Effects of Medical Home and Shared Savings Intervention on Care

Original Investigation Research

Invited Commentary

Does PCMH “Work”?—The Need to Use Implementation Science to Make Sense of Conflicting Results George L. Jackson, PhD, MHA; John W. Williams Jr, MD, MHS

Much as clinical research has the goal of helping clinicians improve their decision making for individual patients, health services research has the ultimate goal of helping managers and policy makers make better decisions for their organizations Related article page 1362 and constituents. Many managers of third-party-payer and provider organizations want to know if the patient-centered medical home (PCMH) framework for providing primary care “works” so they can decide if the significant effort involved in PCMH implementation is worth the potential benefits. In this issue of JAMA Internal Medicine, Friedberg and colleagues1 present results of the Pennsylvania Chronic Care Initiative (PACCI) in the northeastern part of the state. The study found that, compared with control practices, participating in PCMH was associated with better care processes for diabetes and breast cancer screening. No association was found between colorectal cancer screening and PCMH. There were significantly lower rates of all-cause hospitalizations and allcause and ambulatory care–sensitive emergency department visits. More primary care visits were accompanied by fewer specialty visits. Overall, this paper provides strong evidence for the success of the PACCI and PCMH. The complication is that the present article follows approximately a year after the same group, using similar methods, published results in JAMA of the evaluation of the PACCI in southeastern Pennsylvania that essentially indicate none of these positive outcomes (only reporting improvement in 1 of 11 quality indicators).2 The authors note that the initiatives were largely the same, with a few additions in the northeastern PACCI: inclusion of a shared savings plan (without risk), regular feedback to participating practices on utilization, lack of a link between PCMH accreditation and patient management payments (moving work related to accreditation from early to later in the process), and universal presence of electronic health records at baseline. Both of the articles represent state-of-the-art methods for addressing outcomes of observational, organizationally focused interventions occurring in less controlled settings (eg, PCMH implementation). However, there are significant limitations concerning the potential for unobserved confounding, understanding exactly what was or was not implemented, determining appropriate controls, and reliance on secondary data. The authors describe these limitations in both papers. The articles demonstrate key topics that need to be addressed to help organizations determine if they should implement PCMH-inspired changes. First, on what basis do we judge the question “does PCMH work?” It is often hoped that PCMH will improve patient and clinician satisfaction, lead to better measures of care pro-

cesses, improve clinical outcomes, and reduce costs. While these are of course all important goals, few, if any, single interventions have proved to be a “magic bullet” to fix the health care system. Rather, a series of different types of programs may be needed. The newly published article found PCMH practices had significantly less patient utilization during year 3 in areas that are frequently targets of quality improvement efforts: hospitalizations, emergency department visits, and specialty visits. Except for visits to specialists, PCMH practice utilization was not reduced; rather, it increased more slowly than in control practices. Importantly, effects on cost were not reported. Although lower utilization and costs may go together, this is not necessarily the case.3 There are also costs of implementing programs like PCMH that go beyond costs associated with clinical encounters (eg, staff time to plan new programs). As a result, the article does not address one of the hoped-for benefits of PCMH, namely, reducing health care costs. Second, what exactly is PCMH? PCMH is a conceptual framework, not a physical thing. The numerous published definitions frequently lack specific guidance on PCMH activities.4 As a result, what is being tested varies across studies and is frequently not completely described in reports. Although the term “medical home” has a long history (first used by pediatricians to refer to a usual source of care), it really represents an expansion of frameworks such as the Wagner Chronic Care Model that focus on team-based care guided by clinical decision support and information technology systems that facilitate the provision of evidence-based care and selfmanagement support linked to the community.3,5 PCMH extends these evidence-based care frameworks to include prevention and acute care, greater emphasis on patient flow, explicit desire to improve staff satisfaction, and sometimes greater focus on financing.3 A key issue for the PACCI evaluation is the degree of similarity between the initiative in southeastern Pennsylvania (essentially no impact of PCMH) and northeastern Pennsylvania (significant impact). The differences noted above primarily represent variation in implementation strategy (ie, how the PCMH intervention was put into place as opposed to PCMH components) and context.6 The study had limited information on what was actually implemented and on characteristics of control practices, which were selected using different criteria than intervention practices. Therefore, it is not possible to untangle the contributions of these differences. The argument that the shared savings plan was a significant contributor would have been stronger in the presence of information indicating significant cost differences. Third, is the question as to whether PCMH “works” about PCMH or about how it is implemented? PCMH represents a

jamainternalmedicine.com

(Reprinted) JAMA Internal Medicine August 2015 Volume 175, Number 8

Copyright 2015 American Medical Association. All rights reserved.

Downloaded From: by a University of Florida User on 11/18/2017

1369

Research Original Investigation

Effects of Medical Home and Shared Savings Intervention on Care

framework for changing health care systems to provide efficient, patient-centered care aimed at improving the satisfaction of patients and staff. However, changing systems requires more than just a framework. It also requires a concept of what evidence-based, high-quality care looks like (eg, through practice guidelines), a strategy for changing what actually happens on the ground (eg, lean management or plando-study-act cycles), and, frequently, a learning model that will spread the changes across practices or organizations (eg, quality improvement learning collaboratives).7 If a PCMH program does not lead to desired outcomes, it could be because of a breakdown in one or more of these areas. Observational studies are critical for addressing this possibility. However, there has to be detailed measurement of what PCMH components are implemented and the strategy for the implementation so that this can be linked to observed outcomes. As noted by the authors, this was a limitation of their evaluation. Fourth, can implementation science help determine if PCMH “works”? Implementation science is a branch of health services research that seeks to understand how a strategy for putting an innovation into place (eg, what we do to support organizations implementing PCMH) affects whether the innovation is implemented as intended (eg, intervention fidelARTICLE INFORMATION

REFERENCES

Author Affiliations: Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, North Carolina (Jackson, Williams); Division of General Internal Medicine, Duke University, Durham, North Carolina (Jackson, Williams).

1. Friedberg MW, Rosenthal MB, Werner RM, Volpp KG, Schneider EC. Effects of a medical home and shared savings intervention on quality and utilization of care [published online June 1, 2015]. JAMA Intern Med. doi:10.1001/jamainternmed.2015 .2047.

Corresponding Author: George L. Jackson, PhD, MHA, Durham VA Medical Center, HSR&D Service (152), 508 Fulton St, Durham, NC 27705 (george.l [email protected]).

2. Friedberg MW, Schneider EC, Rosenthal MB, Volpp KG, Werner RM. Association between participation in a multipayer medical home intervention and changes in quality, utilization, and costs of care. JAMA. 2014;311(8):815-825.

Published Online: June 1, 2015. doi:10.1001/jamainternmed.2015.2067. Conflict of Interest Disclosures: None reported. Disclaimer: The views expressed in this commentary are those of the authors and do not reflect the position or policy of the Department of Veterans Affairs, United States government, or Duke University.

1370

ity) and whether important clinical or organizational effects are observed in the “real world” (ie, intervention effectiveness). In studies that have shown no impact of PCMH, the issue may be that the implementation strategy failed, rather than the PCMH changes per se being ineffective. Without what Curran et al6 refer to as hybrid implementation studies (addressing both implementation and intervention effectiveness), this is difficult to tease out. Through a combination of quantitative and qualitative methods to examine whether the process of implementing PCMH leads to a functioning program operating as intended and the subsequent outcomes of the program, it is possible to better understand the chain of events that may affect whether PCMH “works.” This can be expensive and beyond the scope of most studies and evaluations. A robust literature that addresses effectiveness of both implementation and intervention in relation to PCMH is therefore needed. Despite conflicting results in the PACCI studies1,2 and the literature more broadly, PCMH remains a conceptually sound, promising framework for primary care.3 Implementation science, in combination with other health services and clinical research methods, can help in the development of a better understanding of the potential of PCMH.

3. Jackson GL, Powers BJ, Chatterjee R, et al. Improving patient care: the patient centered medical home: a systematic review. Ann Intern Med. 2013;158(3):169-178. 4. Vest JR, Bolin JN, Miller TR, Gamm LD, Siegrist TE, Martinez LE. Medical homes: “where you stand

on definitions depends on where you sit.” Med Care Res Rev. 2010;67(4):393-411. 5. Coleman K, Austin BT, Brach C, Wagner EH. Evidence on the Chronic Care Model in the new millennium. Health Aff (Millwood). 2009;28(1): 75-85. 6. Curran GM, Bauer M, Mittman B, Pyne JM, Stetler C. Effectiveness-implementation hybrid designs: combining elements of clinical effectiveness and implementation research to enhance public health impact. Med Care. 2012;50 (3):217-226. 7. Jackson GL, Powell AA, Ordin DL, et al; VA Colorectal Cancer Care Planning Committee Members. Developing and sustaining quality improvement partnerships in the VA: the Colorectal Cancer Care Collaborative. J Gen Intern Med. 2010; 25(suppl 1):38-43.

JAMA Internal Medicine August 2015 Volume 175, Number 8 (Reprinted)

Copyright 2015 American Medical Association. All rights reserved.

Downloaded From: by a University of Florida User on 11/18/2017

jamainternalmedicine.com

Does PCMH "Work"?--The Need to Use Implementation Science to Make Sense of Conflicting Results.

Does PCMH "Work"?--The Need to Use Implementation Science to Make Sense of Conflicting Results. - PDF Download Free
109KB Sizes 0 Downloads 8 Views