Annals Journal Club: Mitigating the Effects of Discontinuity

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:

  1. The larger and local contexts into which this study is nested?

  2. How the practice, physicians, and their patients were selected?

  3. How the main variables were measured?

  4. Confounding (false attribution of causality because 2 variables discovered to be associated actually are associated with a 3rd factor)?

  5. 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?