The American Journal of Managed Care May 2016
Enhanced Primary Care and Impact on Quality of Care in Massachusetts
Objectives: Using Behavioral Risk Factor Surveillance System (BRFSS) telephone survey data, we evaluated whether individuals who reported access to enhanced primary care features experienced improved quality of care.
Study Design: Cross-sectional population-level survey.
Methods: We assessed a sample of 16,731 Massachusetts residents contacted by telephone using random-digit dialing, to complete the BRFSS in 2008. A randomized subset of 5693 respondents received an additional 5-question enhanced primary care assessment module. We defined an “enhanced” primary care group as those who reported having a regular, personal provider and responded that their provider “always” or “almost always” 1) had knowledge of their medical history, 2) gave them an appointment right away when necessary, 3) was up-to-date in their knowledge of the patient’s specialist care, and 4) asked them about all of their medications. Multivariable logistic regression was used to compare the “enhanced” versus “usual care” groups and assess several quality process measures.
Results: Nearly one-third of participants endorsed having indicators of enhanced care, and this group reported significantly higher rates of diabetes process measures (56% vs 38%), cholesterol screening (89% vs 81%), influenza vaccination (57% vs 49%), pneumonia vaccination (51% vs 43%), and lower cost and/or access barriers to care (22% vs 33%).
Conclusions: Enhanced primary care was associated with improved self-reported quality outcomes in a statewide telephone survey. A brief, 5-question module provided a novel population measure of access to enhanced primary care. This is a scalable option for other states hoping to characterize their own primary care improvement efforts through the patient-centered medical home model.
Am J Manag Care. 2016;22(5):e169-e174
- Patient-reported indicators of the PCMH correlated with improved quality process measures in diabetes, cholesterol screening, vaccination, and access to care.
- A brief, 5-question module provided a novel population measure of access to enhanced primary care.
- This may be a scalable option for other states hoping to characterize their own primary care usage and utility as health insurance expansion continues nationally.
Most PCMH assessment surveys are based on individual practice or demonstration reports, and such surveys have been at the forefront of reports on the success of the PCMH model.5-8 Although such demonstrations are a critical part of the evaluation process of new care models, they are context-specific and take time to generate evaluable data. Another approach to evaluate the effect of the PCMH-associated components is to use publically available survey data and parsimonious definitions of what factors compose a PCMH. One such evaluation was performed on the 2007 to 2008 National Survey of Children’s Health, and it identified improvements in 6 of 10 quality measures among children in a PCMH, as defined by a 5-component measure.9 Such patient care experience surveys are often unavailable, however, and to date, there is no state-level evidence on the availability of PCMH components in primary care practices or their association with quality of care.
The Behavioral Risk Factor Surveillance System (BRFSS) was developed by the CDC as a random-digit-dial landline telephone survey.10 The CDC collects data monthly, using this survey in all states and territories of the United States. In order to evaluate the availability of primary care providers, PCMH components in primary care, and sociodemographic predictors of the preceding variables in Massachusetts, a 5-question module was added to the BRFSS for a subset of responders. Using the data provided by this module, we then evaluated the association of PCMH components with quality of care.
The MA-BRFSS survey was completed in 3 waves, and the experimental module was used in the second wave. We used descriptive statistics to characterize the subset of responders and a χ2 test to look for statistical variance between the experimental module—wave 2—and the other survey waves. We then evaluated whether the responder had a primary care physician according to their survey results and used a multivariable logistic regression to test for associated subject characteristics between the subset of responders with a primary care physician and the subset without.
To determine whether having an enhanced primary care experience was related to completion of healthcare process measures, we divided responders into 2 groups. One group, termed the “enhanced primary care” group, endorsed having a primary care physician and responded that their provider “always” or “almost always” 1) had a knowledge of their medical history, 2) gave them an appointment right away when necessary, 3) was up-to-date in their knowledge of the patient’s specialist care, and 4) asked them about all of their medications. A multivariable logistic regression was used to test for associated subject characteristics between the “enhanced primary care” group and the “usual care” group without these PCMH attributes. A χ2 test was used to characterize the 2 groups.
We performed a multivariable logistic regression analysis to assess differences between the enhanced and usual care groups in several quality measures. We selected these indicators because they are common measures of clinical quality in the management of chronic disease and preventive care. Quality measures included diabetes annual care processes (which includes an annual visit, eye exam, foot exam, cholesterol screening, and hemoglobin A1C testing); lipid screenings for patients with cardiovascular disease, diabetes, and hyperlipidemia; annual influenza vaccination in eligible patients (all patients aged ≥6 months)12; and pneumonia vaccinations in eligible patients (all adults ≥65 years and adults aged 19-64 years who smoke, have chronic pulmonary disease, or are immunodeficient).13
An additional binary quality measure assessing cost barriers and access to care was created based on the responses to the following: “Was there a time during the last 12 months when you needed to see a doctor but could not due to the cost?” and “About how long has it been since you last visited a doctor for a routine checkup?” Subjects who responded that they did forgo a visit to the doctor due to cost in the past year or that they had not had a checkup within 1 year were given a positive value on the “cost/access” variable; subjects who did not meet one or both criteria were not given a positive value. The regressions were controlled for age, sex, income, education, and insurance status as covariates.
This study was reviewed by the Institutional Review Board at both the Massachusetts Department of Public Health and the CDC, and was considered exempt due to being a low-risk study without any patient identifiers.
Of the 16,731 respondents to the MA-BRFSS in 2009, 5693 respondents were randomized to receive the short form survey module. Table 2 summarizes subject characteristics for the respondents to the short form survey module (wave 2) compared with other respondents (waves 1 and 3). There were no significant demographic differences between the 2 groups, confirming that the random sampling for the survey module was successful.
Enhanced Primary Care Attributes
Among participants, 29.8% answered “always” or “almost always” to all 5 PCMH module questions, indicating that they had an enhanced primary care experience. Subjects who were aged 50 to 74 years (P = .012) or who were women (P <.001) were more likely to report having an enhanced primary care experience; subjects who were either uninsured (P <.001) or were Asian, Native Hawaiian or Pacific Islander, American-Indian, multiracial, or selected “other” for their racial affiliation (P = .008) were less likely (Table 3 and Figure 1).
A multivariate logistic regression adjusted for age, sex, income, education, and insurance status found significant differences between the enhanced and usual primary care groups in all quality measures tested. Subjects receiving enhanced care were more likely to receive diabetes care
(P = .004), the pneumonia vaccine (P = .025), the flu vaccine (P = .012), and a cholesterol check (P = .002). Subjects in this enhanced group were also less likely to report experiencing barriers to access to care, measured by whether they reported an instance in the past 12 months where they needed to see a doctor but could not due to cost and by whether more than 1 year had elapsed since their last checkup (P <.001) (Figure 2).
For example, a recent prospective multi-payer study in Hudson Valley, New York, found that PCMH practices improved significantly more (from 1% to 9%) on 4 of 10 quality measures than practices with electronic health records and paper records.17 In a single private payer demonstration project in New Jersey in 2011 with 8 medical home practices, mammography and nephropathy screening increased, although changes in 7 other HEDIS measures were not significant.21 A separate randomized controlled trial in New York evaluating PCMH transformation over 2008 to 2010 among 32 practices (18 intervention practices) found improvements in 2 of 11 quality indicators: hypertensive blood pressure control and breast cancer screening.22
Notably, other PCMH studies have not shown significant impact on quality measures,23 enforcing the need for additional research in this area to understand why some initiatives are associated with quality improvement while others are not. Understanding how the PCMH model can impact quality of care is critical for optimal primary care design, especially given the enormous and rapid uptake of the PCMH model. From 2009 to 2014, the number of patients covered by PCMH initiatives increased from nearly 5 million to almost 21 million across more than 100 state and federal initiatives.24