Article Figures & Data
Tables
Demographic Characteristics Not Reassigned Reassigned PValuea ACES-SF = Ambulatory Care Experiences Survey-Short Form; PACIC = Patient Assessment of Chronic Illness Care. a P value from χ2 test comparing percentages and from t test comparing means between reassigned and not reassigned patients. b The ACES-SF and PACIC questions (scored on 6- and 5-point Likert scales, respectively) were totaled within the subscales and then transformed to 100-point summary scores. Eligible patients from automated data, n 6,188 1,817 Age in years, n (%) ≤35 1,137 (18.4) 456 (25.1) <.001 36–45 713 (11.5) 333 (18.3) 46–55 1,199 (19.4) 411 (22.6) 56–65 1,377 (22.3) 359 (19.8) 66–75 870 (14.1) 147 (8.1) ≥76 892 (14.4) 111 (6.1) Male sex, n (%) 2,500 (40.4) 962 (52.9) <.001 DxCG case mix score, n (%) Low morbidity (0.10–0.87) 1,732 (28.0) 790 (44.0) <.001 Moderate morbidity (0.97–1.85) 2,092 (33.8) 641 (35.3) High morbidity (1.85–106) 2,364 (38.2) 377 (20.8) Length of relationship with primary care physician, n (%) <1 year 771 (12.5) 274 (15.1) <.001 1–5 years 2,300 (37.2) 1,025 (56.4) 5+ years 3,117 (50.3) 518 (28.5) Continuity of care index, mean (SD) 0.495 (0.382) 0.442 (0.401) .001 Patients assigned to newly hired doctors, n (%) 356 (5.8) 1,217 (67.0) <.001 Information from baseline patient survey (2006) Patient survey complete, n 938 160 Education, n (%) Less than college 127 (13.9) 13 (8.4) .063 Some college 279 (30.5) 42 (27.3) College graduate or postgraduate 508 (55.6) 99 (64.3) White race, n (%) 801 (87.9) 125 (81.2) .028 Patients assigned to newly hired doctors 48 (5.1) 105 (65.6) <.001 Self-reported health status, n (%) Excellent or very good 461 (51.8) 80 (53.7) .633 Good 302 (33.9) 52 (34.9) Fair or poor 127 (14.3) 17 (11.4) ACES-SF subscales,b mean (SD) Quality of doctor-patient interactions 85.8 (16.3) 85.1 (16.4) .627 Shared decision making 85.1 (22.3) 84.8 (21.7) .883 Coordination of care 81.3 (21.5) 79.4 (22.6) .327 Access 87.1 (17.2) 86.3 (19.3) .645 Helpfulness of office staff 91.4 (15.6) 92.3 (13.0) .499 PACIC subscales,b mean (SD) Patient activation/involvement 77.7 (27.0) 72.7 (29.7) .056 Goal setting/tailoring 69.0 (30.8) 69.4 (31.3) .893 Utilization measures (contacts per person in 2006) Eligible patients from automated data 6,188 1,817 Primary care visits, mean (SD) 3.67 (4.40) 2.44 (2.92) <.001 Emergency department/urgent care visits, mean (SD) 0.374 (0.978) 0.241 (0.694) <.001 Secure message threads, mean (SD) 1.29 (3.46) 0.85 (2.96) <.001 Telephone encounters, mean (SD) 3.74 (6.10) 1.89 (3.48) <.001 - Table 2.
Contrast in Adjusted Patient Experience and Utilization at 12 Months Between Not Reassigned and Reassigned Patients
Characteristic Not Reassigned Estimate (CI) Reassigned Estimate (CI) Mean Differencea Estimate (CI) PValue CI = confidence interval. a Adjusted mean difference and P value from linear regression with cluster-adjusted standard errors. Comparisons are between reassigned and not reassigned patients, over 12-month patient experience measures adjusting for sex, age, educational attainment, self-reported health status at baseline, assignment to new vs existing physician, and 2006 patient experience. b The ACES-SF and PACIC questions (scored on 6- and 5-point Likert scales, respectively) were totaled within the subscales and then transformed to 100-point summary scores. c Adjusted percent difference and P value from a generalized linear model with a log link and Poisson variance, adjusting for overdispersion. Comparisons are between reassigned and not reassigned patients, over 12-month utilization adjusting for sex, age, morbidity, duration of relationship with primary care physician, assignment to new vs existing physician and 2006 utilization. Patient experience Ambulatory Care Experiences Survey (ACES-SF)b Quality of doctor-patient interactions 86.1 (84.9 to 87.2) 86.9 (83.5 to 90.4) 0.88 (−2.99 to 4.75) .656 Shared decision making 86.4 (84.7 to 88.2) 84.0 (78.0 to 90.0) −2.51 (−9.20 to 4.19) .462 Coordination of care 82.0 (80.2 to 83.8) 80.3 (75.1 to 85.4) −1.76 (−7.63 to 4.12) .558 Access 86.8 (85.5 to 88.2) 85.3 (81.3 to 89.2) −1.57 (−5.94 to 2.79) .479 Helpfulness of office staff 90.9 (89.5 to 92.3) 88.7 (84.6 to 92.8) −2.14 (−6.77 to 2.48) .363 Patient Assessment of Chronic Illness Care survey (PACIC)b Activation 81.1 (79.0 to 83.1) 80.0 (74.7 to 85.4) −1.03 (−7.19 to 5.13) .743 Goal setting 74.0 (71.7 to 76.3) 73.9 (67.6 to 80.1) −0.15 (−7.30 to 7.00) .967 Utilization (contacts per person per year) % Difference Estimatec (CI) Primary care visits 3.00 (2.93 to 3.08) 2.67 (2.53 to 2.83) −10.9 (−16.7 to −4.7) .001 Emergency department/urgent care visits 0.295 (0.279 to 3.12) 0.324 (0.289 to 0.363) 9.8 (−4.2 to 25.8) .181 Secure message threads 2.28 (2.20 to 2.36) 2.42 (2.26 to 2.59) 6.1 (−2.3 to 15.2) .157 Telephone encounters 2.84 (2.74 to 2.94) 2.82 (2.63 to 3.03) −0.6 (−9.7 to 8.1) .884
Additional Files
Supplemental Appendix
Supplemental Appendix. Medical Care Survey
Files in this Data Supplement:
- Supplemental data: Appendix - PDF file, 5 pages, 299 KB
The Article in Brief
Implications of Reassigning Patients for the Medical Home: A Case Study
Katie Coleman , and colleagues
Background As part of its pilot test of the patient centered medical home, the Group Health Cooperative reduced clinician panel size in order to strengthen the doctor-patient relationship. This required the reassignment of approximately one-quarter of the practice�s 8,000 patients to new clinicians. This study examined the effects of reassigning patients to new physicians.
What This Study Found Practice redesign initiatives aimed at improving the patient experience may have unanticipated consequences. In this study, researchers found that reassigned patients were less likely to use primary care services but equally likely to use expensive emergency department care as patients who were retained by their existing physicians. Even with the disruption, however, reassigned patients were no less satisfied with their care experience. Physicians in this demonstration project, when given the chance to retain patients in their panels, chose to retain � not drop � those patients who were older and sicker. Patients who were less connected with a physician were more likely to be reassigned.
Implications
- To ensure that practice redesign does not adversely affect relationships with younger, healthier patients, the researchers call for more to be done proactively to connect patients to their new physicians and practice teams after being reassigned.
Annals Journal Club:
Nov/Dec 2010
Mitigating the Effects of Discontinuity
The Annals of Family Medicine encourages readers to develop a learning community of those seeking to improve health care and health through enhanced primary care. You can participate by conducting a RADICAL journal club and sharing the results of your discussions in the Annals online discussion for the featured articles. RADICAL is an acronym for Read, Ask, Discuss, Inquire, Collaborate, Act, and Learn. The word radical also indicates the need to engage diverse participants in thinking critically about important issues affecting primary care and then acting on those discussions.1How it Works
In each issue, the Annals selects an article or articles and provides discussion tips and questions. We encourage you to take a RADICAL approach to these materials and to post a summary of your conversation in our online discussion. (Open the article online and click on "TRACK Comments: Submit a response.") You can find discussion questions and more information online at: http://www.AnnFamMed.org/AJC/.
CURRENT SELECTION
Article for Discussion
- Coleman K, Reid RJ, Johnson E, et al. Implications of reassigning patients for the medical home: a case study. Ann Fam Med. 2010;8(6):493-498.
Discussion Tips
As practices change toward becoming patient-centered medical homes (PCMHs) there are consequences. This article provides an opportunity to consider how to manage those consequences. Group Health Cooperative appears to be having great success in its PCMH transformation.2,3 This article assesses how efforts to reduce panel size affect the patient�s experience. The study also is an opportunity to reflect on one of the fundamental tenets of primary care: continuity of care and ongoing relationships.Discussion Questions
- What question(s) are addressed by this article?
- What is the larger context of the PCMH movement in which this article can be interpreted?
- How is the Group Health approach to PCMH transformation different/similar to other approaches?
- What are the strengths and weaknesses of the study design for answering the question?
- To what degree can the findings be accounted for by:
- The larger and local contexts into which this study is nested?
- How the practice, physicians, and their patients were selected?
- How the main variables were measured?
- Confounding (false attribution of causality because 2 variables discovered to be associated actually are associated with a 3rd factor)?
- How the data were analyzed and interpreted?
- What are the main study findings?
- How comparable is the study sample to similar patients in your practice? What is your judgment about the transportability of the findings?
- What are the parallels between Group Health�s need to reassign patients to reduce panel size as part of its PCMH transformation and the training practices� need to reassign patients when trainees move on?
- How might this study change your practice?
- What are the implications of this study for reform at both the practice and policy levels?
- What are the study�s implications for the design of clinical education programs?
- What important researchable questions remain?
References
- Stange KC, Miller WL, McLellan LA, et al. Annals journal club: It�s time to get RADICAL. Ann Fam Med. 2006;4(3):196-197. http://annfammed.org/cgi/content/full/4/3/196.
- 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.
- Reid RJ, Coleman K, Johnson EA, et al. The group health medical home at year two: cost savings, higher patient satisfaction, and less burnout for providers. Health Aff (Millwood). 2010;29(5):835-843.