Team-based versus traditional primary care models and short-term outcomes after hospital discharge

A community-based geriatric interprofessional education experience and its impact on post-graduate collaborative practice

While a growing body of interprofessional education (IPE) literature demonstrates a positive impact on learner knowledge, there is limited data on its long-term impact on collaborative practice (CP). With the growth of the aging population globally, understanding both the long-term impact on CP and sustainability of community-based geriatric experiential IPE programs are imperative. This study explores the impact of the Interprofessional Geriatric Curriculum (IPGC), a community-based geriatric IPE program, on post-graduate clinical practice among seven health professions. This study utilized a cross-sectional descriptive design, where both qualitative and quantitative data were collected in the same online survey of health professionals' to measure their perceptions of the impact IPGC has had on their respective clinical practice 1-3 years post-graduation. Forty-six per cent of health profession graduates provided clinical care for people 65 years of age or older; 81% worked in interprofessional teams; 80% reported the IPGC experience significantly impacted their practice (N = 137), and all used validated assessment tools taught in the IPGC program in their practice. Eight themes emerged from the list of what health professionals learned from IPGC that they use regularly in their clinical practice: four themes were interprofessional in nature (i.e. teamwork and team-based care, interprofessional communication, roles/responsibilities, and personal/professional) and four themes related to geriatrics (i.e. aging, screening and assessment, medications, and didactic content). This study is one of the first to describe the sustained influence of a community-based IPE program across multiple health professional disciplines on clinical geriatric practice.

Interprofessional collaboration in primary care: what effect on patient health? A systematic literature review

BACKGROUND

In a period of change in the organization of primary care, Interprofessional Collaboration (IPC) is presented as one of the solutions to health issues. Although the number of inter-professional interventions grounded in primary care increases in all developed countries, evidence on the effects of these collaborations on patient-centred outcomes is patchy. The objective of our study was to assess the effects of IPC grounded in the primary care setting on patient-centred outcomes.

METHODS

We conducted a systematic literature review using the PubMed, Embase, PsycINFO and CINAHL databases from 01/01/1995 to 01/03/2021, according to the PRISMA guidelines. Studies reporting the effects of IPC in primary care on patient health outcomes were included. The quality of the studies was assessed using the revised Downs and Black checklist.

RESULTS

Sixty-five articles concerning 61 interventions were analysed. A total of 43 studies were prospective and randomized. Studies were classified into 3 main categories as follows: 1) studies with patients at cardiovascular risk (28 studies)-including diabetes (18 studies) and arterial hypertension (5 studies); 2) studies including elderly and/or polypathological patients (18 studies); and 3) patients with symptoms of mental or physical disorders (15 studies). The number of included patients varied greatly (from 50 to 312,377). The proportion of studies that reported a positive effect of IPC on patient-centred outcomes was as follows: 23 out of the 28 studies including patients at cardiovascular risk, 8 out of the 18 studies of elderly or polypathological patients, and 11 out of the 12 studies of patients with mental or physical disorders.

CONCLUSIONS

Evidence suggests that IPC is effective in the management of patients at cardiovascular risk. In elderly or polypathological patients and in patients with mental or physical disorders, the number of studies remains very limited, and the results are heterogeneous. Researchers should be encouraged to perform studies based on comparative designs: it would increase evidence on the positive effect and benefits of IPC on patient variables.

Person-Centered Models for Cardiovascular Care: A Review of the Evidence: A Scientific Statement From the American Heart Association

Cardiovascular disease remains the leading cause of death and disability in the United States and globally. Disease burden continues to escalate despite technological advances associated with improved life expectancy and quality of life. As a result, longer life is associated with multiple chronic cardiovascular conditions. Clinical guidelines provide recommendations without considering prevalent scenarios of multimorbidity and health system complexities that affect practical adoption. The diversity of personal preferences, cultures, and lifestyles that make up one's social and environmental context is often overlooked in ongoing care planning for symptom management and health behavior support, hindering adoption and compromising patient outcomes, particularly in groups at high risk. The purpose of this scientific statement was to describe the characteristics and reported outcomes in existing person-centered care delivery models for selected cardiovascular conditions. We conducted a scoping review using Ovid MEDLINE, Embase.com, Web of Science, CINAHL Complete, Cochrane Central Register of Controlled Trials through Ovid, and ClinicalTrials.gov from 2010 to 2022. A range of study designs with a defined aim to systematically evaluate care delivery models for selected cardiovascular conditions were included. Models were selected on the basis of their stated use of evidence-based guidelines, clinical decision support tools, systematic evaluation processes, and inclusion of the patient's perspective in defining the plan of care. Findings reflected variation in methodological approach, outcome measures, and care processes used across models. Evidence to support optimal care delivery models remains limited by inconsistencies in approach, variation in reimbursement, and inability of health systems to meet the needs of patients with chronic, complex cardiovascular conditions.

The effect of primary care clinician type and care team characteristics on health care costs

OBJECTIVE

To evaluate health care costs as a function of assigned primary care clinician type and care team characteristics.

METHODS

Administrative data were collected for 68 family medicine clinicians (40 physicians and 28 nurse practitioners [NPs]/physician assistant [PAs]), on 11 care teams (variable MD, NP and PA on teams), caring for 77,141 patients. We performed a generalized linear mixed multivariable regression model of standardized per member per month (PMPM) median cost as the outcome, with four practice sites included as random effects.

RESULTS

In bivariate analysis, cost was higher in physicians than NP/PAs, in more complex patients, and associated with emergency department (ED) visit rate. On multivariate analysis, patient complexity, ED visit rate and higher patient experience ratings were independently associated with greater PMPM cost. More time in practice was associated with lower PMPM cost. In the adjusted multivariate model, physicians had 8.3% lower median PMPM costs than NP/PAs (p = 0.046).

CONCLUSIONS

The primary drivers of greater PMPM cost were patient complexity, ED visits and patient satisfaction.

Interprofessional Education - A Mandate for Today's Radiology Curriculum

Interprofessional education (IPE) brings educators and learners from two or more health professions together in a collaborative learning environment, specifically assuring that learners function as a team to provide patient-centered care, with each team member contributing a unique perspective. The Liaison Committee on Medical Education, the Accreditation Council for Graduate Medical Education, and the American Board of Radiology have endorsed interprofessional and team communication as essential core competencies. Radiology educators must understand, include, and optimize IPE in their pedagogy; as a specialty, radiology must innovate more interprofessional experiences for medical students, residents and other allied health professions.

Impact of Team-Based Care on Emergency Department Use

PURPOSE

We sought to assess the impact of team-based care on emergency department (ED) use in the context of physicians transitioning from fee-for-service payment to capitation payment in Ontario, Canada.

METHODS

We conducted an interrupted time series analysis to assess annual ED visit rates before and after transition from an enhanced fee-for-service model to either a team capitation model or a nonteam capitation model. We included Ontario residents aged 19 years and older who had at least 3 years of outcome data both pretransition and post-transition (N = 2,524,124). We adjusted for age, sex, income quintile, immigration status, comorbidity, and morbidity, and we stratified by rurality. A sensitivity analysis compared outcomes for team vs nonteam patients matched on year of transition, age, sex, rurality, and health region.

RESULTS

We compared 387,607 team and 1,399,103 nonteam patients in big cities, 213,394 team and 380,009 nonteam patients in small towns, and 65,289 team and 78,722 nonteam patients in rural areas. In big cities, after adjustment, the ED visit rate increased by 2.4% (95% CI, 2.2% to 2.6%) per year for team patients and 5.2% (95% CI, 5.1% to 5.3%) per year for nonteam patients in the years after transition (P <.001). Similarly, there was a slower increase in ED visits for team relative to nonteam patients in small towns (0.9% [95% CI, 0.7% to 1.1%] vs 2.9% [95% CI, 2.8% to 3.1%], P <.001) and rural areas (‒0.5% [95% CI, -0.8% to 0.2%] vs 1.3% [95% CI, 1.0% to 1.6%], P <.001). Results were much the same in the matched analysis.

CONCLUSIONS

Adoption of team-based primary care may reduce ED use. Further research is needed to understand optimal team composition and roles.

Avoidable Hospitalizations in Persons with Dementia: a Population-Wide Descriptive Study (2000-2015)

Background

Whether avoidable hospitalizations in community-dwelling persons with dementia have decreased during primary care reforms is unknown.

Methods

We described the prevalence and trends in avoidable hospitalizations in population-based repeated yearly cohorts of 192,144 community-dwelling persons with incident dementia (Quebec, 2000-2015) in the context of a province-wide primary care reform, using the provincial health administrative database.

Results

Trends in both types of Ambulatory Care Sensitive Condition (ACSC) hospitalization (general and older population) and 30-day readmission rates remained constant with average rates per 100 person-years: 20.5 (19.9-21.1), 31.7 (31.0-32.4), 20.6 (20.1-21.2), respectively. Rates of delayed hospital discharge (i.e., alternate level of care (ALC) hospitalizations) decreased from 23.8 (21.1-26.9) to 17.9 (16.1-20.1) (relative change -24.6%).

Conclusions

These figures shed light on the importance of the phenomenon, its lack of improvement for most outcomes over the years, and the need to develop evidence-based policies to prevent avoidable hospitalizations in this vulnerable population.

Primary care teams' experiences of delivering mental health care during the COVID-19 pandemic: a qualitative study

Background

Integrated primary care teams are ideally positioned to support the mental health care needs arising during the COVID-19 pandemic. Understanding how COVID-19 has affected mental health care delivery within primary care settings will be critical to inform future policy and practice decisions during the later phases of the pandemic and beyond. The objective of our study was to describe the impact of the COVID-19 pandemic on primary care teams’ delivery of mental health care.

Methods

A qualitative study using focus groups conducted with primary care teams in Ontario, Canada. Focus group data was analysed using thematic analysis.

Results

We conducted 11 focus groups with 10 primary care teams and a total of 48 participants. With respect to the impact of the COVID-19 pandemic on mental health care in primary care teams, we identified three key themes: i) the high demand for mental health care, ii) the rapid transformation to virtual care, and iii) the impact on providers.

Conclusions

From the outset of the COVID-19 pandemic, primary care quickly responded to the rising mental health care demands of their patients. Despite the numerous challenges they faced with the rapid transition to virtual care, primary care teams have persevered. It is essential that policy and decision-makers take note of the toll that these demands have placed on providers. There is an immediate need to enhance primary care’s capacity for mental health care for the duration of the pandemic and beyond.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-021-01496-8.

Examining the extent and factors associated with interprofessional teamwork in primary care settings

Despite growing emphasis on adopting team-based models of primary care to facilitate patient access to a diverse range of care providers, our understanding of team functioning within primary care teams remains limited. This study examined interprofessional teamwork within primary care practices (Family Health Teams [FHT] and Community Health Centers - [CHC]) in Ontario and explored team-level and organizational factors associated with interprofessional teamwork. Interprofessional teamwork was measured using the Collaborative Practice Assessment Tool (CPAT), which was completed by providers in each participating team. The CPAT responses of 988 providers representing on average 12 professions (sd = 2.1) across 66 teams (44 FHTs and 22 CHCs) were included in the analysis. The average CPAT score was 46.6 (sd = 2.5). CHCs had significantly higher CPAT scores than FHTs (m_diff = 1.7, p = .02). Using diverse communication mechanisms to share information, increasing quality improvement capacities, and age of practice, had a statistically significant positive association with CPAT scores. Increasing team size, using centralized administrative processes, a high level of information exchange, and having a mixed governance board were significantly negatively associated with CPAT score. Findings illustrate factors associated with interprofessional teamwork and offer insight into the comparative performance of two team-based primary care models in Ontario.

Clinician Care Team Composition and Health Care Utilization

Objective

To test the hypothesis that a greater proportion of physician time on primary care teams are associated with decreased emergency department (ED) visits, hospital admissions, and readmissions, and to determine clinician and care team characteristics associated with greater utilization.

Patients and Methods

We retrospectively analyzed administrative data collected from January 1 to December 31, 2017, of 420 family medicine clinicians (253 physicians, 167 nurse practitioners/physician assistants [NP/PAs]) with patient panels in an integrated health system in 59 Midwestern communities serving rural and urban areas in Minnesota, Wisconsin, and Iowa. These clinicians cared for 419,581 patients through 110 care teams, with varying numbers of physicians and NP/PAs. Primary outcome measures were rates of ED visits, hospitalizations, and readmissions.

Results

The proportion of physician full-time equivalents on the team was unrelated to rates of ED visits (rate ratio [RR] = 0.826; 95% confidence interval [CI], 0.624 to 1.063), hospitalizations (RR = 0.894; 95% CI, 0.746 to 1.072), or readmissions (RR = –0.026; 95% CI, 0.364 to 0.312). In separate multivariable models adjusted for clinician and practice-level characteristics, the rate of ED visits was positively associated with mean panel hierarchical condition category (HCC) score, urban vs rural setting, NP/PA vs physician, and lower years in practice. The rate of inpatient admissions was associated with HCC score, and 30-day hospital readmissions were positively associated with HCC score, lower years in practice, and male clinicians.

Conclusion

Care team physician and NP/PA composition was not independently related to utilization. More complex panels had higher rates of ED visits, hospitalization, and readmissions. Statistically significant differences between physician and NP/PA panels were only evident for ED visits.

Assessing Association Between Team Structure and Health Outcome and Cost by Social Network Analysis

BACKGROUND/OBJECTIVE

To assess the impact of team structure composition and degree of collaboration among various providers on process and outcomes of primary care.

DESIGN

Cross-sectional study.

SETTING

Data from 20% randomly selected primary care service areas in the 2015 Medicare claims were used to identify primary care practices.

PARTICIPANTS

449,460 patients with diabetes, heart failure, or chronic obstructive pulmonary disease cared for by the identified primary care practices.

MEASUREMENTS

Social network analysis measures, including edge density, degree centralization, and betweenness centralization for each practice.

RESULTS

When compared with practices with MDs and nurse practitioners (NPs) or/and physicians assistants (PAs), the practices with MDs had only lower degree of centralization and higher MD-to-MD connectedness. Within the primary care practices comprising MDs, NPs, or/and PAs, the nonphysician providers were more connected (measured as edge density) to all providers in the practice but with higher degree of centralization compared with the MDs in the practice. After adjusting for patient characteristics and type of practice, higher edge density was associated with lower odds of hospitalization (odds ratio (OR) = 0.89, 95% confidence interval (CI) = 0.79-0.99), emergency department (ER) admission (OR = 0.80, 95% CI = 0.70-0.92), and total spending (cost ratio (CR) = 0.86, standard error of the mean (SE) = 0.038). Conversely, higher degree centralization was associated with higher rates of hospitalization (OR = 1.15, 95% CI = 1.03-1.28), ER admission (OR = 1.23, 95% CI = 1.08-1.40), and total spending (CR = 1.14, SE = 0.037). However, higher degree centralization was associated with lower rates of potentially inappropriate medications (OR = 0.90, 95% CI = 0.81-0.99). Team leadership by an NP versus an MD was similar in the rate of ER admissions, hospitalizations, or total spending.

CONCLUSION

Our findings showed that highly connected primary care practices with high collaborative care and less top-down MD-centered authority have lower odds of hospitalization, fewer ER admissions, and less total spending; findings likely reflecting better communication and more coordinated care of older patients.

Implementation of interprofessional team-based care: A cross-case analysis

Two out of five Canadians have at least one chronic disease and four out of five are at risk of developing a chronic disease. Successful disease management relies on interprofessional team-based approaches, yet lack of purposeful cultivation and patient engagement has led to systematic inefficiencies. Two primary care teams in Southwestern Ontario implementing interprofessional chronic care programs for patients with chronic obstructive pulmonary disease were compared. A mixed-methods cross-case analysis was conducted including interviews, focus groups, observations and document analysis. Cases (n = 2) were chosen based on intrinsic and unique value. Participants (n = 46) were sampled using a combination of purposive and multi-level sampling. Data was analyzed using an iterative process; inductive coding was used to gain a sense of context followed by a deductive cross-case analysis to compare and contrast themes across sites. Kompier's five-step framework was used to assess factors contributing to successful implementation and to provide insight into interactions between teams, providers and patients. Both cases satisfied all five factors (systemic and gradual approach, identification of risk factors, theory-driven, participatory approach and sustained committed support). However, one case was more successful at fully implementing their model, attributed to a flexible implementation, plans to mitigate risks, theory use, a supportive team and continued buy-in from leadership. By better understanding key facilitators and barriers, we can support the implementation of chronic disease management programs, foster sustainability of high-performing interprofessional teams, and engage patients in the development and maintenance of team-based chronic disease management.

Evaluating the implementation of collaborative teams in community family practice using the Primary Care Assessment Tool

OBJECTIVE

To examine patients' perceptions of care outcomes following the introduction of collaborative teams into community family practices.

DESIGN

Cross-sectional, longitudinal study comprising 4 patient telephone surveys between 2007 and 2016, using random sampling of telephone records based on postal codes.

SETTING

Ten WestView Primary Care Network (WPCN) clinics in Alberta, serving a suburban-rural population of approximately 89 000 and an aggregate clinic panel of 61 611 (in 2016).

PARTICIPANTS

Adults aged 18 and older with a visit to a family physician in a WPCN clinic at least once in the previous 18 months.

INTERVENTIONS

In 2006, WPCN implemented a decentralized and distributed collaborative team model, integrating nonphysician health care professionals into member clinics.

MAIN OUTCOME MEASURES

The Primary Care Assessment Tool (PCAT) was used to evaluate standardized primary care delivery domains. Between-year changes were compared using ANOVA (analysis of variance). Clinic-level subgroup analyses were performed.

RESULTS

The number of completed surveys included 896 in 2007, 904 in 2010, 1000 in 2013, and 1800 in 2016, reaching 90% to 100% of the targeted sample size. In aggregate, the WPCN PCAT summary score and the scores of 4 core and 2 ancillary domains of primary care exceeded the quality threshold of 3.0: extent of affiliation, ongoing care, first-contact utilization, coordination of care, family-centredness, and cultural competence. The first-contact access domain significantly improved from 2007 to 2016 (P < .001). The domains extent of affiliation, first-contact utilization, and coordination of information systems were unchanged. Ongoing care, coordination of care, comprehensiveness, family-centredness, community orientation, and cultural competence decreased. Except for in 2010, the 2 highest scoring clinics were non-participating solo practices; the lowest-scoring clinic was the one with the largest number of physicians. Across survey years, the PCAT summary score increased statistically significantly for 1 solo practice, remained consistent at an above-quality threshold for another, but decreased for all multi-physician clinics. Unattached patients (ie, those without a family doctor) scored the lowest.

CONCLUSION

This study found that WPCN provides high-quality primary care overall, but that patient-perceived outcomes do not indicate global improvement concurrent with team-based initiatives. Decreased standardization of the distributed model likely influenced study-observed variations in clinic performance. Future research should identify clinic and team characteristics that benefit most from team-based care and factors that explain solo practices outperforming models of team-based care.

Measuring Health

Primary care clinicians care for an extremely diverse range of patients, and they therefore have numerous opportunities to measure and act to improve the health of various populations. In order to take effective actions to improve the health of their patient populations, primary care clinicians must measure health. Strong population health metrics are characterized by their high validity, consistency, feasibility, and interpretability. Population health metrics should be applied longitudinally to obtain the most information from available data. Optimal population health metrics are actionable and facilitate the implementation of effective strategies to improve population health through administrative or clinical programs.

Annual Report on Health Care for Children and Youth in the United States: Focus on 30-Day Unplanned Inpatient Readmissions, 2009 to 2014

OBJECTIVE

To describe trends in unplanned 30-day all-condition hospital readmissions for children aged 1 to 17 years between 2009 and 2014.

METHODS

Analysis was conducted with the 2009-14 Nationwide Readmissions Database from the Agency for Healthcare Research and Quality's Healthcare Cost and Utilization Project. Annual hospital readmission rates, resource use, and the most common reasons for readmission were calculated for the 2009-14 period.

RESULTS

The rate of readmission for children aged 1 to 17 years was essentially stable between 2009 and 2014 (5.5% in 2009 and 5.9% in 2014). In 2009, the most common reason (principal diagnosis) for readmission was sickle cell anemia, whereas in 2014 the most common reason was epilepsy. Pneumonia fell from the second to the sixth most common reason for readmission over this period (from 3832 to 2418 stays). Other respiratory infections were among the top 10 principal readmission diagnoses in 2009, but not in 2014. Septicemia was among the 10 most common reasons for readmission in 2014, but not in 2009. Although the average cost of index (ie, initial) stays with a subsequent readmission were similar in 2009 and 2014, the average cost of index stays without a readmission and cost of readmission stays increased by approximately 23%. In both 2009 and 2014, the average cost of the index stays with a subsequent readmission was 73% to 89% higher than that of the index stays of children who were not readmitted within 30 days. The average cost of index stays preceding a readmission was 33% to 45% higher than average costs for readmitted stays. In 2014, the aggregate cost of index stays plus readmissions was $1.58 billion, with 42.9% of the costs attributable to readmissions. Regarding the average costs and lengths of stay for the 10 most common readmission diagnoses, in 2009 the average cost per stay for complications of devices, implants, or grafts was nearly 5 times greater than that of asthma ($21,200 vs $4500, respectively). In 2014, average cost per stay ranged from $5500 for asthma to $39,500 for septicemia. In 2009, the average length of stay (LOS) for complications of devices, implants, or grafts was more than 3 three times higher than that for asthma (7.8 days vs 2.5 days, respectively), and in 2014, the average LOS for septicemia was nearly 4 times higher than that for asthma (10.4 days vs. 2.6 days).

CONCLUSIONS

This study provides a baseline assessment for examining trends in 30-day unplanned pediatric readmissions, an important quality metric as the provisions of the Children's Health Insurance Program Reauthorization Act and the Affordable Care Act are changed and implemented in the future. More than 50,000 pediatric hospital stays in 2014 occurred within 30 days of a previous hospitalization, with an average cost of $13,800. This report is timely, as the health care system works to become more patient-centered and public and private payers grapple with how to pay for quality care for children. The report provides baseline information that can be used to further explore ways to reduce unplanned readmissions.

Comparative analysis of health system performance in Montreal and New York: the importance of context for interpreting indicators

Although eliminating financial barriers to care is a necessary condition for improving access to health services, it is not sufficient. Given the contrasting health systems with regard to financing and organization of health insurance in the United States and Canada, there is a long history of comparing these countries. We extend the empirical studies on the Canadian and US health systems by comparing access to ambulatory care as measured by hospitalization rates for ambulatory care sensitive conditions (ACSC) in Montreal and New York City. We find that, in New York, ACSC rates were more than twice as high (12.6 per 1000 population) as in Montreal (4.8 per 1000 population). After controlling for age, sex, and number of diagnoses, significant differences in ACSC rates are present in both cities, but are more pronounced in New York. Our findings are consistent with the hypothesis that universal, first-dollar health insurance coverage has contributed to lower ACSC rates in Montreal than New York. However, Montreal's surprisingly low ACSC rate calls for further research.

Contextual levers for team-based primary care: lessons from reform interventions in five jurisdictions in three countries

BACKGROUND

Most Western nations have sought primary care (PC) reform due to the rising costs of health care and the need to manage long-term health conditions. A common reform-the introduction of inter-professional teams into traditional PC settings-has been difficult to implement despite financial investment and enthusiasm.

OBJECTIVE

To synthesize findings across five jurisdictions in three countries to identify common contextual factors influencing the successful implementation of teamwork within PC practices.

METHODS

An international consortium of researchers met via teleconference and regular face-to-face meetings using a Collaborative Reflexive Deliberative Approach to re-analyse and synthesize their published and unpublished data and their own work experience. Studies were evaluated through reflection and facilitated discussion to identify factors associated with successful teamwork implementation. Matrices were used to summarize interpretations from the studies.

RESULTS

Seven common levers influence a jurisdiction's ability to implement PC teams. Team-based PC was promoted when funding extended beyond fee-for-service, where care delivery did not require direct physician involvement and where governance was inclusive of non-physician disciplines. Other external drivers included: the health professional organizations' attitude towards team-oriented PC, the degree of external accountability required of practices, and the extent of their links with the community and medical neighbourhood. Programs involving outreach facilitation, leadership training and financial support for team activities had some effect.

CONCLUSION

The combination of physician dominance and physician aligned fee-for-service payment structures provide a profound barrier to implement team-oriented PC. Policy makers should carefully consider the influence of these and our other identified drivers when implementing team-oriented PC.

The effect of provider affiliation with a primary care network on emergency department visits and hospital admissions

BACKGROUND

Primary care networks are designed to facilitate access to inter-professional, team-based care. We compared health outcomes associated with primary care networks versus conventional primary care.

METHODS

We obtained data on all adult residents of Alberta who visited a primary care physician during fiscal years 2008 and 2009 and classified them as affiliated with a primary care network or not, based on the physician most involved in their care. The primary outcome was an emergency department visit or nonelective hospital admission for a Patient Medical Home indicator condition (asthma, chronic obstructive pulmonary disease, heart failure, coronary disease, hypertension and diabetes) within 12 months.

RESULTS

Adults receiving care within a primary care network (n = 1 502 916) were older and had higher comorbidity burdens than those receiving conventional primary care (n = 1 109 941). Patients in a primary care network were less likely to visit the emergency department for an indicator condition (1.4% v. 1.7%, mean 0.031 v. 0.035 per patient, adjusted risk ratio [RR] 0.98, 95% confidence interval [CI] 0.96-0.99) or for any cause (25.5% v. 30.5%, mean 0.55 v. 0.72 per patient, adjusted RR 0.93, 95% CI 0.93-0.94), but were more likely to be admitted to hospital for an indicator condition (0.6% v. 0.6%, mean 0.018 v. 0.017 per patient, adjusted RR 1.07, 95% CI 1.03-1.11) or all-cause (9.3% v. 9.1%, mean 0.25 v. 0.23 per patient, adjusted RR 1.08, 95% CI 1.07-1.09). Patients in a primary care network had 169 fewer all-cause emergency department visits and 86 fewer days in hospital (owing to shorter lengths of stay) per 1000 patient-years.

INTERPRETATION

Care within a primary care network was associated with fewer emergency department visits and fewer hospital days.