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Without adjustment on practice level in the data analysis, appropriate treatment will always be related to poor health outcome, particularly in individual-level studies.
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Primary outcome was the impact of case-mix adjustment on practice-level means (adjusted minus unadjusted) and changes in practice percentile ranks for questions measuring patient experience in three domains of primary care: access; interpersonal care; anticipatory care planning, and overall satisfaction with primary care services.
Table 2 shows the impact of case-mix adjustment on practice-level mean scores and practice ranks.
Our aims are to quantify the impact of case-mix adjustment on practice-level scores in a national survey of patient experience, to identify why and when it may be useful to adjust for case mix, and to discuss unresolved policy issues regarding the use of case-mix adjustment in performance measurement in health care.
The impact of case-mix adjustment on practice-level means varied by patient experience domain, with a larger impact on anticipatory care planning items (questions 28 and 29) and a smaller impact for questions relating to access (getting through on the telephone; getting an urgent appointment; booking ahead; and evaluation of waiting time).
Our results show that the impact of case-mix adjustment on practice-level performance scores is modest for most practices but may meaningfully improve the measurement of performance for practices with less typical patient populations, discouraging practices from 'cream-skimming' by avoiding enrolling patients who could be seen as 'hard to treat'.
6 A particular strength of our study is the large sample size, enabling us to investigate the impact of case-mix adjustment on practices serving less typical patient populations.
Depending on the situation, adjustment for practice organisation may also be appropriate, but as practice organisation may be closely interwoven with other organisational aspects, this may blur important differences between practices that ought to be addressed.
This requires some precision adjustments so practice playing on one string and tuning at the same time.
The oddball schedule requires an adjustment to practice schedules.
22 23 Using data from this survey, we quantify the impact of case-mix adjustment on the mean scores and rankings of primary care practices.
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