George L. Jackson, PhD, MHA; Benjamin J. Powers, MD, MHS; Ranee Chatterjee, MD, MPH; Janet Prvu Bettger, ScD; Alex R. Kemper, MD, MPH, MS; Vic Hasselblad, PhD; Rowena J. Dolor, MD, MHS; R. Julian Irvine, MCM; Brooke L. Heidenfelder, PhD; Amy S. Kendrick, RN, MSN; Rebecca Gray, DPhil; John W. Williams, MD, MHS
Disclaimer: The authors of this report are responsible for its content. Statements in the report should not be construed as endorsements by AHRQ or the U.S. Department of Health and Human Services or necessarily reelections of the position or policy of the Department of Health and Human Services, Department of Veterans Affairs, or the United States government.
Acknowledgment: The authors thank Christine Chang, MD, MPH; Janice Genevro, PhD, MSW; and Kathryn McDonald, MM, for their suggestions on improving the clarity of the AHRQ Evidence Report on which this article is based; and Connie Schardt, MSLS, for help with the literature search and retrieval.
Grant Support: This project was funded under contract 290-2007-10066-I from AHRQ, U.S. Department of Health and Human Services, as part of the series “Closing the Quality Gap: Revisiting the State of the Science.”
Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M12-1295.
Requests for Single Reprints: George L. Jackson, PhD, MHA, Division of General Internal Medicine, Duke University School of Medicine, 307 Trent Drive, DUMC 3322, Durham, NC 27710; e-mail, firstname.lastname@example.org.
Current Author Addresses: Dr. Jackson: Durham Veterans Affairs Medical Center, HSR&D Service (152), 508 Fulton Street, Durham, NC 27705
Dr. Powers: 520 South Eagle Road, Suite 3102, Meridian, IA 83642
Dr. Chatterjee: Duke University, 5832 Fayetteville Road, Suite 113, Durham, NC 27713
Dr. Prvu Bettger: Duke University, 307 Trent Drive, DUMC 3322, Durham, NC 27710
Drs. Kemper, Dolor, Gray, and Heidenfelder; Mr. Irvine; and Ms. Kendrick: Duke University Clinical Research Institute, 2400 Pratt Street, Durham, NC 27705
Dr. Hasselblad: 3534 Bay Island Circle, Jacksonville Beach, FL 32250
Dr. Williams: Duke University School of Medicine, 411 West Chapel Hill Street, Suite 500, Durham, NC 27701
Author Contributions: Conception and design: G.L. Jackson, B.J. Powers, R.J. Dolor, A.S. Kendrick, J.W. Williams.
Analysis and interpretation of the data: G.L. Jackson, B.J. Powers, R. Chatterjee, J. Prvu Bettger, A.R. Kemper, V. Hasselblad, R.J. Dolor, J.W. Williams.
Drafting of the article: G.L. Jackson, B.J. Powers, J. Prvu Bettger.
Critical revision of the article for important intellectual content: B.J. Powers, R. Chatterjee, J. Prvu Bettger, A.R. Kemper, R.J. Dolor, B.L. Heidenfelder, J.W. Williams.
Final approval of the article: G.L. Jackson, B.J. Powers, R. Chatterjee, J. Prvu Bettger, A.R. Kemper, R.J. Dolor, B.L. Heidenfelder, A.S. Kendrick, J.W. Williams.
Provision of study materials or patients: A.S. Kendrick.
Statistical expertise: V. Hasselblad.
Obtaining of funding: R.J. Dolor, J.W. Williams.
Administrative, technical, or logistic support: R.J. Irvine, B.L. Heidenfelder, A.S. Kendrick, R. Gray.
Collection and assembly of data: G.L. Jackson, B.J. Powers, R. Chatterjee, J. Prvu Bettger, A.R. Kemper, R.J. Dolor, R.J. Irvine, B.L. Heidenfelder, A.S. Kendrick, J.W. Williams.
Jackson GL, Powers BJ, Chatterjee R, Prvu Bettger J, Kemper AR, Hasselblad V, et al. The Patient-Centered Medical Home: A Systematic Review. Ann Intern Med. 2013;158:169-178. doi: 10.7326/0003-4819-158-3-201302050-00579
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Published: Ann Intern Med. 2013;158(3):169-178.
The patient-centered medical home (PCMH) describes mechanisms for organizing primary care to provide high-quality care across the full range of individuals' health care needs. It is being widely implemented by provider organizations and third-party payers.
To describe approaches for PCMH implementation and summarize evidence for effects on patient and staff experiences, process of care, and clinical and economic outcomes.
PubMed (through 6 December 2011), Cumulative Index to Nursing & Allied Health Literature, and the Cochrane Database of Systematic Reviews (through 29 June 2012).
English-language trials and longitudinal observational studies that met criteria for the PCMH, as defined by the Agency for Healthcare Research and Quality, and included populations with multiple conditions.
Information on study design, populations, interventions, comparators, financial models, implementation methods, outcomes, and risk of bias were abstracted by 1 investigator and verified by another.
In 19 comparative studies, PCMH interventions had a small positive effect on patient experiences and small to moderate positive effects on the delivery of preventive care services (moderate strength of evidence). Staff experiences were also improved by a small to moderate degree (low strength of evidence). Evidence suggested a reduction in emergency department visits (risk ratio [RR], 0.81 [95% CI, 0.67 to 0.98]) but not in hospital admissions (RR, 0.96 [CI, 0.84 to 1.10]) in older adults (low strength of evidence). There was no evidence for overall cost savings.
Systematic review is challenging because of a lack of consistent definitions and nomenclature for PCMH.
The PCMH holds promise for improving the experiences of patients and staff and potentially for improving care processes, but current evidence is insufficient to determine effects on clinical and most economic outcomes.
Definition of the patient-centered medical home.
Based on the Agency for Healthcare Research and Quality's definition (8). Includes each of categories 1 through 4.
Summary of evidence search and selection.
CINAHL = Cumulative Index to Nursing & Allied Health Literature; PCMH = patient-centered medical home.
* All studies/articles included for effectiveness studies were also included in the analysis of PCMH intervention descriptions.
Appendix Table 1.
Characteristics of Included Studies—Comparative Randomized, Controlled Trials (Questions 1–3)
Appendix Table 2.
Characteristics of Included Studies—Comparative Observational Studies (Questions 1–3)
Appendix Table 3.
Characteristics of Included Studies—Noncomparative Studies (Questions 2 and 3)
Appendix Table 4.
PCMH Components Implemented and Implementation Strategies Used (Questions 2 and 3)
Appendix Table 5.
Meta-analyses for Inpatient and Emergency Department Utilization Reported in Randomized, Controlled Trials
Comparative Study Characteristics and Reported Outcomes
Summary of the Strength of Evidence for Effects of PCMH
Appendix Table 6.
Reported Outcomes by Study
PCMH take-home points.
PCMH = patient-centered medical home.
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