title: Patient complexity and diabetes quality of care in rural settings.
abstract: OBJECTIVE
  Even though pay-for-performance programs are being rapidly implemented, little is known about how patient complexity affects practice-level performance assessment in rural settings. We sought to determine the association between patient complexity and practice-level performance in the rural United States.
  
  
  METHODS
  Using baseline data from a trial aimed at improving diabetes care, we determined factors associated with a practice's proportion of patients having controlled diabetes (hemoglobin A1c<or=7%): patient socioeconomic factors, clinical factors, difficulty with self-testing of blood glucose, and difficulty with keeping appointments. We used linear regression to adjust the practice-level proportion with A1c controlled for these factors. We compared practice rankings using observed and expected performance and classified practices into hypothetical pay-for-performance categories.
  
  
  RESULTS
  Rural primary care practices (n=135) in 11 southeastern states provided information for 1641 patients with diabetes. For practices in the best quartile of observed control, 76.1% of patients had controlled diabetes vs 19.3% of patients in the worst quartile. After controlling for other variables, proportions of diabetes control were 10% lower in those practices whose patients had the greatest difficulty with either self testing or appointment keeping (p<.05 for both). Practice rankings based on observed and expected proportion of A1c control showed only moderate agreement in pay-for-performance categories (kappa=0.47; 95% confidence interval, 0.32-0.56; p<001).
  
  
  CONCLUSIONS
  Basing public reporting and resource allocation on quality assessment that does not account for patient characteristics may further harm this vulnerable group of patients and physicians.
authors.affiliation: VA Tennessee Valley Geriatric Research, Education, and Clinical Center and Section of Hospital Medicine at Vanderbilt University, Room A-414, 1310 24th Ave S, Nashville, TN 37212, USA. amanda.salanitro@vanderbilt.edu
authors.forename: Amanda H
authors.initials: AH
authors.lastname: Salanitro
authors.forename: Monika M
authors.initials: MM
authors.lastname: Safford
authors.forename: Thomas K
authors.initials: TK
authors.lastname: Houston
authors.forename: Jessica H
authors.initials: JH
authors.lastname: Williams
authors.forename: Fernando
authors.initials: F
authors.lastname: Ovalle
authors.forename: Pamela
authors.initials: P
authors.lastname: Payne-Foster
authors.forename: Jeroan J
authors.initials: JJ
authors.lastname: Allison
authors.forename: Carlos A
authors.initials: CA
authors.lastname: Estrada
mesh_terms: D000367:Age Factors; D000368:Aged; D000407:Alabama; D003627:Data Interpretation, Statistical; D003920:Diabetes Mellitus / Q000628:therapy*; D005260:Female; D006442:Glycated Hemoglobin / Q000032:analysis; D006801:Humans; D007004:Hypoglycemic Agents / Q000627:therapeutic use; D007328:Insulin / Q000627:therapeutic use; D008297:Male; D008875:Middle Aged; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D011320:Primary Health Care / Q000592:standards*; D011787:Quality of Health Care; D016032:Randomized Controlled Trials as Topic; D012307:Risk Factors; D019035:Rural Health Services / Q000592:standards*; D012424:Rural Population; D014481:United States
chemical_list: D006442:Glycated Hemoglobin; D007004:Hypoglycemic Agents; D007328:Insulin