caring for 2.9 million capitated patients.

Main Outcome Measures.
—Self-reported use of quality monitoring and improvement methods.

Results.
—All capitated physician groups conducted some QA. Groups' QA programs monitored areas subject to overuse, such as cesarean delivery and angioplasty rates, more than areas subject to underuse, such as childhood immunization rates and performance of retinal examinations for diabetic patients (64% vs 43%, P<.001). They monitored underuse of preventive services more than follow-up services for chronic diseases (54% vs 31%, P<.001). Groups also used reminders for preventive services more than they monitored follow-up services for chronic diseases (26% vs 15%, P<.01). Physician group characteristics independently associated with higher overall QA activity were greater number of years in existence, higher profitability, and capitated care penetration.

Conclusion.
—Capitation places a large share of responsibility for QA in the hands of physician groups, but not all aspects of QA are being equally addressed. The emphasis on overuse may result from financial incentives inherent in capitation, while the focus on preventive services may stem from lack of adequate quality measurement tools for monitoring chronic disease care. Further research efforts should address how capitated physician groups might expand their QA programs to include monitoring of underuse, especially for patients with chronic disease.

Author Affiliations
From the Department of Medicine, University of California, Los Angeles (Drs Kerr, Hays, Leake, and Brook); RAND, Santa Monica, Calif (Drs Kerr, Mittman, Hays, and Brook); Sepulveda (Calif) Veterans Affairs Health Services Research and Development Service Field Program, Center for the Study of Healthcare Provider Behavior (Dr Mittman); and the School of Public Health, University of California, Los Angeles (Dr Brook). Dr Kerr is now with the Ann Arbor (Mich) Veterans Affairs Health Services Research and Development Field Program.

Footnotes
Some results contained in this paper were presented at the Society of General Internal Medicine National Meeting, San Diego, Calif, May 5, 1995.

Opinions expressed are those of the authors and do not necessarily reflect those of their institutions or the funding agencies.

Reprints: Eve A. Kerr, MD, MPH, Ann Arbor Veterans Affairs Health Services Research and Development Field Program, PO Box 130170, Ann Arbor, Ml 48113-0170.

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