Swietek Karen E, Gaynes Bradley N, Jackson George L, Weinberger Morris, Domino Marisa Elena
Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
NORC at the University of Chicago, Chicago, IL, USA.
J Gen Intern Med. 2020 Aug;35(8):2304-2313. doi: 10.1007/s11606-020-05729-x. Epub 2020 Feb 24.
Research demonstrates that the patient-centered medical home (PCMH) is associated with improved clinical outcomes and quality of care, and the populations that can most benefit from this model require long-term management, e.g., persons with chronic illness and behavioral health conditions. However, different populations may not benefit equally from the PCMH, and empirical evidence about the effects of this model on racial disparities is limited.
Estimate the association between enrollment in National Committee for Quality Assurance (NCQA)-recognized PCMHs and racial disparities in quality of care for adults with major depressive disorder (MDD) and comorbid medical conditions.
Applying a quasi-experimental instrumental variable design to account for differential selection into the PCMH, we used generalized estimating equations to determine the probability of receiving eight disease-specific quality measures.
Medicaid enrollees in three states not dually enrolled in Medicare, ages 18-64 with MDD and > 1 other chronic condition. A subgroup analysis was conducted for enrollees with comorbid diabetes.
Enrollment in an NCQA-recognized PCMH.
Disease-specific quality indicators for MDD (e.g., antidepressant use, receipt of psychotherapy), and for diabetes, (e.g. A1c testing, LDL-C testing, retinal exams, and medical attention for nephropathy).
PCMH enrollment was associated with an increase in the overall likelihood of receiving six of eight recommended services and a decrease in the likelihood of receiving any psychotherapy (4.94 percentage points, p < 0.01) and retinal exams (5.51 percentage points, p < 0.05). Although both groups improved, PCMH enrollment was associated with an exacerbation of the Black-white disparity in adequate antidepressant use by 4.20 percentage points (p < 0.01).
While PCMH enrollment may improve the overall quality of care, the effect is inconsistent across racial groups and not always associated with reductions in racial disparities in quality.
研究表明，以患者为中心的医疗之家（PCMH）与改善临床结局和医疗质量相关，而最能从该模式中受益的人群需要长期管理，例如患有慢性病和行为健康问题的人。然而，不同人群可能无法从PCMH中平等受益，且关于该模式对种族差异影响的实证证据有限。
评估在国家质量保证委员会（NCQA）认可的PCMH注册与患有重度抑郁症（MDD）及合并其他疾病的成年人医疗质量种族差异之间的关联。
应用准实验性工具变量设计以解释进入PCMH的差异选择，我们使用广义估计方程来确定接受八项特定疾病质量指标的概率。
三个州未同时参加医疗保险的医疗补助参保人，年龄在18 - 64岁，患有MDD且还有一种以上其他慢性病。对合并糖尿病的参保人进行了亚组分析。
在NCQA认可的PCMH注册。
MDD的特定疾病质量指标（如抗抑郁药使用、接受心理治疗）以及糖尿病的特定疾病质量指标（如糖化血红蛋白检测、低密度脂蛋白胆固醇检测、视网膜检查以及肾病医疗护理）。
在PCMH注册与接受八项推荐服务中的六项的总体可能性增加以及接受任何心理治疗（4.94个百分点，p < 0.01）和视网膜检查（5.51个百分点，p < 0.05）的可能性降低相关。虽然两组都有所改善，但在PCMH注册与黑人和白人在充分使用抗抑郁药方面的差距加剧4.20个百分点相关（p < 0.01）。
虽然在PCMH注册可能会改善总体医疗质量，但效果在不同种族群体中并不一致，且并不总是与医疗质量的种族差异减少相关。
