• Nancy L Keating, Mary Beth Landrum, Bruce E Landon, John Z Ayanian, Catherine Borbas, Robert Wolf, and Edward Guadagnoli.
• Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts 02115, USA. keating@hcp.med.harvard.edu
• Med Care. 2004 Sep 1;42(9):829-39.

ContextHealth care organizations use many strategies to influence physician behavior and the care delivered, but the effect of such strategies on quality is not known.ObjectiveWe sought to assess the influence of practice management strategies and financial arrangements on the quality of diabetes care.DesignThis was a retrospective cohort study including medical record reviews and a physician survey.ParticipantsPatients with diabetes mellitus (n=652) enrolled in 3 health plans located in Minnesota and 399 physicians in 135 practices who cared for them participated in this study.Main Outcome MeasureOur main outcome measures was a quality score indicating receipt of care in accordance with 6 accepted quality indicators.ResultsThe mean quality score was 2.4 (SD 1.2) on a 6-point scale. Only a small proportion of the variation in quality was attributed to characteristics of physicians' practices (5%). Quality scores tended to be higher for patients whose physicians received quality performance reports or utilization profiles from more than 1 source (P=0.08), routinely enrolled diabetic patients in disease-management programs (P=0.06), or received diabetes-specific reports (P=0.06). Quality scores were lower for patients whose physicians were paid according to fee-for-service compared with salary (P=0.04) and served as gatekeepers for >50% of their patients (P=0.06). However, these findings were all of borderline statistical significance, and the absolute differences in quality were small.ConclusionsCurrent practice management strategies and financial arrangements have a limited impact on the quality of care for patients with diabetes. These findings suggest that other strategies may be necessary for health care organizations to improve care for patients with diabetes.

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