Martsolf Grant R, Kandrack Ryan, Baird Matthew, Friedberg Mark W
RAND Corporation, Pittsburgh, PA.
RAND Corporation.
Med Care. 2018 Jan;56(1):25-30. doi: 10.1097/MLR.0000000000000842.
Methodological differences between evaluations of medical home adoption might complicate readers' ability to draw conclusions across studies.
To study whether associations between medical home adoption and patient care are affected by methodological choices.
DESIGN, SETTING, AND SUBJECTS: Among 71 practices participating in the Pennsylvania Chronic Care Initiative (a medical home pilot), we estimated cross-sectional and longitudinal associations between 4 definitions of "medical home adoption" [National Committee on Quality Assurance (NCQA) recognition in year 3, Medical Home Index scores at baseline and 3, and within-practice changes in Medical Home Index scores between baseline and year 3] and utilization and quality.
Six utilization and 6 quality measures.
In cross-sectional analyses at year 3, NCQA recognition was associated with higher rates of nephropathy monitoring (7.23 percentage points; confidence interval, 0.45-14.02), breast cancer screening (7.48; 2.11-12.86), and colorectal cancer screening (8.43; 2.44-14.42). In longitudinal analyses, NCQA recognition was associated with increases in hospitalization rates (2.75 per 1000 patient-months; 0.52-4.98). In baseline cross-sectional analyses, higher Medical Home Index scores were associated with fewer ambulatory care-sensitive hospitalizations (-0.61 per 1000 patient per month; -1.11 to -0.11), all-cause emergency department visits (-6.80; -12.28 to -1.32), and ambulatory care-sensitive emergency department visits (-5.60; 10.32 to -0.88). There were no statistically significant associations between any other measure of medical home adoption and quality or utilization.
The findings of medical home evaluations are sensitive to methodological choices. Meta-analyses, narrative reviews, and other syntheses of medical home studies should consider subdividing their findings by analytic approach.
医疗之家采用情况评估之间的方法学差异可能会使读者难以在各项研究之间得出结论。
研究医疗之家采用情况与患者护理之间的关联是否受方法学选择的影响。
设计、设置和研究对象：在参与宾夕法尼亚州慢性病照护计划（一项医疗之家试点项目）的71家医疗机构中，我们估计了“医疗之家采用情况”的4种定义（第3年的国家质量保证委员会（NCQA）认证、基线时和第3年的医疗之家指数得分，以及基线到第3年医疗之家指数得分的机构内部变化）与医疗服务利用和质量之间的横断面及纵向关联。
6项医疗服务利用指标和6项质量指标。
在第3年的横断面分析中，NCQA认证与更高的肾病监测率（7.23个百分点；置信区间，0.45 - 14.02）、乳腺癌筛查率（7.48；2.11 - 12.86）和结直肠癌筛查率（8.43；2.44 - 14.42）相关。在纵向分析中，NCQA认证与住院率增加相关（每1000患者月增加2.75例；0.52 - 4.98）。在基线横断面分析中，更高的医疗之家指数得分与更少的非卧床护理敏感型住院（每1000患者每月减少0.61例； - 1.11至 - 0.11）、全因急诊就诊（ - 6.80； - 12.28至 - 1.32）和非卧床护理敏感型急诊就诊（ - 5.60； - 10.32至 - 0.88）相关。医疗之家采用情况的任何其他测量指标与质量或医疗服务利用之间均无统计学上的显著关联。
医疗之家评估的结果对方法学选择敏感。医疗之家研究的荟萃分析、叙述性综述和其他综合分析应考虑按分析方法对其结果进行细分。
