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The Association Among Medical Home Readiness, Quality, and Care of Vulnerable Patients
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The Association Among Medical Home Readiness, Quality, and Care of Vulnerable Patients

Lena M. Chen, MD, MS; Joseph W. Sakshaug, PhD; David C. Miller, MD, MPH; Ann-Marie Rosland, MD, MS; and John Hollingsworth, MD, MS
The characteristics of patients who visit practices that are ready versus unready for the patient-centered medical home differ in important ways.
ABSTRACT
 
Objectives: Despite broad support for the patient-centered medical home (PCMH), the implications of PCMH implementation efforts that require that participants have some degree of PCMH readiness at baseline are unclear. Therefore, we sought to examine the association among PCMH readiness, quality, and the care of vulnerable patients.

Study Design: We conducted a cross-sectional study of adult visits to a nationally representative sample of US office-based primary care physicians in 2007 and 2008.

Methods: Using National Committee for Quality Assurance criteria, we determined whether or not a visit occurred at a PCMH-ready practice. We used t tests and multiple linear regression to measure the association between PCMH readiness and performance on 9 validated outpatient quality indicators.

Results: Among 12,235 visits to general practitioners and 5123 visits to general internists, 73% occurred at practices that were PCMH-ready. Visits by patients with 3 or more chronic medical conditions were more likely to occur at ready practices (P = .001). Visits by patients that were poor or minority were equally likely to occur at ready and unready practices. Performance at ready practices was higher for 3 of 9 quality indicators related to chronic disease management and preventive counseling (P = .031 [beta-blocker or diuretic prescribed for hypertension]; P = .018 [diet counseling]; and P <.001 [exercise counseling]).
 
Conclusions: Implementation efforts that encourage the enrollment of practices most ready for the PCMH could improve the quality of care for complex patients without exacerbating socioeconomic disparities in access to care.

Am J Manag Care. 2015;21(8):e480-e486
Take-Away Points
 
Despite substantial support for the patient-centered medical home (PCMH), the implications of PCMH implementation efforts that require that participants have some degree of PCMH readiness at baseline are unclear. Our data suggest that PCMH program design that encourages the enrollment of practices most ready for the PCMH could improve the quality of care for complex patients without exacerbating socioeconomic disparities in access to care.
Empirical work provides mixed evidence that implementation of the patient-centered medical home (PCMH) will improve the quality and costs of healthcare. Some demonstration projects have shown that the PCMH is associated with increased use of preventive services,1,2 greater patient satisfaction,3 and reductions in emergency department visits and/or hospital admissions.1,4-8 Evidence that the PCMH positively impacts clinical processes of care and patient outcomes is weaker and more inconsistent.3,9,10 However, there is little to suggest that the PCMH will harm patients, and many policy makers hope that the PCMH will eventually improve care. In this context, efforts are under way to disseminate the PCMH,11 including a multi-state pilot initiative from CMS.12

While many PCMH programs are voluntary, a substantial number require that participants have a baseline level of medical home readiness.11 Other programs require that practices attain a minimum level of medical home readiness within 12 to 18 months of program entry.11 Such choices about PCMH program design would seem to favor the enrollment of practices that are PCMH-ready (or nearly ready). If there is no differential access to care between PCMH-ready and PCMH-unready practices, then current program design makes sense, as PCMH-ready practices also tend to be multi-specialty practices with substantial visit volume.13 However, if practices that are least ready for the PCMH also disproportionately treat vulnerable populations, then overlooking such practices could initially exacerbate existing disparities. In this case, a purely voluntary approach without any prerequisites for PCMH program enrollment, combined with improvement metrics tailored to a practice’s baseline PCMH readiness, might be preferred.

Since no prior research has investigated the strengths and weaknesses of either strategy, we used data from a nationally representative sample of visits by adults to general practitioners and internists to examine the characteristics of visits to practices stratified by their medical home readiness. We addressed 2 questions: 1) What types of patients are more likely to be seen in visits to practices that are more PCMH-ready? and 2) Is there an association between PCMH readiness and quality of care delivered?

METHODS
Data Source and Study Population
For our study, we used data from the 2007 and 2008 National Ambulatory Medical Care Survey (NAMCS), which is an annual multistage probability sample of outpatient visits to randomly selected, nonfederally employed, office-based physicians in the United States.14 Practices are sampled during a 1-week time frame, so the sample is unlikely to include 2 visits by the same patient. In 2007 and 2008, data were collected from 32,778 and 28,741 office-based visits, respectively. The data files contain practice-, physician-, patient-, and visit-level characteristics. Weighted estimates from them are considered representative of all US outpatient visits. We focused on adult (ie, aged ≥18 years) ambulatory visits occurring at general and internal medicine practices.
 
Assessing PCMH Readiness
We assessed the medical home readiness of each practice where a visit occurred using previously described methods.13 In brief, we mapped practice-level characteristics reported by physicians in the NAMCS to the 2011 National Committee for Quality Assurance (NCQA) PCMH certification standards (see eAppendix 1, available at www.ajmc.com).15 The NCQA assigns a point value to each of the 30 elements (including 6 “must-pass” elements) outlined in the PCMH standards. We mapped 14 elements (including 3 “must-pass” elements), representing 6 of the medical home standards, to items collected in the NAMCS. The 6 PCMH standards were: 1) enhanced access and continuity (8 points); 2) identifying and managing patient populations (16 points); 3) planning and managing care (7 points); 4) providing self-care support and community resources (6 points); 5) tracking and coordinating care (6 points); and 6) measuring and improving performance (13 points).

To calculate a practice’s PCMH readiness score, we used the NCQA scoring system15 to derive a cumulative point total for each practice by summing across all of the passed elements. Based on the 14 measured elements, the maximum point total was 56 when no missing data were present. In the case of missing data, the maximum point total was based on all non-missing data (see eAppendix 2). The practice-level readiness score was then calculated by dividing the cumulative point total by the total number of available points. The resulting readiness score is expressed as a percentage and can be interpreted as the percentage of measureable NCQA elements that the practice (where the visit occurred) possesses. Based on the NCQA’s levels of medical home recognition, we categorized practices into 2 groups: unready (<35 %) and ready (≥35 %) for medical home implementation.
 
Measuring Quality of Care
To measure the quality of care provided at each visit, we first determined whether or not the visit met any of 6 validated medication quality indicators.16-19 These indicators were: 1) angiotensin-converting-enzyme inhibitor/angiotensin receptor blocker for congestive heart failure (CHF); 2) beta-blocker for CHF; 3) diuretic or beta-blocker for hypertension; 4) beta-blocker for coronary artery disease; 5) statin for hyperlipidemia; and 6) the prescribing of no inappropriate medications during the visit. We coded these indicators using diagnosis and medication codes in NAMCS, as well as responses to questions about the presence or absence of specific chronic diseases. For each visit, the treating physician can list up to 3 diagnoses (primary, secondary, or tertiary) on the patient record form. In addition to diagnoses, the patient record form lists up to 8 original and 8 generic medications prescribed by the treating physician.

In addition to the 6 medication quality indicators, we examined 3 previously validated prevention and counseling quality indicators: diet and exercise counseling (yes/no responses in NAMCS), and blood pressure monitoring at any general medical exam visit.17 The NAMCS asks respondents to enter blood pressure readings (if blood pressure was measured at the visit). In defining a general medical exam, a visit for preventive care was defined as a general medical exam, but a follow-up visit was not considered a general medical exam.
 
Statistical Analysis
We first described the characteristics of visits occurring at practices that were PCMH-ready versus unready. We used Student’s t tests to test for differences in visit characteristics. We also used t tests to determine whether the percentage of visits meeting each of the 9 quality-of-care indicators differed between ready and unready practices.

We applied appropriate sampling weights, clusters, and stratification to correct our standard error estimates for the complex survey design. We performed all analyses using Stata version 11.0 (StataCorp LP, College Station, Texas). The University of Michigan Health Sciences and Behavioral Sciences Institutional Review Board determined that this study was exempt from its oversight.


 
Copyright AJMC 2006-2017 Clinical Care Targeted Communications Group, LLC. All Rights Reserved.
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