Date: 04 Feb 2014
Specialty Use Among Patients With Treated Hypertension in a Patient-Centered Medical Home
Rent the article at a discountRent now
* Final gross prices may vary according to local VAT.Get Access
Little is known about how delivery of primary care in the patient-centered medical home (PCMH) influences outpatient specialty care use.
To describe changes in outpatient specialty use among patients with treated hypertension during and after PCMH practice transformation.
One-group, 48-month interrupted time series across baseline, PCMH implementation and post-implementation periods.
Adults aged 18–85 years with treated hypertension.
System-wide PCMH redesign implemented across 26 clinics in an integrated health care delivery system, beginning in January 2009.
Resource Utilization Band variables from the Adjusted Clinical Groups case mix software characterized overall morbidity burden (low, medium, high). Negative binomial regression models described adjusted annual differences in total specialty care visits. Poisson regression models described adjusted annual differences in any use (yes/no) of selected medical and surgical specialties.
Compared to baseline, the study population averaged 7 % fewer adjusted specialty visits during implementation (P < 0.001) and 4 % fewer adjusted specialty visits in the first post-implementation year (P = 0.02). Patients were 12 % less likely to have any cardiology visits during implementation and 13 % less likely during the first post-implementation year (P < 0.001). In interaction analysis, patients with low morbidity had at least 27 % fewer specialty visits during each of 3 years following baseline (P < 0.001); medium morbidity patients had 9 % fewer specialty visits during implementation (P < 0.001) and 5 % fewer specialty visits during the first post-implementation year (P = 0.007); high morbidity patients had 3 % (P = 0.05) and 5 % (P = 0.009) higher specialty use during the first and second post-implementation years, respectively.
Results suggest that more comprehensive primary care in this PCMH redesign enabled primary care teams to deliver more hypertension care, and that many needs of low morbidity patients were within the scope of primary care practice. New approaches to care coordination between primary care teams and specialists should prioritize high morbidity, clinically complex patients.
A comment to this article is available at http://dx.doi.org/10.1007/s11606-014-2824-y.
American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, American Osteopathic Association. Joint principles of the patient-centered medical home. 2007; http://www.aafp.org/dam/AAFP/documents/practice_management/pcmh/initiatives/PCMHJoint.pdf. Accessed January 10, 2014.
Peikes D, Zutshi A, Genevro JL, Parchman ML, Meyers DS. Early evaluations of the medical home: building on a promising start. Am J Manag Care. 2012;18(2):105–116.PubMed
Williams JW, Jackson GL, Powers BJ, et al. The Patient-Centered Medical Home. Closing the Quality Gap: Revisiting the State of the Science. Agency for Healthcare Research and Quality: Rockville, MD; 2012.
Jackson GL, Powers BJ, Chatterjee R, et al. The Patient-Centered Medical Home: A Systematic Review. Ann Int Med. 2013;158(3):169–178.CrossRef
Reid RJ, Fishman PA, Yu O, et al. Patient-centered medical home demonstration: a prospective, quasi-experimental, before and after evaluation. Am J Manag Care. 2009;15(9):e71–e87.PubMed
American College of Physicians. The Patient-Centered Medical Home Neighbor: The Interface of the Patient-Centered Medical Home with Specialty/Subspecialty Practices. 2010; www.acponline.org/advocacy/where_we_stand/policy/pcmh_neighbors.pdf. Accessed January 10, 2014.
Forrest CB, Reid RJ. Prevalence of health problems and primary care physicians’ specialty referral decisions. J Fam Pract. 2001;50(5):427–432.PubMed
Margolius D, Bodenheimer T. Controlling hypertension requires a new primary care model. Am J Manag Care. 2010;16(9):648–650.PubMed
Hsu C, Coleman K, Ross TR, et al. Spreading a patient-centered medical home redesign: a case study. J Ambul Care Manag. 2012;35(2):99–108.CrossRef
Liss DT, Fishman PA, Rutter CM, et al. Outcomes among chronically ill adults in a medical home prototype. Am J Manag Care. 2013;19(10):e348–e358.PubMed
Shadish WR, Cook TD, Campbell DT. Experimental and Quasi-Experimental Designs for Generalized Causal Inference. Boston: Houghton Mifflin; 2002.
Sibai BM. Diagnosis and management of chronic hypertension in pregnancy. Obstet Gynecol. 1991;78(3 Pt 1):451–461.PubMed
Carrell D, Ralston J. Messages, strands and threads: measuring use of electronic patient-provider messaging. AMIA Annu Symp Proc. 2005:913.
The Johns Hopkins ACG System: Technical Reference Guide, Version 10.0. Baltimore, MD: Johns Hopkins University; 2011.
Forrest CB, Nutting PA, Starfield B, von Schrader S. Family physicians’ referral decisions: results from the ASPN referral study. J Fam Pract. 2002;51(3):215–222.PubMed
Zou GY, Donner A. Extension of the modified Poisson regression model to prospective studies with correlated binary data. Stat Methods Med Res. 2011.
Diggle P, Heagerty P, Liang K, Zeger S. Analysis of Longitudinal Data. 2nd ed. Norfolk, UK: Oxford University Press; 2002.
Rockford Register Star. Key dates of the Great Recession. 2012; http://www.rrstar.com/x417563916/Key-dates-of-the-Great-Recession. Accessed January 10, 2014.
- Specialty Use Among Patients With Treated Hypertension in a Patient-Centered Medical Home
Journal of General Internal Medicine
Volume 29, Issue 5 , pp 732-740
- Cover Date
- Print ISSN
- Online ISSN
- Springer US
- Additional Links
- primary care redesign
- patient centered care
- health care delivery
- specialty care
- Industry Sectors
- Author Affiliations
- 1. Division of General Internal Medicine and Geriatrics, Northwestern University, Feinberg School of Medicine, 750 N. Lake Shore Drive, 10th floor, Chicago, IL, 60611, USA
- 2. Group Health Research Institute, Seattle, WA, USA
- 3. Department of Health Services, University of Washington, Seattle, WA, USA
- 4. Department of Biostatistics, University of Washington, Seattle, WA, USA