Khanna Niharika, Shaya Fadia T, Chirikov Viktor V, Sharp David, Steffen Ben
From the Department of Family and Community Medicine, University of Maryland School of Medicine, Baltimore (NK); the Department of Pharmaceutical Health Services Research, University of Maryland School of Pharmacy, Baltimore (FTS, VVC); the Center for Health Information Technology and Innovative Care Delivery, Department of Health and Mental Hygiene, Baltimore, MD (DS); and the Maryland Health Care Commission, Department of Health and Mental Hygiene, Baltimore (BS).
J Am Board Fam Med. 2016 Jan-Feb;29(1):116-25. doi: 10.3122/jabfm.2016.01.150067.
We present data on quality of care (QC) improvement in 35 of 45 National Quality Forum metrics reported annually by 52 primary care practices recognized as patient-centered medical homes (PCMHs) that participated in the Maryland Multi-Payor Program from 2011 to 2013.
We assigned QC metrics to (1) chronic, (2) preventive, and (3) mental health care domains. The study used a panel data design with no control group. Using longitudinal fixed-effects regressions, we modeled QC and case mix severity in a PCMH.
Overall, 35 of 45 quality metrics reported by 52 PCMHs demonstrated improvement over 3 years, and case mix severity did not affect the achievement of quality improvement. From 2011 to 2012, QC increased by 0.14 (P < .01) for chronic, 0.15 (P < .01) for preventive, and 0.34 (P < .01) for mental health care domains; from 2012 to 2013 these domains increased by 0.03 (P = .06), 0.04 (P = .05), and 0.07 (P = .12), respectively. In univariate analyses, lower National Commission on Quality Assurance PCMH level was associated with higher QC for the mental health care domain, whereas case mix severity did not correlate with QC. In multivariate analyses, higher QC correlated with larger practices, greater proportion of older patients, and readmission visits. Rural practices had higher proportions of Medicaid patients, lower QC, and higher QC improvement in interaction analyses with time.
The gains in QC in the chronic disease domain, the preventive care domain, and, most significantly, the mental health care domain were observed over time regardless of patient case mix severity. QC improvement was generally not modified by practice characteristics, except for rurality.
我们展示了2011年至2013年参与马里兰州多支付方项目的52家被认可为以患者为中心的医疗之家（PCMH）的初级医疗实践机构每年报告的45项国家质量论坛指标中35项的医疗质量（QC）改善数据。
我们将QC指标分为（1）慢性病、（2）预防和（3）精神卫生保健领域。该研究采用无对照组的面板数据设计。使用纵向固定效应回归，我们对PCMH中的QC和病例组合严重程度进行建模。
总体而言，52家PCMH报告的45项质量指标中有35项在3年内有所改善，病例组合严重程度并未影响质量改善的实现。从2011年到2012年，慢性病领域的QC增加了0.14（P <.01），预防领域增加了0.15（P <.01），精神卫生保健领域增加了0.34（P <.01）；从2012年到2013年，这些领域分别增加了0.03（P =.06）、0.04（P =.05）和0.07（P =.12）。在单变量分析中，较低的国家质量保证委员会PCMH级别与精神卫生保健领域较高的QC相关，而病例组合严重程度与QC无关。在多变量分析中，较高的QC与规模较大的机构、老年患者比例较高以及再入院就诊相关。农村机构的医疗补助患者比例较高、QC较低，在与时间的交互分析中QC改善较高。
随着时间的推移，无论患者病例组合严重程度如何，慢性病领域、预防保健领域，尤其是精神卫生保健领域的QC都有提高。除了农村地区外，QC的改善一般不受机构特征的影响。
