RESUMEN
BACKGROUND: There is growing evidence that even small and solo primary care practices can successfully transition to full Patient Centered Medical Home (PCMH) status when provided with support, including practice redesign, care managers, and a revised payment plan. Less is known about the quality and efficiency outcomes associated with this transition. OBJECTIVE: Test quality and efficiency outcomes associated with 2-year transition to PCMH status among physicians in intervention versus control practices. DESIGN: Randomized Controlled Trial. PARTICIPANTS: Eighteen intervention practices with 43 physicians and 14 control practices with 24 physicians; all from adult primary care practices. INTERVENTIONS: Modeled on 2008 NCQA PPC®-PCMH™, intervention practices received 18 months of tailored practice redesign support; 2 years of revised payment, including up to $2.50 per member per month (PMPM) for achieving quality targets and up to $2.50 PMPM for PPC-PCMH recognition; and 18 months of embedded care management support. Controls received yearly participation payments. MAIN MEASURES: Eleven clinical quality indicators from the 2009 HEDIS process and health outcomes measures derived from patient claims data; Ten efficiency indicators based on Thomson Reuter efficiency indexes and Emergency Department (ED) Visit Ratios; and a panel of costs of care measures. KEY RESULTS: Compared to control physicians, intervention physicians significantly improved TWO of 11 quality indicators: hypertensive blood pressure control over 2 years (intervention +23 percentage points, control -2 percentage points, p =0.02) and breast cancer screening over 3 years (intervention +3.5 percentage points, control -0.4 percentage points, p =0.03). Compared to control physicians, intervention physicians significantly improved ONE of ten efficiency indicators: number of care episodes resulting in ED visits was reduced (intervention -0.7 percentage points, control + 0.5 percentage points, p = 0.002), with 3.8 fewer ED visits per year, saving approximately $1,900 in ED costs per physician, per year. There were no significant cost-savings on any of the pre-specified costs of care measures. CONCLUSIONS: In a randomized trial, we observed that some indicators of quality and efficiency of care in general adult primary care practices transitioning to PCMH status can be significantly, but modestly, improved over 2 years, although most indicators did not improve and there were no cost-savings compared with control practices. For the most part, quality and efficiency of care provided in unsupported control practices remained unchanged or worsened during the trial.
Asunto(s)
Eficiencia Organizacional , Atención Dirigida al Paciente/organización & administración , Atención Primaria de Salud/organización & administración , Calidad de la Atención de Salud , Adulto , Anciano , Femenino , Reforma de la Atención de Salud , Humanos , Masculino , Persona de Mediana Edad , Innovación Organizacional , Evaluación de Procesos y Resultados en Atención de Salud/métodos , Atención Dirigida al Paciente/normas , Atención Primaria de Salud/normas , Garantía de la Calidad de Atención de Salud/métodos , Estados UnidosRESUMEN
BACKGROUND: Transition to a Patient-Centered Medical Home (PCMH) is challenging in primary care, especially for smaller practices. OBJECTIVE: To test the effectiveness of providing external supports, including practice redesign, care management and revised payment, compared to no support in transition to PCMH among solo and small (<2-10 providers) primary care practices over 2 years. DESIGN: Randomized Controlled Trial. PARTICIPANTS: Eighteen supported practices (intervention) and 14 control practices (controls). INTERVENTIONS: Intervention practices received 6 months of intensive, and 12 months of less intensive, practice redesign support; 2 years of revised payment, including cost of National Council for Quality Assurance's (NCQA) Physician Practice Connections(®)-Patient-Centered Medical Home™ (PPC(®)-PCMH™) submissions; and 18 months of care management support. Controls received yearly participation payments plus cost of PPC(®)-PCMH™. MAIN MEASURES: PPC(®)-PCMH™ at baseline and 18 months, plus intervention at 7 months. KEY RESULTS: At 18 months, 5 % of intervention practices and 79% of control practices were not recognized by NCQA; 10% of intervention practices and 7% of controls achieved PPC(®)-PCMH™ Level 1; 5% of intervention practices and 0% of controls achieved PPC(®)-PCMH™ Level 2; and 80% of intervention practices and 14% of controls achieved PPC(®)-PCMH™ Level 3. Intervention practices were 27 times more likely to improve PPC(®)-PCMH™ by one level, irrespective of practice size (p < 0.001) 95% CI (5-157). Among intervention practices, a multilevel ordinal piecewise model of change showed a significant and rapid 7-month effect (p(time7) = 0.01), which was twice as large as the sustained effect over subsequent 12 months (p(time18) = 0.02). Doubly multivariate analysis of variance showed significant differential change by condition across PPC(®)-PCMH™ standards over time (p(time x group)=0.03). Intervention practices improved eight of nine standards, controls improved three of nine (p(PPC1) = 0.009; p(PPC2) = 0.005; p(PPC3) = 0.007). CONCLUSIONS: Irrespective of size, practices can make rapid and sustained transition to a PCMH when provided external supports, including practice redesign, care management and payment reform. Without such supports, change is slow and limited in scope.
Asunto(s)
Reforma de la Atención de Salud/organización & administración , Atención Dirigida al Paciente/organización & administración , Atención Primaria de Salud/organización & administración , Atención a la Salud/economía , Atención a la Salud/organización & administración , Tamaño de las Instituciones de Salud , Investigación sobre Servicios de Salud/métodos , Humanos , Estudios Longitudinales , Mentores , Ciudad de Nueva York , Innovación Organizacional , Evaluación de Resultado en la Atención de Salud/métodos , Atención Dirigida al Paciente/economía , Atención Primaria de Salud/economía , Mecanismo de Reembolso/organización & administración , Factores de TiempoRESUMEN
OBJECTIVE: To assess changes in health status of women with fibromyalgia (FM) over 5 years and determine whether baseline employment status influences health outcomes adjusting for other baseline factors. METHODS: Two hundred eighty-seven women with FM were recruited from a national sample of rheumatologists and interviewed by phone at baseline and annually for 4 years. Data were collected on pain, fatigue, Center for Epidemiologic Studies Depression Scale and Modified Health Assessment Questionnaire (M-HAQ) scores, demographic characteristics, and employment status. At the end of the study, 211 participants remained. Data were analyzed using multilevel modeling techniques. Bootstrap methods adjusted for the cluster sampling. RESULTS: The participants' mean +/- SD age was 47 +/- 11 years, their mean +/- SD education level was 14 +/- 2 years, 90% were white, 50% employed, 64% married, and their median household income was >or=$50,000. Mean +/- SD scores at baseline were 57.2 +/- 24 for pain, 75.4 +/- 22 for fatigue, 22.9 +/- 13 for depression, and 0.73 +/- 0.5 for the M-HAQ. Multilevel modeling indicated that all health status measures declined significantly over time except for pain. Rates of change varied from -1.22 for fatigue to -0.03 for the M-HAQ. Except for pain, patients who were employed at baseline had better health status over time. The employment and time interaction was not significant, indicating that health status changed at the same rate regardless of employment status. Other significant factors were age and income. CONCLUSION: Employed women with FM have better health status at baseline and maintain that advantage over time. Employment does not seem to provide a protective health benefit.