Morgan Toyosi O, Everett Darcie L, Dunlop Anne L
Department of Family and Preventive Medicine, Emory University School of Medicine, Atlanta, GA, USA.
Health Serv Res Manag Epidemiol. 2014 Oct 31;1:2333392814556153. doi: 10.1177/2333392814556153. eCollection 2014 Jan-Dec.
To review the impact of the Joint Principle of the Patient Centered Medical Home (PCMH) on hemoglobin A1C (HbA1C) in primary care patients with diabetes.
Systematic review of English articles using approximate terms for (1) the 7 principles of the PCMH, (2) primary care, and (3) HbA1C. We included experimental and observational studies. Three authors independently extracted data and obtained summary estimates for concepts with more than 2 high-quality studies.
Forty-three studies published between 1998 and 2012 met inclusion criteria, 33 randomized and 10 controlled before-after studies. A physician-directed medical practice (principle 2) lowered HbA1C values when utilizing nursing (mean difference [MD] -0.36, 95% confidence interval [CI] -0.43 to -0.28) or pharmacy care management (MD -0.76; 95% CI -0.93 to -0.59). Whole-person orientation (principle 3) also lowered HbA1C (MD -0.72, 95% CI -0.98 to -0.45). Studies of coordinated and integrated care (principle 4) and quality and safety interventions (principle 5) did not consistently lower HbA1C when reviewed in aggregate. We did not identify high-quality studies to make conclusions for personal physician (principle 1), enhanced access (principle 6), and payment (principle 7).
Our review found individual interventions that reduced the HbA1C by up to 2.0% when they met the definitions set by of the Joint Principles of the PCMH. Two of the principles-physician-led team and whole-person orientation-consistently lowered the HbA1C. Other principles had limited data or made little to no impact. Based on current evidence, PCMH principles differentially influence the HbA1C, and there are opportunities for additional research.
回顾以患者为中心的医疗之家（PCMH）联合原则对初级保健糖尿病患者糖化血红蛋白（HbA1C）的影响。
系统回顾英文文章，使用近似术语检索（1）PCMH的7项原则、（2）初级保健和（3）HbA1C。纳入实验性和观察性研究。三位作者独立提取数据，并对超过2项高质量研究的概念获得汇总估计值。
1998年至2012年发表的43项研究符合纳入标准，其中33项为随机对照研究，10项为前后对照研究。当采用护理（平均差[MD] -0.36，95%置信区间[CI] -0.43至-0.28）或药学护理管理（MD -0.76；95% CI -0.93至-0.59）时，由医生主导的医疗实践（原则2）可降低HbA1C值。全人导向（原则3）也可降低HbA1C（MD -0.72，95% CI -0.98至-0.45）。总体回顾时，协调和综合护理（原则4）及质量与安全干预（原则5）的研究并未一致降低HbA1C。我们未找到高质量研究以对个人医生（原则1）、增强可及性（原则6）和支付（原则7）得出结论。
我们的综述发现，当符合PCMH联合原则所设定的定义时，个别干预措施可使HbA1C降低达2.0%。其中两项原则——医生主导团队和全人导向——持续降低了HbA1C。其他原则的数据有限或几乎没有影响。基于现有证据，PCMH原则对HbA1C的影响存在差异，仍有进一步研究的机会。
