| Various organizational strategies have been used to improve quality of care in persons with diabetes. We concurrently examined effects of cardiovascular care management strategies, provider financial incentives, and organizational model on appropriate cardiovascular medication use, intermediate cardiovascular outcomes, cardiovascular procedures, admissions, and mortality. Using data from 57 provider groups in six states and a sample of 9746 patients with diabetes, we constructed multi-level models, adjusted states and a sample of 9746 patients with diabetes, we constructed multi-level models, adjusted for patient demographic and clinical characteristics to assess the relationship between our provider group level variables and patient processes and outcomes. We found that higher intensity of cardiovascular care management resulted in lower rates of lipid lowering therapy, higher proportion of patients with LDL-C out of control, and higher rates of cardiovascular hospitalizations. Higher intensity of clinical information systems was associated with higher beta blocker use, fewer cardiovascular admissions, and lower cardiovascular mortality; these associations were all clinically, but not statistically significant. We also found that aligning provider financial incentives with quality resulted in higher rates of lipid lowering therapy, fewer patients out of control for LDL-C, and lower cardiovascular admissions. Financial incentives that promoted a provider's gatekeeping role resulted in lower rates of lipid lowering therapy, more patients out of control for LDL-C and higher rates of cardiovascular admissions. Greater use of cardiovascular care management was associated with worse processes and outcomes. Alignment of provider financial incentives led to better processes and outcomes, while incentives directed at increasing a provider's gatekeeping role were associated with worse processes and outcomes. |
