使用した指標 1)66−69歳のマンモグラフィ実施率、2)66−75歳の糖尿病患者におけるA1c測定率、3)予防可能な入院の発生率、4)心不全退院後の30日以内再入院率





10%でなく5%の差の検出ならばもう少し症例数は少なくて済むだろう。ではそこで証明された統計学的有意差は、診療報酬の差に反映してしかるべき臨床上意味のある差か、という問題は別。 (例えば診療所Aと診療所Bでマンモグラフィー実施率80%vs90%の場合と85%vs90%の場合など)


Relationship of Primary Care Physicians' Patient Caseload With Measurement of Quality and Cost Performance
David J. Nyweide, PhD; William B. Weeks, MD, MBA; Daniel J. Gottlieb, MS; Lawrence P. Casalino, MD, PhD; Elliott S. Fisher, MD, MPH
JAMA. 2009;302(22):2444-2450.
Context Sufficient numbers of patients are necessary to generate statistically reliable measurements of physicians' quality and cost performance.
Objective To determine whether primary care physicians in the same physician practice collectively see enough Medicare patients annually to detect meaningful differences between practices in ambulatory quality and cost measures.
Design, Setting, and Patients Primary care physicians in the United States were linked to their physician practices using the Healthcare Organization Services database maintained by IMS Health. Patients who visited primary care physicians in the 2005 Medicare Part B 20% sample were used to estimateMedicare caseloads per practice. Caseloads necessary to detect 10% relative differences in costs and quality were calculated using national mean ambulatory Medicare spending, rates of mammography for women 66 to 69 years, and hemoglobin A1c testing for 66- to 75-year-olds with diabetes, preventable hospitalization rate, and 30-day readmission rate after discharge for congestive heart failure (CHF).
Main Outcome Measures Percentage of primary care physician practices with a sufficient number of eligible patients to detect a 10% relative difference in each performance measure.
Results Primary care physician practices had annual median caseloads of 260 Medicare patients (interquartile range [IQR], 135-500), 25 women eligible for mammography (IQR, 10-50), 30 patients with diabetes eligible for hemoglobin A1c testing (IQR, 15-55), and 0 patients hospitalized for CHF. For ambulatorycosts, mammography rate, and hemoglobin A1c testing rate, the percentage of primary care physician practices with sufficient caseloads to detect 10% relative differences in performance ranged from less than 10% of practices with fewer than 11 primary care physicians to 100% of practices with more than 50 primary care physicians. None of the primary care physician practices had sufficient caseloads to detect 10% relative differences in preventable hospitalization or 30-day readmission after discharge for CHF.
Conclusion Relatively few primary care physician practices are large enough to reliably measure 10% relative differences in common measures of quality and cost performance among fee-for-service Medicare patients.

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