Article Figures & Data
Tables
- Table 1
Practice Systems Questions for HCH Certification That Address Diabetes Care, in 5 Domains
Access: continuous access and communications with patients and family 1. “Advanced access” or “open access” visits (scheduling that encourages your office staff to offer same-day appointments to virtually all patients who want to be seen) 2. Scheduling system to encourage patients to see their personal physician 3. Follow-up when diabetes patients have missed important appointments 4. System to identify and remind patients with diabetes who are due for a follow-up visit 5. System to identify and remind patients with diabetes who are due for testing 6. System to identify and remind patients with diabetes who are due for a prescription renewal 7. System to identify and notify patients who are due for age-appropriate preventive services 8. Routine use of secure e-mail to support self-management for patients and their families 9. Routine use of an interactive website to support self-management for patients and their families 10. Routine use and data exchange with patients who have access to their own electronic health record Registry: an electronically searchable registry to identify care gaps and manage services 1. A registry for diabetes (list of patients along with associated data) 2. Guideline-based reminders for services the diabetic patient should receive that appear when seeing the patient 3. Checklists of tests or interventions that are needed for prevention or monitoring of diabetes 4. System to provide alerts about important abnormal test results to the doctors at the time they are received Coordination of care: care coordination for patient- and family-centered care 1. Nurse managers to coordinate care for patients with especially complicated conditions 2. System for tracking laboratory or radiology tests until results are available to the clinician 3. System to track critical referrals until the consultation report returns to the practice 4. Designated primary care teams, defined as a physician and other staff that collaborate in the care of a defined group of patients 5. Previsit planning routinely provided to patients with diabetes by someone other than a physician, PA, or NP 6. After-visit follow-up routinely provided to patients with diabetes by someone other than a physician, PA, or NP 7. Provide or refer patient with diabetes to formal support programs to assist in self-management 8. System to promptly learn when one of your patients has been discharged from a hospital 9. System in place to manage recently discharged patients Care plans: care plans that involve patients with chronic or complex conditions 1. Routine development of individualized self-management plans with goals for patients with diabetes 2. Routine provision and review of self-monitoring instructions for patients with diabetes 3. Provide written materials that explain to the patient the recommended medical care guidelines for diabetes 4. Systems to encourage diabetes patient self-management 5. A systematic process to conduct shared decision making with patients 6. Develop care plans with patients to manage care for diabetes Quality improvement: continuous improvement in patient satisfaction, outcomes, cost-effectiveness 1. A formal process for measuring performance for individual physicians or for the practice site 2. Provision of data to individual physicians on the quality of their care for patients with specific chronic conditions 3. Conduct or participate in formal quality improvement activities HCH = health care home; NP = nurse practitioner; PA = physician assistant.
Note: For each system, practice leaders were asked whether their practice had any such system in place.
- Table 2
Characteristics of Participating Practices and Their Diabetic Patients, by HCH Certification Status and Overall
Characteristic Certified Practices Uncertified Practices P Valuea Total Practices Number 258 136 … 394 Ownership, % .75 Large hospital-affiliated medical group 78.3 75.7 77.4 Medium/small medical group 18.6 19.9 19.0 Single site 3.1 4.4 3.6 Federally Qualified Health Center, % 3.9 1.5 .19 3.1 Location, % <.001 Metropolitan/urban 76.0 49.3 66.8 Large rural town 6.2 15.4 9.4 Small rural town 7.0 5.2 6.4 Isolated rural town 10.9 30.2 17.5 Patients with diabetes Number 158,547 58,932 … 217,479 Age, mean (SD), y 58.0(11.5) 59.4(11.4) <.001 58.4(11.5) Female, % 46.6 45.8 .46 46.3 Insurance, % <.001 Commercial 44.6 43.9 44.5 Medicaid 11.0 6.5 9.8 Medicare 36.9 43.4 38.7 Dual Medicare-Medicaid 4.4 4.4 4.4 Self-pay/uninsured 3.0 1.8 2.7 Ischemic vascular disease prevalence, % 15.2 16.9 <.001 15.7 Depression prevalence, % 23.9 22.7 <.001 23.5 HCH = health care home.
↵a Difference in practice characteristics by certification status tested using a Pearson χ2 test. Difference in patient characteristics by certification status tested by modeling outcome as a function of the certification variable, with practice random effects and clustered standard errors to account for correlation in patient outcomes within practice.
Variable Certified Practices Uncertified Practices P Valuea Total Practices Number 258 136 … 394 Practice systems score, mean (SD), %b Overall 79.2 (16.2) 74.9 (15.0) .01 77.7 (15.9) Access 75.9 (19.8) 72.7 (19.3) .13 74.8 (19.7) Registry 92.3 (15.2) 91.3 (15.9) .54 92.0 (15.5) Coordination of care 74.9 (20.5) 68.7 (23.2) .006 72.8 (21.7) Care plan 75.4 (27.8) 66.6 (26.2) .003 72.4 (27.5) Quality improvement 91.9 (18.7) 93.9 (14.1) .27 92.6 (17.3) Patients with diabetes Number 158,547 58,932 … 217,479 Diabetes care measure, % Composite optimal diabetes carec 46.8 43.2 <.001 45.8 Aspirin use 99.6 99.5 .02 99.6 Hypertension control 84.4 83.4 .38 84.1 Statin use 88.5 84.7 <.001 87.4 Hemoglobin A1c control 70.1 69.9 .83 70.1 Nonsmoking status 84.7 83.1 .001 84.3 HCH = health care home.
↵a Difference in practice characteristics by certification status tested using a 1-way ANOVA test. Difference in patient characteristics by certification status tested by modeling outcome as a function of the certification variable, with practice random effects and clustered standard errors to account for correlation in patient outcomes within practice.
↵b Percentage of possible total score, where higher values indicate larger percentage of practices having that system in place.
↵c To be included in the numerator for this measure, a patient must have had met all 5 components.
Variable Mean, % Difference Between Groupsa P Value Practice systems score Overall 77.7 +5.3 .002 Access 74.8 +4.5 .04 Registry 92.0 +1.5 .38 Coordination of care 72.8 +7.7 .001 Care plans 72.4 +9.5 .002 Quality improvement 92.6 –1.3 .50 Diabetes care measure Composite optimal 45.8 +5.1 <.001 diabetes care Aspirin use 99.6 +0.1 .048 Hypertension control 84.1 +1.0 .11 Statin use 87.4 +4.4 <.001 Hemoglobin A1c control 70.1 +1.5 .006 Nonsmoking status 84.3 +1.7 <.001 HCH = health care home.
Note: After regression adjustments. For practice system scores, marginal effects of difference in certification status computed from clinic-level linear regression analyses controlling for practice characteristics (system size, Federally Qualified Health Center status, and rurality). For diabetes care outcomes, marginal effects of difference in HCH certification status computed from both patient-level logit regression analyses controlling for patient characteristics (age, sex, presence of ischemic disease or depression, insurance type, and census-based estimates of wealth, education, and race in patient neighborhood) and practice characteristics (system size, Federally Qualified Health Center status, and location). Diabetes care outcome regression analyses include practice random effects.
↵a Difference in mean score or mean probability of meeting the diabetes care measure between HCH-certified and -uncertified practices.
- Table 5
Adjusted Association of a 1-SD Increase in Overall Practice Systems Score With Diabetes Care Measures
Diabetes Care Measure Mean, % Change in Probability of Meeting Measure, %a P Value Composite optimal diabetes care 45.8 +1.4 <.001 Aspirin use 99.6 0.0 .16 Hypertension control 84.1 +1.2 <.001 Statin use 87.4 +0.2 .41 Hemoglobin A1c control 70.1 +0.9 <.001 Nonsmoking status 84.3 +0.2 .36 Note: After regression adjustments. Marginal effects of changes in score computed from patient-level logit regression analyses controlling for patient characteristics (age, sex, presence of ischemic disease or depression, insurance type, and census-based estimates of wealth, education, and race in patient neighbor-hood) and practice characteristics (system size, Federally Qualified Health Center status, and location). Regression analyses include practice random effects.
↵a The percentage-point change in probability of meeting the diabetes care measure associated with a 1-SD increase in overall score.
Additional Files
The Article in Brief
Differences in Diabetes Care With and Without Certification as a Medical Home
Leif I. Solberg , and colleagues
Background There are still many unanswered questions on what makes a patient-centered medical home (PCMH) distinct from non-certified practices in primary care. Researchers pose the question: How do practice systems and outcomes in a PCMH-recognized practice different from those in others without that designation? And further, are PCMH practice system requirements associated with better diabetes outcomes?
What This Study Found Researchers compared 258 certified medical home primary care practices in Minnesota to 136 non-certified practices, to see if certification had any bearing on performance measures related to the quality of diabetes care. Certified practices were found to have slightly more medical home practice systems than uncertified practices. Additionally, certified practices had somewhat better performance outcomes on quality measures related to diabetes care. Uncertified practices, comprising 39 percent of the surveyed practices, were noted to be more rural but had similar patient populations.
Implications
- Practices certified as medical homes have more systems and improved performance for diabetes care, but the differences are modest.
- According to the authors, the data collected suggests that practices that chose to be certified may have done so in part because they already had more systems and were performing better on outcome measures.
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