Quality vs. Volume

I am not a big believer in quality metrics, as you may know, but I found this study interesting. Doctors were graded on these metrics for diabetics over a two year period:

  • Disease monitoring (eye examination, hemoglobin A1c testing, and low-density lipoprotein cholesterol testing)
  • Prescription of appropriate medications (angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers and statins)
  • Adverse clinical outcomes (emergency department visits for hypoglycemia or hyperglycemia).

It turns out that there was a correlation between higher overall ambulatory volume and lower rates of appropriate diabetes monitoring and medication prescription.

“Primary care physicians with busier ambulatory patient practices delivered lower-quality diabetes care, but those with greater diabetes-specific experience delivered higher-quality care,” the authors write.

So, if you have a jam-packed schedule in an industrialized mode,l then the odds are you are doing crappier work.  It’s also a reason why doctors with much less volume do better on these scores (DPC docs) or even why midlevels do as well in their home-cooked studies.

How about when you have a supposed “quality based practice” with less patients but half the visit is taken up with the MA (as well as the doctor)  asking meaningless quality metric questions?  I venture to guess they do a crappier job, too.   That’s a study we will never see but I guarantee it would show that the time wasted asking bogus metric questions lowers the quality of that visit.


Douglas Farrago MD

Douglas Farrago MD is a full-time practicing family doc in Forest, Va. He started Forest Direct Primary Care where he takes no insurance and bills patients a monthly fee. He is board certified in the specialty of Family Practice. He is the inventor of a product called the Knee Saver which is currently in the Baseball Hall of Fame. The Knee Saver and its knock-offs are worn by many major league baseball catchers. He is also the inventor of the CryoHelmet used by athletes for head injuries as well as migraine sufferers. Dr. Farrago is the author of four books, two of which are the top two most popular DPC books. From 2001 – 2011, Dr. Farrago was the editor and creator of the Placebo Journal which ran for 10 full years. Described as the Mad Magazine for doctors, he and the Placebo Journal were featured in the Washington Post, US News and World Report, the AP, and the NY Times. Dr. Farrago is also the editor of the blog Authentic Medicine which was born out of concern about where the direction of healthcare is heading and the belief that the wrong people are in charge. This blog has been going daily for more than 15 years Article about Dr. Farrago in Doximity Email Dr. Farrago – [email protected] 

  4 comments for “Quality vs. Volume

  1. Kurt
    December 21, 2016 at 2:49 pm

    Lemme tell you something, not a damned thing is going to change with the lousy overall health in this country until people are held accountable with their lousy health behaviors. They turn down diabetic instruction or don’t heed it when they attend it and continue their path to hell and early demise. Oh and besides, unless they drop over dead all at once, they end up spending $$$$ like crazy for their care. The “pages and pages” of health information I print off and that
    can amount to 75++ pages likely ends up in a wood stove. I do it anyways as we get “brownie
    points” for doing it. Little good it does.
    Holding primary care doctors accountable for patient non-compliance is insane and that is what
    all this “Alphabet” accountability is leading to. I pity the docs not near retirement and implore students to stay away. Let the NP’s have it. Once they find out what a P.I.T.A it is (and since they wouldn’t have a supervising MD to throw under the bus anymore) they’ll take their masters degrees to work for specialists.

  2. Pat
    December 18, 2016 at 11:21 am

    That study we will never see would also quantify lost practice revenue as a consequence of these stupid metrics questions, and the time/money they waste, paradoxically forcing the practice to try and run more through.

  3. Thomas Guastavino
    December 18, 2016 at 8:28 am

    Riddle me this. Why does every “quality metric” not take into account patient cooperation.? Do the boneheads who are pushing tis nonsense assume that patients are mindless automatons that automatically follow every physician request?
    I semi-retired two years ago. Honestly, I don’t see how any physician could practice under these conditions.

    • Bridget Reidy
      December 18, 2016 at 10:24 pm

      Short answer, yes. And they are helped by our colleagues who don’t practice or have residents take care of the mundane details.
      Long answer, administrators think they are representative of average patients, and that the average visit involves an average patient when in most specialties, including primary care, it doesn’t. I once had one tell me she didn’t know much about outpatient medicine because her kids didn’t get sick much, and I couldn’t manage to explain that even if they did, she would know no more.

Comments are closed.