Does Having a Personal Physician Improve Quality of Care in Diabetes?
Does Having a Personal Physician Improve Quality of Care in Diabetes?
Purpose: Although having a continuous relationship with a physician is a defining feature of primary care, few studies have evaluated the effect of this on chronic disease management. This aim of this study was to examine whether having a regular physician is associated with improvements in reaching treatment goals for patients with diabetes.
Methods: Through the use of a diabetes registry, patients diagnosed with diabetes mellitus for a minimum of 6 months cared for in a large, single academic family medicine practice were compared based on whether they had a regular physician or not. The 2 groups were compared in the frequency in which they achieved goals for management of glycated hemoglobin, blood pressure, low-density lipoprotein cholesterol, and other aspects of diabetes care.
Results: Patients with a regular provider were slightly older than those without a provider (57.5 years vs. 50.9 years; P = .002), but the gender distribution and percent who were smokers was the same. In assessing diabetes quality measures, patients with a regular provider had lower average levels of glycated hemoglobin (7.70 vs 8.53; P = .01), but no difference was noted in the percentage achieving a goal of ≤ 7.0. No differences were noted between the groups in either the average systolic or diastolic blood pressures or low-density lipoprotein cholesterol or in the percentages of patients achieving recognized goals for these measures. When examining other preventive services, patients with a regular provider were more likely to receive an influenza immunization within the last year (51.8% vs 35.6%; P = .02) but no more likely to receive a pneumococcal vaccine or take an aspirin each day.
Conclusion: This study suggests that there are few benefits for patients with diabetes in having an established regular provider over having a regular place of service.
Along with first contact, comprehensiveness, and coordination of care, continuity is considered one of the 4 cornerstones of primary care. The belief in the value of patient continuity with a regular provider who can develop intimate knowledge of the patient's clinical condition and establish a trusting, healing relationship with the patient is widely accepted among primary care providers and health policy experts. Having a regular physician has been shown to have a beneficial effect on a large range of health care services, including preventive services in children and reductions in hospital and emergency department use among patients with chronic health problems.
The effects of having a regular physician would seem to have the greatest benefit for patients who have complex chronic diseases for which the frequency of care and the necessity of multiple therapeutic interventions would be enhanced by an ongoing relationship with a single physician. However, there is conflicting evidence that having a regular physician makes a difference in the management of diabetes, a highly complex chronic medical illness. In an analysis of diabetes intermediate outcomes among a small sample of patients from 19 inner city practices in England, Gulliford and colleagues found no association between increasing levels of continuity and diabetes quality measures. Similarly, a large cross-sectional study using an administrative database failed to find a relationship between individual physician continuity and the performance of recommended testing. Finally, a study of participants in the National Health and Nutrition Examination Survey did not find any association between having a personal physician and glycemic control. However, this study did find an association between having a regular location of care and glycemic control.
In contrast, other evidence suggests some benefits of continuity on the management of patients with diabetes. In a group of patients from a health maintenance organization, OÂ’Connor et al found that those who had a regular provider were more likely to follow a diabetic diet, monitor their sugars at home, and receive recommended preventive services examinations. A smaller study at a training site also showed that, as continuity with a resident physician improved, so did glycemic control.
A drawback of all these studies was the definition of what having a regular physician meant. In some cases, investigators relied on patients to state whether they had a personal physician without inquiring whether the physician was aware of this. In other studies, authors did not define whether the provider was the patient's regular physician but instead focused on continuity, which was represented by who a patient saw most often.
Another drawback of previous studies is that continuity may not have been synonymous with a personal physician-patient relationship. If a physician does not view a particular patient as her or his patient, the care they render for patients may differ from that provided to a patient who the physician considers "theirs." One study conducted in a network of 18 practices found that physicians designated only 68% of patients they saw as "their patients." This implies that physicians often care for individuals with whom they do not feel they have a continuous relationship. It is unclear whether this lack of connection has any detrimental impact on the quality of care that patients receive over time.
The purpose of this study was to examine, from the physician perspective, the impact of having a regular physician on the management of diabetes in a single large practice. Because this study utilizes data from a single practice it allowed for the assessment of having a regular physician while controlling for the overall practice environment. Put another way, this study sought to determine whether having a physician identify patients as their own improves care more than when the same group of physicians manage patients but do not acknowledge any ongoing personal relationship with the patient.
Abstract and Introduction
Abstract
Purpose: Although having a continuous relationship with a physician is a defining feature of primary care, few studies have evaluated the effect of this on chronic disease management. This aim of this study was to examine whether having a regular physician is associated with improvements in reaching treatment goals for patients with diabetes.
Methods: Through the use of a diabetes registry, patients diagnosed with diabetes mellitus for a minimum of 6 months cared for in a large, single academic family medicine practice were compared based on whether they had a regular physician or not. The 2 groups were compared in the frequency in which they achieved goals for management of glycated hemoglobin, blood pressure, low-density lipoprotein cholesterol, and other aspects of diabetes care.
Results: Patients with a regular provider were slightly older than those without a provider (57.5 years vs. 50.9 years; P = .002), but the gender distribution and percent who were smokers was the same. In assessing diabetes quality measures, patients with a regular provider had lower average levels of glycated hemoglobin (7.70 vs 8.53; P = .01), but no difference was noted in the percentage achieving a goal of ≤ 7.0. No differences were noted between the groups in either the average systolic or diastolic blood pressures or low-density lipoprotein cholesterol or in the percentages of patients achieving recognized goals for these measures. When examining other preventive services, patients with a regular provider were more likely to receive an influenza immunization within the last year (51.8% vs 35.6%; P = .02) but no more likely to receive a pneumococcal vaccine or take an aspirin each day.
Conclusion: This study suggests that there are few benefits for patients with diabetes in having an established regular provider over having a regular place of service.
Introduction
Along with first contact, comprehensiveness, and coordination of care, continuity is considered one of the 4 cornerstones of primary care. The belief in the value of patient continuity with a regular provider who can develop intimate knowledge of the patient's clinical condition and establish a trusting, healing relationship with the patient is widely accepted among primary care providers and health policy experts. Having a regular physician has been shown to have a beneficial effect on a large range of health care services, including preventive services in children and reductions in hospital and emergency department use among patients with chronic health problems.
The effects of having a regular physician would seem to have the greatest benefit for patients who have complex chronic diseases for which the frequency of care and the necessity of multiple therapeutic interventions would be enhanced by an ongoing relationship with a single physician. However, there is conflicting evidence that having a regular physician makes a difference in the management of diabetes, a highly complex chronic medical illness. In an analysis of diabetes intermediate outcomes among a small sample of patients from 19 inner city practices in England, Gulliford and colleagues found no association between increasing levels of continuity and diabetes quality measures. Similarly, a large cross-sectional study using an administrative database failed to find a relationship between individual physician continuity and the performance of recommended testing. Finally, a study of participants in the National Health and Nutrition Examination Survey did not find any association between having a personal physician and glycemic control. However, this study did find an association between having a regular location of care and glycemic control.
In contrast, other evidence suggests some benefits of continuity on the management of patients with diabetes. In a group of patients from a health maintenance organization, OÂ’Connor et al found that those who had a regular provider were more likely to follow a diabetic diet, monitor their sugars at home, and receive recommended preventive services examinations. A smaller study at a training site also showed that, as continuity with a resident physician improved, so did glycemic control.
A drawback of all these studies was the definition of what having a regular physician meant. In some cases, investigators relied on patients to state whether they had a personal physician without inquiring whether the physician was aware of this. In other studies, authors did not define whether the provider was the patient's regular physician but instead focused on continuity, which was represented by who a patient saw most often.
Another drawback of previous studies is that continuity may not have been synonymous with a personal physician-patient relationship. If a physician does not view a particular patient as her or his patient, the care they render for patients may differ from that provided to a patient who the physician considers "theirs." One study conducted in a network of 18 practices found that physicians designated only 68% of patients they saw as "their patients." This implies that physicians often care for individuals with whom they do not feel they have a continuous relationship. It is unclear whether this lack of connection has any detrimental impact on the quality of care that patients receive over time.
The purpose of this study was to examine, from the physician perspective, the impact of having a regular physician on the management of diabetes in a single large practice. Because this study utilizes data from a single practice it allowed for the assessment of having a regular physician while controlling for the overall practice environment. Put another way, this study sought to determine whether having a physician identify patients as their own improves care more than when the same group of physicians manage patients but do not acknowledge any ongoing personal relationship with the patient.