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Smaller is Better

Patients cared for by doctors in smaller practices receive better care.

More than 3.9 million “ambulatory care-sensitive” admissions of adults were made to US hospitals in 2010, with as much as 40% of them being preventable. But which primary care practices are best at preventing these kind of avoidable hospitalizations?

Source: LASZLO ILYES (Flickr/CC)

Source: LASZLO ILYES (Flickr/CC)

Researchers stratified practices by characteristics including: number of physicians, hospital vs. physician ownership, public reporting incentives on quality and patient satisfaction, pay-for-performance incentives, patient characteristics, and amount of financial risk assumed for hospital care. Each was then given a patient-centered medical home score calculated from the number of process improvement strategies utilized (e.g. primary care teams, patient care coordination, electronic prescribing, and point-of-care guideline based reminders).

Large practices (10-19 physicians) used significantly more patient-centered medical home processes than small practices with 1-2 physicians (24.1% vs. 19.1% of possible processes), but not more than mid-size practices with 3-9 physicians (25.6%). However, small practices had a significantly lower ambulatory care-sensitive admission rate than large practices (4.31 per 100 beneficiaries per year vs. 6.47 per 100 per year). Mid-size practices also had much lower admission rates than large practices.

Hospital-owned practices used more processes than physical-owned practices (27.7% vs. 21.2%). However, physician-owned practices had ambulatory care-sensitive admission rates that were significantly lower than that of hospital-owned practices (4.63 vs. 5.31).

Practices with incentives from pay-for-performance and public reporting programs used significantly more patient-centered medical home processes than practices without these incentives, as did practices that took some financial risk for the cost of hospital care for at least 10 percent of the practice’s patients. Neither the incentives, public reporting, nor financial risk showed any significant difference in ambulatory care-sensitive admission rates.

Higher usage of patient-centered medical home processes are valued by policymakers; however, their ability to prevent admissions is in question. Smaller practices may have greater ease of access at those critical points of communication with patients to prevent such admission, which may be hard to replicate in large practices without a close patient-doctor relationship.

Other factors – such as community and environmental factors that might otherwise impact admissions rates – should not be ignored.

commentary by Kameron Matthews, MD, JD


Nearly two-thirds of US office-based physicians work in practices of fewer than seven physicians. It is often assumed that larger practices provide better care, although there is little evidence for or against this assumption. What is the relationship between practice size–and other practice characteristics, such as ownership or use of medical home processes–and the quality of care? We conducted a national survey of 1,045 primary care-based practices with nineteen or fewer physicians to determine practice characteristics. We used Medicare data to calculate practices’ rate of potentially preventable hospital admissions (ambulatory care-sensitive admissions). Compared to practices with 10-19 physicians, practices with 1-2 physicians had 33 percent fewer preventable admissions, and practices with 3-9 physicians had 27 percent fewer. Physician-owned practices had fewer preventable admissions than hospital-owned practices. In an era when health care reform appears to be driving physicians into larger organizations, it is important to measure the comparative performance of practices of all sizes, to learn more about how small practices provide patient care, and to learn more about the types of organizational structures–such as independent practice associations–that may make it possible for small practices to share resources that are useful for improving the quality of care. PMID: 25122562

Casalino, LP, et al. Health Affairs. 2014; 33 (9): 1690-8.

Kameron Matthews, MD, JD, FAAFP
About Kameron Matthews, MD, JD, FAAFP

Lead Analyst – Access to Care Kameron Matthews MD, JD is a board-certified family physician and currently serves as Deputy Executive Director of Provider Relations and Services in the Office of Community Care at the Veterans Health Administration in Washington, DC. She earned her medical degree from Johns Hopkins University and her law degree from the University of Chicago. Contact: Facebook | Twitter | More Posts