Quality and Efficiency in Small Practices Transitioning to Patient Centered Medical Homes: A Randomized Trial
Quality and Efficiency in Small Practices Transitioning to Patient Centered Medical Homes: A Randomized Trial
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小型诊所过渡到以患者为中心的医疗之家的质量和效率：随机试验
DOI：
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发表时间：
2013
影响因子：
5.7
通讯作者：
William Gillespie
中科院分区：
文献类型：
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作者：
J. Fifield;D. Forrest;J. Burleson;Melanie Martin;William Gillespie
摘要背景 越来越多的证据表明，即使是小型和单独的初级保健诊所，在提供支持（包括诊所重新设计、护理管理人员和修订的付款计划）后，也可以成功过渡到完全以患者为中心的医疗之家 (PCMH) 状态。对于与这种转变相关的质量和效率结果知之甚少。目的在干预与控制实践中测试医生与 2 年过渡到 PCMH 状态相关的质量和效率结果。设计随机对照试验。参与者由 43 名医生参与的 18 项干预实践和由 24 名医生参与的 14 项控制实践；全部来自成人初级保健实践。干预以 2008 年 NCQA PPC®-PCMH™ 为蓝本，干预实践获得了 18 个月的定制实践重新设计支持；修改后的 2 年付款方式，包括为实现质量目标而为每位会员每月 (PMPM) 提供高达 2.50 美元的费用，为获得 PPC-PCMH 认可而提供高达 2.50 美元的 PMPM 费用；以及 18 个月的嵌入式护理管理支持。对照者每年收到参与付款。 主要指标 2009 年 HEDIS 流程中的 11 项临床质量指标以及源自患者索赔数据的健康结果指标；基于汤森路透效率指数和急诊科 (ED) 就诊率的十个效率指标；主要结果与对照医生相比，干预医生显着改善了 11 项质量指标中的两项：2 年多的高血压控制（干预 +23 个百分点，控制 –2 个百分点，p = 0.02）和 3 年多的乳腺癌筛查（干预 +3.5 个百分点，控制 -0.4 个百分点，p = 0.03）。与对照医生相比，干预医生显着改善了十个效率指标之一：导致急诊就诊的护理次数减少（干预-0.7个百分点，对照 + 0.5个百分点，p = 0.002），每年急诊就诊次数减少3.8次，每位医生每年节省约1,900美元的急诊费用。任何预先指定的护理成本措施都没有显着节省成本。结论在一项随机试验中，我们观察到，一般成人初级护理实践中过渡到 PCMH 状态的一些护理质量和效率指标在 2 年内可以得到显着但适度的改善，尽管大多数指标没有改善，并且与对照实践相比没有成本节省。在大多数情况下，在试验期间，在不受支持的控制实践中提供的护理质量和效率保持不变或恶化。
ABSTRACTBACKGROUNDThere 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.OBJECTIVETest quality and efficiency outcomes associated with 2-year transition to PCMH status among physicians in intervention versus control practices.DESIGNRandomized Controlled Trial.PARTICIPANTSEighteen intervention practices with 43 physicians and 14 control practices with 24 physicians; all from adult primary care practices.INTERVENTIONSModeled 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 MEASURESEleven 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 RESULTSCompared 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.CONCLUSIONSIn 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.
性别与工作经历和心理困扰之间的关系：双职工夫妇的研究。
影响因子：
7.6
作者：
Barnett,RC;Marshall,NL;Raudenbush,SW;Brennan,RT
通讯作者：
Brennan,RT