Physician and patient influences on provider performance: β-blockers in postmyocardial infarction management in the MI-Plus study.
BACKGROUND
Efforts to improve the quality of care for patients with cardiovascular disease frequently target the decrease of physician-level performance variability. We assessed how variability in providing β-blockers to ambulatory postmyocardial infarction (MI) patients was influenced by physician and patient level characteristics.


RESULTS
β-Blocker prescription and patient characteristics were abstracted from charts of post-MI patients treated by 133 primary care physicians between 2003 and 2007 and linked to physician and practice characteristics. Associations of β-blocker prescription with physician- and patient-level characteristics were examined using mixed-effects models, with physician-level effects as random. Mean physician-specific predicted probabilities and the intraclass correlations, which assessed the proportion of variance explainable at the physician level, were estimated. Of 1901 patients without major contraindication, 69.1% (range across physicians, 20% to 100%) were prescribed β-blockers. Prescription varied with comorbidity from 78.3% in patients with chronic kidney disease to 54.7% for patients with stroke. Although physician characteristics such as older physician age, group practice, and rural location were each positively associated with β-blocker prescription, physician factors accounted for only 5% to 8% of the variance in β-blocker prescription; the preponderance of the variance, 92% to 95%, was at the patient level. The mean physician-specific probability of β-blocker prescription (95% confidence interval) in the fully adjusted model was 63% (61% to 65%).


CONCLUSIONS
β-Blocker prescription rates were surprisingly low. The contribution of physician factors to overall variability in β-blocker prescription, however, was limited. Increasing evidence-based use of β-blockers may not be accomplished by focusing mostly on differential performance across physicians.
Division of Preventive Medicine, School of Medicine, University of Alabama-Birmingham, 1717 11th Ave S., Birmingham, AL 35205, USA. emfunk@uab.edu
Ellen
E
Funkhouser
Thomas K
TK
Houston
Deborah A
DA
Levine
Joshua
J
Richman
Jeroan J
JJ
Allison
Catarina I
CI
Kiefe
D000319:Adrenergic beta-Antagonists / Q000627:therapeutic use*; D000328:Adult; D000368:Aged; D003430:Cross-Sectional Studies; D055317:Evidence-Based Practice; D005260:Female; D006282:Health Personnel; D006801:Humans; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009203:Myocardial Infarction / Q000188:drug therapy*; D010818:Practice Patterns, Physicians'; D011787:Quality of Health Care; D016032:Randomized Controlled Trials as Topic
D000319:Adrenergic beta-Antagonists