The Patient-Centered Medical Home: How Is It Related to Quality and Equity Among the General Adult Population?

Using medical expenditure panel survey data to explore the relationship between patient-centered medical homes and racial disparities in severe maternal morbidity outcomes

BACKGROUND

There are persistent racial/ethnic disparities in the occurrence of severe maternal morbidity. Patient-centered medical home care has the potential to address disparities in maternal outcomes.

OBJECTIVES

To examine (1) the association between receiving patient-centered medical home care and severe maternal morbidity outcomes and (2) the interaction of race/ethnicity on patient-centered medical home status and severe maternal morbidity.

DESIGN/METHODS

Using 2007 to 2016 data from the Medical Expenditures Panel Survey, we conducted a cross-sectional study to estimate the association between receipt of care from a patient-centered medical home and the occurrence of severe maternal morbidity, and racial-specific (White, Black, Asian, Other) relative risks of severe maternal morbidity. Our study used race as a proxy measure for exposure racism. We identified mothers (⩾15 years) who gave birth during the study period. We identified patient-centered medical home qualities using 11 Medical Expenditures Panel Survey questions and severe maternal morbidities using medical claims, and calculated generalized estimating equation models to estimate odds ratios of severe maternal morbidity and 95% confidence intervals.

RESULTS

Among all mothers who gave birth (N = 2801; representing 5,362,782 US lives), only 25% received some exposure patient-centered medical home care. Two percent experienced severe maternal morbidity, and this did not differ statistically (p = 0.11) by patient-centered medical home status. However, our findings suggest a 85% decrease in the risk of severe maternal morbidity among mothers who were defined as always attending a patient-centered medical home (odds ratios: 0.15; 95% confidence interval:0.01-1.87; p = 0.14) and no difference in the risk of severe maternal morbidity among mothers who were defined as sometimes attending a patient-centered medical home (odds ratios: 1.00; 95% confidence interval:0.16-6.42; p = 1.00). There was no overall interaction effect in the model between race and patient-centered medical home groups (p = 0.82), or ethnicity and patient-centered medical home groups (p = 0.62) on the severe maternal morbidity outcome.

CONCLUSION

While the rate of severe maternal morbidity was similar to US rates, few mothers received care from a patient-centered medical home which may be due to underreporting. Future research should further investigate the potential for patient-centered medical home-based care to reduce odds of severe maternal morbidity across racial/ethnic groups.

The patient-centered oncology care on health care utilization and cost: A systematic review and meta-analysis

BACKGROUND

Optimal cancer care entails coordination among multiple providers and continued follow-up and surveillance over time. The patient-centered care brings opportunities to improve the delivery of cancer care. The adoption of patient-centered oncology care (PCOC) is in its infancy. Evidence synthesis on the model's effectiveness is scant.

PURPOSES

This is the first systemic review and meta-analysis on associations of PCOC with cancer patients' adverse health care utilization, cost, patient satisfaction, and quality of care.

METHODS

Our study was guided by the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) framework. Quality appraisal was performed using Downs and Black's quality checklist. Study-level effect sizes of adverse health care utilization were computed using Cohen's d and summarized using forest plots. Funnel plots were constructed to examine publication bias.

RESULTS

Of 334 studies that were reviewed, 10 met eligibility criteria and were included into the final analysis. Many included studies implemented almost all six of patient-centered care core attributes, plus three additional attributes that specifically addressed cancer patients' needs, including triage pathways, standardized and evidence-based symptom management, as well as support patient navigation. PCOC patients had lower utilization of inpatient care (standardized means difference [SMD] = -0.027, p = .049). Overall positive effect of PCOC on emergency department use was small and not significant (SMD = -0.023, p = .103). With regard to cost and quality of care, our narrative summaries showed an overall positive direction, though we found limitations in individual study quality that precluded a meta-analysis.

PUBLIC IMPLICATION

The results showed that it is possible to utilize patient-centered model to support best practice of cancer care. Early evidence shows that the PCOC model has potential to improve health care utilization, cost, and quality of care, but limited numbers of included articles and heterogeneity of those studies implied that more rigorous research is expected to further investigate the model's effects.

Community social determinants and health outcomes drive availability of patient-centered medical homes

The collaborative design of America's patient-centered medical homes places these practices at the forefront of emerging efforts to address longstanding inequities in the quality of primary care experienced among socially and economically marginalized populations. We assessed the geographic distribution of the country's medical homes and assessed whether they are appearing within communities that face greater burdens of disease and social vulnerability. We assessed overlapping spatial clusters of mental and physical health surveys; health behaviors, including alcohol-impaired driving deaths and drug overdose deaths; as well as premature mortality with clusters of medical home saturation and community socioeconomic characteristics. Overlapping spatial clusters were assessed using odds ratios and marginal effects models, producing four different scenarios of resource need and resource availability. All analyses were conducted using county-level data for the contiguous US states. Counties having lower uninsured rates and lower poverty rates were the most consistent indicators of medical home availability. Overall, the analyses indicated that medical homes are more likely to emerge within communities that have more favorable health and socioeconomic conditions to begin with. These findings suggest that intersecting the spatial footprints of medical homes in relation to health and socioeconomic data can provide crucial information for policy makers and payers invested in narrowing the gaps between clinic availability and the communities that experience the brunt of health and social inequalities.

Effect of the Patient-Centered Medical Home on Racial Disparities in Quality of Care

BACKGROUND

Research demonstrates that the patient-centered medical home (PCMH) is associated with improved clinical outcomes and quality of care, and the populations that can most benefit from this model require long-term management, e.g., persons with chronic illness and behavioral health conditions. However, different populations may not benefit equally from the PCMH, and empirical evidence about the effects of this model on racial disparities is limited.

OBJECTIVE

Estimate the association between enrollment in National Committee for Quality Assurance (NCQA)-recognized PCMHs and racial disparities in quality of care for adults with major depressive disorder (MDD) and comorbid medical conditions.

DESIGN

Applying a quasi-experimental instrumental variable design to account for differential selection into the PCMH, we used generalized estimating equations to determine the probability of receiving eight disease-specific quality measures.

SUBJECTS

Medicaid enrollees in three states not dually enrolled in Medicare, ages 18-64 with MDD and > 1 other chronic condition. A subgroup analysis was conducted for enrollees with comorbid diabetes.

INTERVENTIONS

Enrollment in an NCQA-recognized PCMH.

MAIN MEASURES

Disease-specific quality indicators for MDD (e.g., antidepressant use, receipt of psychotherapy), and for diabetes, (e.g. A1c testing, LDL-C testing, retinal exams, and medical attention for nephropathy).

KEY RESULTS

PCMH enrollment was associated with an increase in the overall likelihood of receiving six of eight recommended services and a decrease in the likelihood of receiving any psychotherapy (4.94 percentage points, p < 0.01) and retinal exams (5.51 percentage points, p < 0.05). Although both groups improved, PCMH enrollment was associated with an exacerbation of the Black-white disparity in adequate antidepressant use by 4.20 percentage points (p < 0.01).

CONCLUSIONS

While PCMH enrollment may improve the overall quality of care, the effect is inconsistent across racial groups and not always associated with reductions in racial disparities in quality.

Patient-centered medical home care access among adults with chronic conditions: National Estimates from the medical expenditure panel survey

BACKGROUND

The Patient-Centered Medical Home (PCMH) model is a coordinated-care model that has served as a means to improve several chronic disease outcomes and reduce management costs. However, access to PCMH has not been explored among adults suffering from chronic conditions in the United States. Therefore, the aim of this study was to describe the changes in receiving PCMH among adults suffering from chronic conditions that occurred from 2010 through 2015 and to identify predisposing, enabling, and need factors associated with receiving a PCMH.

METHODS

A cross-sectional analysis was conducted for adults with chronic conditions, using data from the 2010-2015 Medical Expenditure Panel Surveys (MEPS). Most common chronic conditions in the United States were identified by using the most recent data published by the Agency for Healthcare Research and Quality (AHRQ). The definition established by the AHRQ was used as the basis to determine whether respondents had access to PCMH. Multivariate logistic regression analyses were conducted to detect the association between the different variables and access to PCMH care.

RESULTS

A total of 20,403 patients with chronic conditions were identified, representing 213.7 million U.S. lives. Approximately 19.7% of the patients were categorized as the PCMH group at baseline who met all the PCMH criteria defined in this paper. Overall, the percentage of adults with chronic conditions who received a PCMH decreased from 22.3% in 2010 to 17.8% in 2015. The multivariate analyses revealed that several subgroups, including individuals aged 66 and older, separated, insured by public insurance or uninsured, from low-income families, residing in the South or the West, and with poor health, were less likely to have access to PCMH.

CONCLUSION

Our findings showed strong insufficiencies in access to a PCMH between 2010 and 2015, potentially driven by many factors. Thus, more resources and efforts need to be devoted to reducing the barriers to PCMH care which may improve the overall health of Americans with chronic conditions.

The Politics of Primary Care Expansion: Lessons From Cancer Survivorship and Substance Abuse

EXECUTIVE SUMMARY

The purpose of this study is to understand the perspectives of primary care innovators treating patient populations not traditionally considered to be within the purview of primary care. Data were obtained from the 2015 Working Conference for PCMH (Patient-Centered Medical Home) Innovation funded by the Agency for Healthcare Research and Quality. The conference convened representatives from 10 innovative primary care practices and content experts to discuss experiences with integrating care for two nontraditional populations: patients with substance abuse issues and cancer survivors. Transcripts of the conference, one-on-one interviews, and written summaries of practice innovations were coded in NVivo (QSR International) and analyzed by means of an immersion/crystallization approach to identifying thematic patterns. Our study findings suggest that the politics surrounding entrenched professional identities contributed to barriers faced by conference participants in their efforts to provide innovative care for these nontraditional populations. Specifically, obstacles surfaced in relation to sharing patients across disciplinary boundaries, which resulted in issues of possessiveness, a questioning of provider qualifications, and a lack of interprofessional trust. Though support is increasing for primary care expansion and care integration, policy change may precede the identity transformations necessary for medical practitioners to embrace new primary care-centered models. For this reason, it is important that the formation and entrenchment of professional identities be critically considered as part of future efforts to transform primary care practice.

Organizational Processes and Patient Experiences in the Patient-centered Medical Home

BACKGROUND

There is increasing emphasis on the use of patient-reported experience data to assess practice performance, particularly in the setting of patient-centered medical homes. Yet we lack understanding of what organizational processes relate to patient experiences.

OBJECTIVE

Examine associations between organizational processes practices adopt to become PCMH and patient experiences with care.

RESEARCH DESIGN

We analyzed visit data from patients (n=8356) at adult primary care practices (n=22) in a large health system. We evaluated the associations between practice organizational processes and patient experience using generalized estimating equations (GEE) with an exchangeable correlation structure to account for patient clustering by practice in multivariate models, adjusting for several practice-level and patient-level characteristics. We evaluated if these associations varied by race/ethnicity, insurance type, and the degree of patient comorbidity MEASURES:: Predictors include overall PCMH adoption and adoption of six organizational processes: access and communications, patient tracking and registry, care management, test referral tracking, quality improvement and external coordination. Primary outcome was overall patient experience.

RESULTS

In our full sample, overall PCMH adoption score was not significantly associated with patient experience outcomes. However, among subpopulations with higher comorbidities, the overall PCMH adoption score was positively associated with overall patient experience measures [0.2 (0.06, 0.4); P=0.006]. Differences by race/ethnicity and insurance type in associations between specific organizational processes and patient experience were noted.

CONCLUSION

Although some organizational processes relate to patients' experiences with care irrespective of the background of the patient, further efforts are needed to align practice efforts with patient experience.

Do Patient-Centered Medical Homes Improve Health Behaviors, Outcomes, and Experiences of Low-Income Patients? A Systematic Review and Meta-Analysis

OBJECTIVES

To examine: (1) what elements of patient-centered medical homes (PCMHs) are typically provided to low-income populations, (2) whether PCMHs improve health behaviors, experiences, and outcomes for low-income groups.

DATA SOURCES/STUDY SETTING

Existing literature on PCMH utilization among health care organizations serving low-income populations.

STUDY DESIGN

Systematic review and meta-analysis.

DATA COLLECTION/EXTRACTION METHODS

We obtained papers through existing systematic and literature reviews and via PubMed, Web of Science, and the TRIP databases, which examined PCMHs serving low-income populations. A total of 434 studies were reviewed. Thirty-three articles met eligibility criteria.

PRINCIPAL FINDINGS

Patient-centered medical home interventions usually were composed of five of the six recommended components. Overall positive effect of PCMH interventions was d = 0.247 (range -0.965 to 1.42). PCMH patients had better clinical outcomes (d = 0.395), higher adherence (0.392), and lower utilization of emergency rooms (d = -0.248), but there were apparent limitations in study quality.

CONCLUSIONS

Evidence shows that the PCMH model can increase health outcomes among low-income populations. However, limitations to quality include no assessment for confounding variables. Implications are discussed.