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The American Journal of Managed Care November 2016
Referrals and the PCMH: How Well Do We Know Our Neighborhood?
Andrew Schreiner, MD; Patrick Mauldin, PhD, Jingwen Zhang, MS; Justin Marsden, BS; and William Moran, MD, MS
Does Medicare Advantage Enrollment Affect Home Healthcare Use?
Daniel A. Waxman, MD, PhD; Lillian Min, MD, MSHS; Claude M. Setodji, PhD; Mark Hanson, PhD; Neil S. Wenger, MD, MPH; and David A. Ganz, MD, PhD
A New Chapter in Health Reform
Michael E. Chernew, PhD, and A. Mark Fendrick, MD
Prescribers' Perceptions of Medication Discontinuation: Survey Instrument Development and Validation
Amy Linsky, MD, MSc; Steven R. Simon, MD, MPH; Kelly Stolzmann, MS; Barbara G. Bokhour, PhD; and Mark Meterko, PhD
Enhancing Patient and Family Engagement Through Meaningful Use Stage 3: Opportunities and Barriers to Implementation
Jaclyn Rappaport, MPP, MBA; Sara Galantowicz, MPH; Andrea Hassol, MSPH; Anisha Illa, BS; Sid Thornton, PhD; Shan He, PhD; Jean Adams, RN, ACIO; and Charlie Sawyer, MD, FACP
Integrated Care Organizations: Medicare Financing for Care at Home
Karen Davis, PhD; Amber Willink, PhD; and Cathy Schoen, MS
Reconsidering the Economic Value of Multiple Sclerosis Therapies
Tiffany Shih, PhD; Craig Wakeford, MA; Dennis Meletiche, PharmD; Jesse Sussell, PhD; Adrienne Chung, PhD; Yanmei Liu, MS; Jin Joo Shim, MS; and Darius Lakdawalla, PhD
Health Systems Tackling Social Determinants of Health: Promises, Pitfalls, and Opportunities of Current Policies
Krisda H. Chaiyachati, MD, MPH; David T. Grande, MD, MPA; and Jaya Aysola, MD, DTMH, MPH
Maternal Mental Health and Infant Mortality for Healthy-Weight Infants
Susan E. White, PhD, RHIA, CHDA, and Robert W. Gladden, MA, BS
The Role of Internal Medicine Subspecialists in Patient Care Management
Jonathan L. Vandergrift, MS; Bradley M. Gray, PhD; James D. Reschovsky, PhD; Eric S. Holmboe, MD; and Rebecca S. Lipner, PhD
Currently Reading
Medical Home Transformation and Breast Cancer Screening
Amy W. Baughman, MD, MPH; Phyllis Brawarsky, MPH; Tracy Onega, PhD, MS; Tor D. Tosteson, ScD; Qianfei Wang, MS; Anna N.A. Tosteson, ScD; and Jennifer S. Haas, MD, MSc

Medical Home Transformation and Breast Cancer Screening

Amy W. Baughman, MD, MPH; Phyllis Brawarsky, MPH; Tracy Onega, PhD, MS; Tor D. Tosteson, ScD; Qianfei Wang, MS; Anna N.A. Tosteson, ScD; and Jennifer S. Haas, MD, MSc
Breast cancer screening may not improve in early medical home implementation.
ABSTRACT

Objectives: The patient-centered medical home (PCMH) continues to gain momentum as a primary care delivery system. We evaluated whether medical home transformation of primary care practices is associated with the use of breast cancer screening, a broadly endorsed preventive service.

Study Design: Retrospective cohort study evaluating 12 Brigham and Women’s Hospital (BWH)-affiliated primary care clinics in greater Boston, Massachusetts.

Methods: Practice transformation was measured quarterly using a continuous PCMH transformation score (range = 0-100) modeled after National Committee for Quality Assurance recognition requirements. We included women aged 50 to 74 years who had at least 1 primary care visit at a participating clinic between April 2012 and December 2013 (n = 20,349)—a period of medical home transformation. The main measures included: a) whether screening was up-to-date at the time of the visit (mammography completion within 24 months prior to the visit); and b) if screening was overdue at the visit (ie, it had been more than 24 months since the last mammogram), and whether timely screening was completed within 3 months after the visit.

Results: In adjusted analyses, PCMH transformation scores were negatively associated with up-to-date screening status (odds ratio [OR] for a 20-point change, 0.93; 95% confidence interval [CI], 0.89-0.96) and with timely screening of women who were overdue (OR, 0.94; 95% CI, 0.87-1.02).

Conclusions: Preventative care, such as breast cancer screening, may not improve in early PCMH implementation.

Am J Manag Care. 2016;22(11):e382-e388
Take-Away Points

  • The patient-centered medical home (PCMH) model has received widespread support, yet to our knowledge, there are no validated measures to track this complex care transition or with which to examine the impact of this transition on well-accepted quality measures, like breast cancer screening. 
  • Using a locally developed measure of PCMH transformation over a 2-year period, we found that transformation scores were negatively associated with up-to-date, timely breast cancer screening. 
  • Care redesign should include the development of valid measures so that unexpected effects of care transformation on important quality metrics can be examined.
Among women in the United States, breast cancer is the most common cancer and is the second most common cause of cancer-related death.1 Primary care plays a critical role in breast cancer screening and detection. One primary care model that may improve the use of screening is the patient-centered medical home (PCMH), which advocates believe can achieve the “triple aim” of improving health, decreasing cost, and enhancing patient experiences.2-4 Core components of the PCMH model include: patient-centered access, team-based care, population health management, care management and support, care coordination and care transitions, and performance measurement and quality improvement.5

National initiatives in PCMH adoption have expanded rapidly; the number of patients cared for in medical homes increased from approximately 5 million in 2009 to 21 million in 2013.3 The model has received widespread support from policy makers and industry stakeholders, including all major US primary care physician organizations2; however, research on the effect of the medical home model overall has been mixed,4,6-9 underscoring the need for additional research given the rapid uptake of this care model.

Understanding how the PCMH model can impact care quality and processes early on, as well as in the long term, is critical for policy planning, primary care design, and resource allocation. Medical home transformation is a dynamic and complex transition that may take several years and may be implemented differently in different settings.9-11 Additionally, exploring how processes are impacted during this early period can help optimize and standardize future initiatives. Our study focuses on this implementation period and examines in depth how 1 strategy of implementation and assessment may impact an important indicator of primary care: the delivery of breast cancer screening. Importantly, to our knowledge, there are no validated measures of the process of primary care transformation to a PCMH, so settings interested in assessing progress toward PCMH recognition may define their own measures.

Breast cancer screening may be an important indicator of successful PCMH transformation, as several of the required PCMH components (patient-centered access to scheduling and convenient appointment times, team-based care with integration with specialty providers in obstetrics/gynecology and radiology, population health management, and performance measurement and quality improvement) may facilitate completion. Evaluating whether the PCMH can improve the use of breast cancer screening is also important, as it is strongly recommended for women aged 50 to 74 years by the US Preventive Services Task Force, the American Cancer Society, and other specialty societies.12,13 Yet, PCMH also places significant emphasis on chronic disease management, utilization, and the prevention of readmission.4,14 This emphasis may divert focus from cancer screening and other preventive care. We evaluated whether medical home transformation of primary care practices is associated with the use of breast cancer screening—a broadly endorsed preventative service.

METHODS

Study Design and Data Source


We conducted a retrospective cohort study evaluating 12 participating Brigham and Women’s Hospital (BWH)-affiliated primary care clinics. Clinical data were extracted from the BWH Population-based Research Optimizing Screening through Personalized Regimens (PROSPR) Registry supplemented with additional data elements from the electronic health record (EHR). This study was conducted as part of the National Cancer Institute (NCI)-funded consortium PROSPR.15 The overall aim of PROSPR is to conduct multi-site, coordinated, trans-disciplinary research to evaluate and improve cancer-screening processes. This study was approved by the Partners Healthcare Institutional Review Board.

Study Population

We included women aged 50 to 74 years who had at least 1 primary care visit to 1 of 12 participating BWH-affiliated primary care clinics between April 2012 and December 2013 (n = 20,349), a period when the institution was undertaking medical home transformation. Women were excluded if they had a prior history of breast cancer (n = 2085) or died during the follow-up period (n = 279).

Exposure: Practice Transformation

In 2012, BWH began measuring PCMH transformation using a framework called “Primed Status” that was modeled on the National Committee for Quality Assurance (NCQA) requirements for medical home recognition. Primed Status was developed by Partners Healthcare Population Health Management as a metric for progress toward PCMH implementation (ie, it is intended to indicate whether a practice is “primed” for PCMH recognition). Although other studies have used NCQA audit data following PCMH recognition, this measure was developed to help guide practices before recognition status was achieved. This measure of PCMH transformation is the exposure variable for this analysis. This score was assessed quarterly for each practice based on achieving targets for the following elements: use of EHR, patient access to a Web-based portal, team-based care, practice redesign and process improvement, and care management of high-risk patients (Table 1). Several of these features could positively influence the use of cancer screening (eg, EHR use could facilitate use of provider reminders or panel management to identify overdue screening, patient portals could be used for patient reminders, quality improvement initiatives could focus on cancer screening); however, several of the measures could be negatively associated with cancer screening if resources were more focused on high-risk patients (ie, the care management criteria). The measure was developed to reflect the institutional need for practice transformation to achieve NCQA recognition. Partners Healthcare supported practices both by providing quarterly financial incentives for reaching these targets and by providing practice change support, such as consultants and increased staffing.16

We evaluated an aggregate 0-to-100 “PCMH Transformation Score” based on the percentage of elements achieved. The most recent quarter’s score was assigned to a woman’s primary care visit. If there were multiple visits within a quarter, the first visit score was used for analysis.

Outcome Measures

We examined 2 outcome measures using data from the EHR and our PROSPR data repository: a) whether screening was up-to-date at the visit (defined as mammography completion within 24 months prior to the visit); and b) if screening was overdue at the visit (ie, it had been >24 months since the last mammography), and whether timely screening was completed within 3 months after the visit. We included uses of screening both observed in the EHR or noted in the EHR to have occurred elsewhere. These outcome definitions follow from Healthcare Effectiveness Data and Information Set measures for breast cancer screening.17

Data Analysis

The primary care visit was the unit of analysis. The continuous 0-to-100 PCMH Transformation Score was used as the exposure variable. Covariates included patient age, race/ethnicity, education level, insurance status, known family history of breast cancer, Charlson Comorbidity Index score,18 smoking history, number of primary care visits in the prior year, marital status, body mass index, and a linear time trend to account for secular changes in screening.

Adjusting for the above covariates, we used 2-level hierarchical logistic regression with PROC GLIMMIX version 9.2 (SAS Institute, Cary, North Carolina) to examine the impact of medical home transformation on status indicators of breast cancer screening. The regression coefficients for the PCMH Transformation Score were used to calculate the odds ratio for a 20-point change on the screening status indicators. A 20-point change was chosen to reflect a meaningful amount of transformation change. Regression analyses were clustered at the level of the patient and primary care practice. If there were missing data for a given variable, it was included in the model as a dummy variable.

RESULTS

Study Sample and Practice Characteristics


The cohort included 20,349 women who made 94,014 primary care visits (Figure). The average age of women in the cohort was 60 years and these women made an average of 2.8 primary care visits in the prior year (Table 2). A majority of women had Charlson Comorbidity Index scores of 0 (67%). A majority of patients were white (72%), with similar reported percentages of Hispanics (12%) and blacks (13%). Nearly all women had insurance (99%), with a majority having commercial (60%) or Medicare (27%) and the remainder having Medicaid or another federal program (12%). The majority of women had at least a college education. Four percent of women had a family history of breast cancer noted in the EHR. One-third of women were obese, and nearly one-third were overweight.

All 12 practices had improvements in their PCMH Transformation Scores over the study period; the average practice score increased from 26% in the first quarter to 81% in the final quarter (Table 3). The first practice to achieve a score in the highest quintile did so in the first quarter of 2013 and the last practices achieved this goal in the final quarter of 2013.

Use of Breast Cancer Screening and Practice Transformation

Women were up-to-date with screening at a majority of visits (81%) and were overdue at only 18% (Figure). At visits when a woman was overdue for screening, timely screening was not completed within 3 months for a majority of the visits (77%).

In adjusted analyses, PCMH Transformation Scores had a slightly negative correlation with up-to-date screening status (odds ratio [OR] for a 20-point change, 0.93; 95% confidence interval [CI], 0.89-0.96) and for timely screening of women who were overdue (OR, 0.94; 95% CI, 0.87-1.02) (Table 4).

Increasing age (up until age 70), Hispanic (OR, 1.82; 95% CI, 1.69-1.97) and black (OR, 1.11; 95% CI 1.05-1.18) race/ethnicity, greater number of primary care visits, and having higher levels of education were all positively correlated with up-to-date screening. Negatively correlated predictors of current screening included being unmarried, having a comorbid condition, Asian race, having insurance other than Medicare or commercial, or being a smoker. Up-to-date screenings in 2012 and the first quarter of 2013 were lower than those observed in the last quarter of 2013.

Positively correlated predictors of timely completion of screening when overdue at the time of the visit were Hispanic (OR, 1.46; 95% CI, 1.25-1.70) and black (OR, 1.15; 95% CI, 1.02-1.30) race/ethnicity and having a known family history of breast cancer (OR, 1.37; 95% CI, 1.15-1.63). Negatively correlated predictors were being in the oldest age category, being unmarried, having a comorbid condition, greater number of visits, and being a smoker. Timely completion of screening when overdue at the time of the visit was highest in the last quarter of 2012 and the first half of 2013.

DISCUSSION

 
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