Aug. 14—Practices with the fewest physicians had about one-third fewer preventable hospital readmissions among their patients than larger practices, a new study found.

The study, which was based on surveys of 1,045 primary care practices with up to 19 physicians, found that practices with one or two physicians had 33 percent fewer preventable hospital admissions than practices with 10 to 19 physicians, and practices with three to nine physicians had 27 percent fewer admissions. The authors of the study, published in Health Affairs, linked the survey results to 2008 Medicare claims on ambulatory care-sensitive admissions, defined by the Agency for Healthcare Research and Quality as admissions for conditions for which good primary care may prevent the need for hospitalization.

“It is often assumed that ‘bigger is better’—even in the world of health care, where larger physician practices are thought to provide better care,” according to a synopsis of the study by the Commonwealth Fund, which funded the research. “This study, however, turns that notion on its head.”

Taking a Closer Look

The findings came amid unprecedented primary practice consolidation and acquisition drive by larger entities, which has been accelerated by the Affordable Care Act. The movement toward larger practices has stemmed from the need for resources to provide innovations believed to improve the quality of care, such as patient-centered medical homes and electronic prescribing.

However, the study found that more avoidable readmissions occurred in the largest practices examined—10 to 19 physicians—that had significantly more patient-centered medical home processes, such as primary care teams, guideline-based reminders to providers at the point of care, and electronic prescribing. Additionally, practices owned by physicians had significantly lower ambulatory care-sensitive admission rates than those owned by hospitals, which also used more medical home practices.

“These findings were unexpected, since small practices presumably have fewer resources to hire staff to help them implement systematic processes to improve the care they provide,” the authors wrote.

Neither the patient-centered medical home score, nor pay-for-performance incentives, nor the acceptance of risk for the cost of hospital care for the practice’s patients was significantly associated with the ambulatory care-sensitive admission rate, according to the study.

“It is often assumed that larger practices provide better care, although there is little evidence to support this, and the majority of U.S. office-based physicians work in practices with fewer than seven physicians,” the Commonwealth synopsis wrote.

Possible Explanations Offered

The authors wrote that it is possible that “characteristics that are not easily measured” among small practices improve outcomes. For example, previous research has found that patients more easily obtain appointments in smaller practices at the time they want them and are more likely to reach their physician over the telephone, compared with larger practices. Additionally, the closer relationships among staff and patients in small practices may result in fewer avoidable admissions.

The study authors wrote that hospitals and large medical groups that acquire smaller practices should consider preserving the small-practice environment within their organizations. Additionally, policymakers and insurers should consider taking steps to help small practices share resources, such as nurse care managers for patients with chronic illness.

Publication Date: Thursday, August 14, 2014