0

The full content of Annals is available to subscribers

Subscribe/Learn More  >
Original Research |

The Patient-Centered Medical Home and Associations With Health Care Quality and Utilization: A 5-Year Cohort StudyThe Patient-Centered Medical Home and Health Care Quality and Utilization

Lisa M. Kern, MD, MPH; Alison Edwards, MStat; and Rainu Kaushal, MD, MPH
[+] Article, Author, and Disclosure Information

This article was published at www.annals.org on 16 February 2016.


From Weill Cornell Medical College, Health Information Technology Evaluation Collaborative, and New York-Presbyterian Hospital, New York, New York.

Acknowledgment: This study was conducted as part of the work of the Health Information Technology Evaluation Collaborative. The authors specifically thank Susan Stuard, MBA, executive director of THINC, and A. John Blair III, MD, president of the Taconic IPA and chief executive officer of MedAllies.

Financial Support: By The Commonwealth Fund (grant 20130685) and the New York State Department of Health (contract C025877).

Disclosures: Authors have disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M14-2633.

Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that she has no financial relationships or interests to disclose. Darren B. Taichman, MD, PhD, Executive Deputy Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Deborah Cotton, MD, MPH, Deputy Editor, reports that she has no financial relationships or interest to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Catharine B. Stack, PhD, MS, Deputy Editor for Statistics, reports that she has stock holdings in Pfizer.

Reproducible Research Statement:Study protocol: Selected portions are available to approved persons from Dr. Kern (e-mail, lmk2003@med.cornell.edu). Statistical code and data set: Not available.

Requests for Single Reprints: Lisa Kern, MD, MPH, Department of Healthcare Policy and Research, Weill Cornell Medical College, 402 East 67th Street, New York, NY 10065; e-mail, lmk2003@med.cornell.edu.

Current Author Addresses: Drs. Kern and Kaushal and Ms. Edwards: Weill Cornell Medical College, 402 East 67th Street, 2nd Floor, New York, NY 10065.

Author Contributions: Conception and design: L.M. Kern, A. Edwards.

Analysis and interpretation of the data: L.M. Kern, A. Edwards, R. Kaushal.

Drafting of the article: L.M. Kern, A. Edwards.

Critical revision of the article for important intellectual content: L.M. Kern, A. Edwards.

Final approval of the article: L.M. Kern, A. Edwards, R. Kaushal.

Statistical expertise: A. Edwards, R. Kaushal.

Obtaining of funding: L.M. Kern.

Administrative, technical, or logistic support: L.M. Kern, R. Kaushal.

Collection and assembly of data: L.M. Kern, A. Edwards.


Ann Intern Med. 2016;164(6):395-405. doi:10.7326/M14-2633
© 2016 American College of Physicians
Text Size: A A A

Background: Effects of the patient-centered medical home (PCMH) are unclear. Previous studies had relatively short follow-up and may not have distinguished effects of the PCMH (which involves electronic health records [EHRs] plus organizational changes) from those of EHRs alone.

Objective: To determine effects of the PCMH on health care quality and utilization compared with paper records alone and EHRs alone, with extended follow-up.

Design: Prospective cohort study (2008 to 2012), including 3 years after PCMH implementation. (ClinicalTrials.gov: NCT00793065)

Setting: The Hudson Valley, a multipayer, multiprovider region in New York.

Participants: 438 primary care physicians in 226 practices, with 136 480 patients across 5 health plans.

Intervention: Level III PCMH, as defined by the National Committee for Quality Assurance.

Measurements: Claims-based outcomes included 8 quality and 7 utilization measures. Generalized estimating equations were used to compare adjusted differences in rates of change across study groups.

Results: Patterns of quality were fairly similar across groups. Utilization patterns were similar across groups from 2008 to 2011 but showed modest differences between the PCMH and control groups on most measures in 2012. For example, hospitalizations were relatively stable from 2008 to 2011 (approximately 3.9 to 5.2 per 100 patients per year) but decreased in the PCMH group in 2012 (incidence rate ratio, 0.79 [95% CI, 0.69 to 0.90] compared with paper records). Emergency department visits were highest for the PCMH group (16.7 per 100 patients at baseline and 15.4 per 100 patients at the end of the study period) and lowest for the paper group (14.3 per 100 patients at baseline and 12.2 per 100 patients at the end of the study period), but the rate of change did not differ across groups.

Limitation: Possible unmeasured confounding.

Conclusion: The PCMH was associated with modest changes in most utilization measures and provided similar quality compared with EHRs and paper records.

Primary Funding Source: The Commonwealth Fund and the New York State Department of Health.

Figures

Grahic Jump Location
Appendix Figure 1.

Study flow diagram.

PCP = primary care physician.

* The PCPs were required to have patients in all 5 y of the study, but they did not need to be the same patients across all 5 y.

Grahic Jump Location
Grahic Jump Location
Figure 1.

Adjusted probability of receiving recommended care, by quality measure and by study group over time.

EHR = electronic health record; HbA1c = hemoglobin A1c; LDL = low-density lipoprotein; PCMH = patient-centered medical home.

* P < 0.05 for ≥1 pairwise difference-in-differences over time (see also Appendix Table 1 for details).

Grahic Jump Location
Grahic Jump Location
Figure 2.

Adjusted rates of health care utilization, by type of utilization and by study group over time.

EHR = electronic health record; PCMH = patient-centered medical home.

* P < 0.05 for ≥1 pairwise difference-in-differences over time (see also Appendix Table 1 for details).

Grahic Jump Location
Grahic Jump Location
Appendix Figure 2.

Proportions of patients from each of the participating health plans, by study group over time.

These figures show that any secular trends in the proportion of patients coming from each plan over time affected the study groups similarly. As a result, the likelihood of substantial bias from these secular trends is relatively low. EHR = electronic health record; PCMH = patient-centered medical home.

Grahic Jump Location

Tables

References

Letters

NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).

Comments

Submit a Comment/Letter
PCMHs work but doctors need to work harder
Posted on March 20, 2016
Ronald L. Hirsch, MD, FACP
Accretive Health
Conflict of Interest: None Declared
The study by Kern et al demonstrating the benefits of the PCMH in utilization measures was interesting but what stood out to me is that in 2012, less than 70% of diabetics had an HbA1c, LDL measurement, or screening for nephropathy. Why is that number not near 100%, excluding only those nearing the end of life? I can understand the lower rate of screening for breast and colorectal cancer and eye examinations since those require time and effort by the patient, but HbA1c, LDL and urine tests are all simple tests that can be performed at any office visit, without the need for special preparation and are crucial to the care of diabetics.

As long as physicians continue to under perform on such simple yet crucial measures, we cannot complain when Medicare and other payers impose what we consider to be onerous and time-consuming quality standards upon us. We all must do better for our patients.
Medical Homes gaining traction at both sides of the Atlantic
Posted on April 4, 2016
Odone A. MD MSc MPH, Chiesa V. MD, Bombardini C. MD, Miduri A. MD, Signorelli C. MD MSc PhD
Department of Global Health & Social Medicine, Harvard Medical School - School of Medicine, University of Parma
Conflict of Interest: None Declared
Corresponding author:
Anna Odone MD, MSc, MPH

Strengthening primary care systems is key to achieve high-quality, accessible and efficient healthcare; this has been recognized by the US Agency for Healthcare Research and Quality (AHRQ) but holds true at the global level.

The patient-centered medical home (PCMH) model promises to improve the organization and delivery of primary care. It has been first conceptualized and implemented in the US but offers great potentials to European health systems. Does the ‘Medical homeness’ (1) work? As outlined by Mark Friedberg in its editorial (1) PCMH models have been assessed in the scientific literature in terms of interventions, characteristics of primary care practices or patterns of care; the former being identified as the only useful approach to inform policy change1. We follow with great interest the growing body of evidence on PCMHs. Available data, although heterogeneous in methods and outcomes, support ongoing efforts to promote PCMHs in the US (1-3).

What about Europe? Building on key features of the American PCMH model, several European countries including France, UK, Belgium, Denmark, Spain and Italy have implemented PCMH-based primary care models in recent years; this to meet communities’ changing health needs and to support public health systems’ sustainability (4,5).

Similarly to what done by Jackson and colleagues 3, we conducted a systematic review to summarize the available evidence on PCMH effects on healthcare and economic outcomes. The systematic review’s methods followed the PRISMA guidelines. Studies were included if: 1)the PCMH model they described met the criteria defined by the AHRQ, 2)had a comparative study design, and 3)were conducted in Europe. Of 3047 records retrieved from selected databases* only two studies met the inclusion criteria (6,7). The main reason of exclusion for studies describing PCMH interventions was not having a comparison group. Both included studies were published on Medical Care and assessed the implementation of PCMHs in Belgium on a large national representative sample. They reported increased quality of care and reduced costs in PCMH practices as compared to individual practices (6,7).


PCMHs offer great potential to value primary healthcare. Although key PCMH features have been introduced in selected European primary care systems, our systematic assessment shows that evidence proving theirs effect on health and healthcare costs is still limited. As lessons could be learned from the US experience, long follow-up comparative studies, like the one conducted by Kern and colleagues 2, should be carried out to measure the effects of its implementation in Europe.


*search strategy and PRISMA flowchart available as supplementary material, upon request


References

1. Friedberg MW. What Do You Mean by Medical Home? Annals of internal medicine 2016;164(6):444-5.
2. Kern LM, Edwards A, Kaushal R. The Patient-Centered Medical Home and Associations With Health Care Quality and Utilization: A 5-Year Cohort Study. Annals of internal medicine 2016;164(6):395-405.
3. Jackson GL, Powers BJ, Chatterjee R, Bettger JP, Kemper AR, Hasselblad V, et al. Improving patient care. The patient centered medical home. A Systematic Review. Annals of internal medicine 2013;158(3):169-78.
4. Odone A, Saccani E, Chiesa V, Brambilla A, Brianti E, Fabi M, et al. The implementation of a Community Health Centre-based primary care model in Italy. The experience of the Case della Salute in the Emilia-Romagna Region. Ann Ist Super Sanita 2016;52(1):70-7.
5. Faber M, Voerman G, Erler A, Eriksson T, Baker R, De Lepeleire J, et al. Survey of 5 European countries suggests that more elements of patient-centered medical homes could improve primary care. Health affairs (Project Hope) 2013;32(4):797-806.
6. Moureaux C, Perelman J, Mendes da Costa E, Roch I, Annemans L, Heymans I, et al. Impact of the medical home model on the quality of primary care: the Belgian experience. Med Care 2015;53(5):396-400.
7. Perelman J, Roch I, Heymans I, Moureaux C, Lagasse R, Annemans L, et al. Medical homes versus individual practice in primary care: impact on health care expenditures. Med Care 2013;51(8):682-8.


Submit a Comment/Letter

Summary for Patients

Clinical Slide Sets

Terms of Use

The In the Clinic® slide sets are owned and copyrighted by the American College of Physicians (ACP). All text, graphics, trademarks, and other intellectual property incorporated into the slide sets remain the sole and exclusive property of the ACP. The slide sets may be used only by the person who downloads or purchases them and only for the purpose of presenting them during not-for-profit educational activities. Users may incorporate the entire slide set or selected individual slides into their own teaching presentations but may not alter the content of the slides in any way or remove the ACP copyright notice. Users may make print copies for use as hand-outs for the audience the user is personally addressing but may not otherwise reproduce or distribute the slides by any means or media, including but not limited to sending them as e-mail attachments, posting them on Internet or Intranet sites, publishing them in meeting proceedings, or making them available for sale or distribution in any unauthorized form, without the express written permission of the ACP. Unauthorized use of the In the Clinic slide sets will constitute copyright infringement.

Toolkit

Buy Now for $32.00

to gain full access to the content and tools.

Want to Subscribe?

Learn more about subscription options

Advertisement
Related Articles
Topic Collections
PubMed Articles
Forgot your password?
Enter your username and email address. We'll send you a reminder to the email address on record.
(Required)
(Required)