Synthesis Of Research On Patient-Centered Medical Homes Brings Systematic Differences Into Relief

Sinaiko AD, Landrum MB, Meyers DJ, Alidina S, Maeng DD, Friedberg MW, Kern LM, Edwards AM, Flieger Sp, Houck PR, Peele P, Reid RJ, McGraves-Lloyd K, Finison K, Rosenthal MB
Source: Health Affairs
Publication Year: 2017
Patient Need Addressed: Care Coordination/Management
Intervention Type: Service redesign
Study Design: Review
Type of Literature: White
link: https://www.healthaffairs.org/doi/10.1377/hlthaff.2016.1235
Abstract

The patient-centered medical home (PCMH) model emphasizes comprehensive, coordinated, patient-centered care, with the goals of reducing spending and improving quality. To evaluate the impact of PCMH initiatives on utilization, cost, and quality, we conducted a meta-analysis of methodologically standardized findings from evaluations of eleven major PCMH initiatives. There was significant heterogeneity across individual evaluations in many outcomes. Across evaluations, PCMH initiatives were not associated with changes in the majority of outcomes studied, including primary care, emergency department, and inpatient visits and four quality measures. The initiatives were associated with a 1.5 % reduction in the use of specialty visits and a 1.2 % increase in cervical cancer screening among all patients, and a 4.2 % reduction in total spending (excluding pharmacy spending) and a 1.4 % increase in breast cancer screening among higher-morbidity patients. These associations were significant. Identification of the components of PCMHs likely to improve outcomes is critical to decisions about investing resources in primary care.

Insights Results

Overview of article

  • This meta-analysis synthesizes evidence across studies on the impact of 11 initiatives that promote PCMH transformation, specifically assessing outcomes likes changes in cost and the use of hospitalizations and physician visits
  • Patient-centered medical homes (PCMH) have generated mixed evidence leading to 2 possible explanations: 1) PCMH interventions are dissimilar to each other goals, designs and contexts; and 2) Many intervention evaluations have been relatively small and underpowered

Methods of article

  • The study partnered with the Patient-Centered Medical Home Evaluators’ Collaborative, a collaborative of expert researchers who conduct and establish best practices for PCMH evaluations
  • The standardized methodology for identified and reviewed articles had 3 components: 1) Common approach to patient attribution; 2) Standardized definitions for measures of utilization, quality, and cost; and 3) Generation of new estimates of PCMH impact using standardized difference-in-differences models
  • Authors evaluated the impact of PCMH transformation on the full sample of adult patients at PCMHs and comparison practices and on a subsample of patients with 2 or more major medical comorbidities
  • Outcome measures were use of primary, specialist, and inpatient care and of the ED; screening for cervical, breast, and colorectal cancer; and, for patients with diabetes, dilated eye exams, hemoglobin A1c testing, and lipid testing. They also examined PCMH impact on ambulatory care–sensitive hospital admissions and potentially avoidable ED visits

Results

  • The study found significant effects of PCMHs on 2 screening measures (for breast and cervical cancer) and 2 utilization measures (specialty care visits and total cost of care, excluding pharmacy spending). However, it found no evidence of a significant effect on other utilization measures (primary care, ambulatory care–sensitive inpatient, all inpatient, potentially avoidable ED visits, and all ED visits) or on other quality measures (screening for colorectal cancer and three tests for patients with diabetes)
  • Overall, they found no overall effect of PCMH transformation on the majority of measures evaluated, indicating that the assessed 11 initiatives did not have its intended effects on cost, utilization and quality. However, it is likely that the specific context in which a PCMH is implemented and how and by whom it’s championed are very important in achieving the desired impact on primary care
  • Change in total healthcare spending based on PCMH transformation was not observed
  • PCMH transformation was associated with a small and significant reduction (1.5 %) of specialty visits among all patients
  • PCMH transformation was associated with a 1.2% increase in recommended cervical cancer screenings among all patients and a 1.4% increase in recommended breast cancer screenings
  • The consistency with which individual practices within a PCMH initiative embrace transformation may vary, contributing to heterogeneity

Key takeaways/implications

  • Recent work identifies 5 domains to consider when interpreting findings of practice transformation: 1) The practice setting; 2) The organizational setting; 3) The external environment; 4) The implementation pathway; and 5) The motivation for transformation. Understanding which specific components of the PCMH contribute most to success is critical to determining how to invest resources in primary care transformation
  • Policy implications for payers and policy makers include: 1) Recognize that implementing PCMHs fundamentally transforms how primary care is delivered, warranting examination of costs and benefits of the long-term investments and strategies in developing, implementing, and sustaining PCMHs; 2) Consider the heterogeneity in the design and implementation of PCMHs and investigate how such difference in features may contribute to PCMH success; and 3) Recognize that PCMHs alone cannot solve the current challenges involved in delivering patient-oriented primary care
  • Limitations to the study include use of estimates from a small number of studies, inability to examine effects beyond 2 years from the start of the PCMH programs, nonexamination of all relevant impacts of PCMHs due to administrative limitations, and nonexamination of patient experience
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