The Physicians Practice Profile: a piece of the quality puzzle

Physician Executive, Sept-Oct, 1991 by Laurence G. Roth

In the controversy that preceded passage in 1985 of New York State legislation aimed at reforming medical and dental malpractice litigation, the medical profession had repeatedly emphasized the provision of high-quality health care as its primary goal. It is not certain if there was a cause and effect relationship between the imminent passage of the legislation and this expressed goal, but it is now clear that high-quality health services are legally required in New York. As part of the package has also come greater scrutiny of physicians and dentists prior to the granting of hospital privileges. This latter requirement is now manifest in the Physicians Practice Profile as produced by the New York State Department of Health.

The New York State physician profile represents a departure from profiles currently described in the literature. Koska's report [1] of a recent survey of approximately 650 hospitals found 52.1 percent had physician-specific profiles, with another 7.6 percent having them under consideration. They were described as being used for tracking DRG performance, for physician recruitment planning, to plot strategies for the development or expansion of specific clinical departments, and to flag inefficiencies in the use of resources. The typical profile outlines the total charges per patient or per physician, or perhaps an average of these charges, and then follows up with what the DRG paid for that case.

Horn and Horn [2] described a computerized severity index to be used to adjust physician practice profiles for accuracy of utilization of DRGs. Feinglass et al. [3] discussed the use of severity-adjusted physician practice profiles to identify cost-effective patterns of care. Because of the discretionary nature of medical decision making and geographic variations, their study of the literature indicated variations in illness rates, demographic or socioeconomic characteristics, insurance coverage, and access to services. Appropriately, they also commented on differences in patient expectations, values, and capabilities. Zuckerman et al. [4] had earlier noted that states with mandatory hospital rate-setting programs have significantly different practice patterns.

All of these conclusions are valid, but they do not bear directly on a practice profile with the components listed by the New York State Department of Health. The New York system is intended to be utilized in credentialing as part of the process of legalizing quality health services.

Genesee Memorial Hospital, an acute care community hospital with 70 certified beds, is now in its fifth year of maintaining physician practice profile as part of an ongoing quality assurance activity. The hospital had a medical records department, a staff of utilization coordinators, and an infection control nurse before the profile system was established and added a quality assurance/risk management coordinator shortly after it began to develop the physician practice profiles. The cooperation of these individuals has been essential to the development of the profiles.

Because these profiles are about the medical staff, the first step was to involve the medical staff in defining the categories that were listed in the regulations. This set the limits of study and allowed medical staff participation in the development and subsequent modification of profile content. There is no doubt that the most important decision was to include in the profile only physician performance data that were derived from decisions and judgments made in peer review and duly recorded in committee and department minutes. Any other data have been limited to objective items, such as the number of patient discharges.

A decision was made to utilize computer capability in recording data for ease of review and analysis. For completeness of the study, categories were added to address pertinent demographics. The original list had 32 categories (figure 1, above). The current list has 41 categories (figure 2, page 18). The differences between the two lists are significant both as to the number of categories and to show the content of categories has been modified.

Category Changes

Transfer for acute care was added to enlarge patient demographics.

"Unimproved" had been on the diagnostic front sheet of the medical record for years, but no physician would admit to this possibility unless there was a mortality. The category was also ambiguous in terms of chronic conditions. It was therefore dropped.

"Unexpected morbidity" was not accepted by the medical staff and was changed to "Infections." This change was followed by protests from physicians that they did not cause infections. Now there is a record of "Patients with infections," and the accompanying data are coded to indicate physician, hospital, or undetermined cause of a nosocomial infection, as decided by physicians on the Infection Control Committee. This code is now modified to recognize the immuno-compromised patient as well. Physicians found this necessary when the hospital had its first AIDS patient, with resultant infections.