Patient complexity and diabetes quality of care in rural settings

J Natl Med Assoc. 2011 Mar;103(3):234-40. doi: 10.1016/s0027-9684(15)30297-2.


Purpose: 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.

Basic procedures: 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.

Main findings: 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).

Principal 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.

Publication types

  • Research Support, N.I.H., Extramural
  • Research Support, U.S. Gov't, Non-P.H.S.

MeSH terms

  • Age Factors
  • Aged
  • Alabama
  • Data Interpretation, Statistical
  • Diabetes Mellitus / therapy*
  • Female
  • Glycated Hemoglobin A / analysis
  • Humans
  • Hypoglycemic Agents / therapeutic use
  • Insulin / therapeutic use
  • Male
  • Middle Aged
  • Practice Patterns, Physicians' / statistics & numerical data*
  • Primary Health Care / standards*
  • Quality of Health Care*
  • Randomized Controlled Trials as Topic
  • Risk Factors
  • Rural Health Services / standards*
  • Rural Population
  • United States


  • Glycated Hemoglobin A
  • Hypoglycemic Agents
  • Insulin