Comparison of primary care physician payment models in the management of hypertension

Karen Tu; Karen Cauch-Dudek; Zhongliang Chen

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Figure 1
Hypertension screening, treatment, and control rates by primary care payment model

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Table 1

Physician demographics by model of care: A) Number and proportion of physicians with various characteristics; B) Mean age, age at graduation, weekly hours worked, and number of physicians in group.

A)
	MODEL
PHYSICIAN CHARACTERISTICS	CHC, N (%)(N = 45)	FFS, N (%)(N = 45)	PCN, N (%)(N = 45)	OVERALL, N (%)(N = 135)	P VALUE
Female	23 (51.1)	15 (33.3)	22 (48.9)	60 (44.4)	.18
Hospital privileges^*	32 (71.1)	35 (77.8)	45 (100.0)	112 (83.0)	< .01
Rural practice	18 (40.0)	10 (22.2)	18 (40.0)	46 (34.1)	.12
Community practice (vs academic practice)	40 (88.9)	44 (97.8)	40 (88.9)	124 (91.9)	.23
Solo practice^*	≤ 5	17 (37.8)	16 (35.6)	34 (25.2)	< .01
Nurse available in practice^*	39 (86.7)	20 (44.4)	30 (66.7)	89 (65.9)	< .01
Nurse practitioner available in practice^*	45 (100.0)	≤ 5	25 (55.6)	73 (54.1)	< .01
Computerized progress notes^*	≤ 5	≤ 5 (11.1)	38 (84.4)	46 (34.1)	< .01
Computerized cumulative patient profiles^*	27 (60.0)	10 (22.2)	37 (82.2)	74 (54.8)	< .01
B)
	MODEL
PHYSICIAN CHARACTERISTICS	CHC, MEAN (SD) (N = 45)	FFS, MEAN (SD) (N = 45)	PCN, MEAN (SD) (N = 45)	OVERALL, MEAN (SD) (N = 135)	P VALUE

Physician age in 2005	46.3 (8.6)	46.8 (7.9)	50.2 (8.6)	47.7 (8.5)	.06
Physician age at graduation	27.0 (3.6)	26.3 (1.9)	26.0 (2.3)	26.4 (2.7)	.21
Physician weekly hours worked^*	39.3 (10.2)	46.1 (13.9)	43.0 (11.5)	42.8 (12.2)^†	.04
Physicians in group	4.0 (1.6)	4.0 (7.3)	4.0 (3.1)	4 (4.6)	.89

CHC–community health centre, FFS–fee-for-service, PCN–primary care network.
↵* P < .05, statistically significant difference between models.
↵† This information was not available for 13 of the physicians.

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Table 2

Patient demographics by model of care: A) All patients; B) Patients with hypertension.

A)
	MODEL
PATIENT CHARACTERISTICS	CHC, MEAN (SD)	FFS, MEAN (SD)	PCN, MEAN (SD)	OVERALL, MEAN (SD)	P VALUE
Female, %	58.7 (16.0)	54.6 (16.5)	59.6 (18.7)	57.6 (17.1)	.33
Age at date of abstraction, y	54.1 (5.7)	56.3 (4.2)	55.5 (3.9)	55.3 (4.7)	.08
Socioeconomic status, %
• Income quintile 1 (lowest)^*	40.0 (23.3)	15.4 (13.1)	16.9 (12.8)	24.1 (20.4)	< .01
• Income quintile 2	21.8 (12.7)	22.1 (9.7)	19.3 (10.9)	21.1 (11.2)	.44
• Income quintile 3^*	14.7 (8.8)	20.0 (10.6)	18.9 (11.1)	17.9 (10.4)	.04
• Income quintile 4^*	12.6 (11.8)	19.5 (9.7)	20.3 (11.4)	17.5 (11.5)	< .01
• Income quintile 5 (highest)^*	10.8 (11.4)	23.0 (13.6)	24.5 (20.4)	19.4 (16.7)	< .01
Cardiovascular-related comorbidities, %
• Dyslipidemia	31.5 (13.3)	34.4 (16.5)	33.3 (12.7)	33.1 (14.2)	.63
• Stroke	2.4 (2.8)	2.7 (3.3)	2.3 (2.8)	2.5 (3.0)	.80
• Transient ischemic attack	2.0 (3.1)	1.5 (2.1)	1.7 (2.2)	1.7 (2.5)	.64
• Angina	5.1 (6.0)	6.0 (5.2)	6.2 (6.3)	5.8 (5.8)	.67
• Myocardial infarction	4.9 (4.9)	4.4 (5.6)	4.8 (6.3)	4.7 (5.6)	.88
• Congestive heart failure	2.3 (3.3)	1.7 (2.9)	1.4 (2.4)	1.8 (2.9)	.35
• Atrial fibrillation	2.1 (3.3)	2.8 (4.3)	2.6 (3.0)	2.5 (3.6)	.63
• Coronary artery bypass graft	1.4 (2.7)	1.7 (2.5)	2.1 (4.0)	1.7 (3.1)	.65
• Previous angioplasty or stent	1.8 (2.6)	1.3 (2.8)	2.5 (3.4)	1.9 (3.0)	.15
• Peripheral vascular disease	3.3 (5.0)	3.2 (3.7)	2.0 (3.2)	2.8 (4.0)	.23
• Diabetes	12.9 (8.9)	13.5 (8.2)	11.5 (8.9)	12.6 (8.6)	.54
• Renal disease	1.2 (2.0)	1.7 (3.0)	2.6 (3.7)	1.9 (3.0)	.08
• Hypothyroidism	7.0 (6.0)	6.0 (5.7)	9.3 (7.1)	7.4 (6.4)	.05
• Current smoker^*	31.6 (15.6)	23.9 (15.3)	25.9 (13.9)	27.1 (15.2)	.04
B)
	MODEL
PATIENT CHARACTERISTICS	CHC, MEAN (SD)	FFS, MEAN (SD)	PCN, MEAN (SD)	OVERALL, MEAN (SD)	P VALUE

Female, %	60.6 (22.0)	49.8 (21.8)	57.0 (23.5)	55.8 (22.7)	.07
Age at date of abstraction, y	61.0 (6.8)	62.1 (6.4)	63.7 (4.3)	62.2 (6.0)	.11
Socioeconomic status, %
• Income quintile 1 (lowest)^*	42.2 (28.1)	17.3 (19.8)	18.6 (17.3)	26.0 (24.9)	< .01
• Income quintile 2	25.0 (18.6)	24.1 (16.1)	20.0 (17.3)	23.1 (17.4)	.36
• Income quintile 3^*	11.6 (11.9)	20.0 (17.4)	18.8 (16.9)	16.8 (15.9)	.02
• Income quintile 4^*	11.8 (15.7)	20.3 (19.8)	20.9 (19.3)	17.7 (18.7)	.04
• Income quintile 5 (highest)^*	9.4 (12.2)	18.3 (15.8)	21.8 (24.8)	16.5 (19.0)	< .01
Cardiovascular-related comorbidities, %
• Dyslipidemia	55.0 (19.0)	53.5 (22.9)	58.4 (18.8)	55.6 (20.3)	.51
• Stroke	4.0 (6.9)	5.5 (7.3)	7.1 (8.9)	5.5 (7.8)	.17
• Transient ischemic attack	3.4 (5.5)	3.4 (5.4)	3.9 (5.8)	3.5 (5.5)	.88
• Angina	10.6 (12.8)	12.4 (11.6)	12.8 (11.7)	11.9 (12.0)	.64
• Myocardial infarction	9.9 (11.0)	9.8 (12.2)	11.1 (14.6)	10.3 (12.6)	.87
• Congestive heart failure	4.9 (7.4)	4.1 (6.9)	3.6 (6.9)	4.2 (7.1)	.70
• Atrial fibrillation	3.1 (6.0)	4.0 (5.9)	5.4 (9.5)	4.1 (7.3)	.21
• Coronary artery bypass graft	3.3 (5.4)	2.8 (5.9)	5.1 (8.0)	3.8 (6.6)	.34
• Previous angioplasty or stent	3.3 (6.3)	5.9 (8.4)	5.8 (8.7)	5.0 (7.9)	.21
• Peripheral vascular disease	7.0 (9.1)	7.0 (9.9)	4.5 (7.3)	6.2 (8.9)	.29
• Diabetes	28.0 (16.9)	28.2 (16.5)	30.0 (20.7)	28.7 (18.0)	.84
• Renal disease^*	2.0 (4.5)	4.6 (9.2)	6.8 (10.0)	4.5 (8.5)	.03
• Hypothyroidism	10.3 (11.3)	7.0 (8.6)	11.6 (12.1)	9.6 (10.9)	.12
• Current smoker	30.3 (22.5)	20.8 (18.3)	21.6 (22.1)	24.2 (21.3)	.07

CHC–community health centre, FFS–fee-for-service, PCN–primary care network.
↵* P < .05, statistically significant difference between models.

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Table 3

Hypertension screening rates and number of visits in the past 3 years by model of care

	MODEL
SCREENING	CHC, MEAN (SD)	FFS, MEAN (SD)	PCN, MEAN (SD)	OVERALL, MEAN (SD)	P VALUE
At least 1 BP visit in past 3 y, %	93.5 (8.9)	93.3 (7.2)	90.6 (9.6)	92.5 (8.7)	.22
Average no. of visits in the past 3 y,^* %	14.9 (3.7)	12.9 (4.2)	9.9 (2.2)	12.6 (4.0)	< .01
Proportion of total visits in the past 3 y in which BP was measured	43.3 (13.1)	48.7 (15.0)	47.0 (17.0)	46.3 (15.2)	.22

BP–blood pressure, CHC–community health centre, FFS–fee-for-service, PCN–primary care network.
↵* P <.05, statistically significant difference between models.

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Table 4

Adjusted treatment and control rates for patients with hypertension by model of care

	MODEL
TREATMENTS AND MEASURES OF CONTROL	CHC, MEAN (SD)	FFS, MEAN (SD)	PCN, MEAN (SD)	OVERALL, MEAN (SD)	ANOVA P VALUE
Patients with hypertension, %^*	33.7 (10.5)	36.7 (8.8)	30.3 (8.4)	33.6 (9.3)	.01
Currently taking at least 1 BP medication, %^*	81.0 (4.9)	87.4 (4.5)	90.9 (4.9)	86.4 (4.6)	.01
Currently taking at least 2 BP medications, %^*	47.7 (6.2)	60.0 (5.3)	59.8 (5.9)	55.8 (6.6)	< .01
Currently taking ASA, %	34.9 (10.5)	38.7 (9.9)	37.9 (7.4)	37.2 (9.4)	.67
Currently taking lipid-lowering medication, %	36.4 (8.1)	44.5 (6.3)	46.4 (6.9)	42.4 (7.6)	.06
Types of medication, %
• ACE inhibitors	47.8 (4.2)	56.5 (5.0)	57.1 (4.0)	53.8 (5.0)	.06
• Angiotensin II receptor blockers^*	8.9 (4.6)	19.1 (4.5)	15.1 (3.9)	14.3 (4.2)	.03
• β-Blockers^*	25.2 (3.0)	32.2 (5.7)	34.6 (4.2)	30.7 (4.6)	.03
• Calcium channel blockers	24.1 (7.8)	28.2 (6.2)	29.9 (7.0)	27.4 (7.1)	.19
• Diuretics	50.7 (6.0)	50.3 (4.5)	53.9 (4.8)	51.6 (5.2)	.67
Last individual BP reading below target,^*^† %	38.6 (5.9)	41.6 (6.8)	54.5 (5.6)	44.9 (6.7)	< .01
Average no. of visits in the past 3 y^*	19.1 (1.2)	16.9 (1.3)	14.0 (1.0)	16.7 (1.4)	< .01
Proportion of total visits in the past 3 y in which BP was measured	63.4 (3.8)	67.8 (3.5)	66.5 (3.7)	65.9 (3.8)	.22

ACE–angiotensin-converting enzyme, ANOVA–analysis of variance, ASA–acetylsalicylic acid, BP–blood pressure, CHC–community health centre, FFS–fee-for-service, PCN–primary care network.
↵* P < .05, statistically significant difference between models.
↵† Target BP < 140/80 mm Hg, < 130/80 mm Hg for patients with diabetes, and < 120/75 for patients with renal disease.