College of Nursing, University of South Carolina, Columbia, South Carolina, United States of America.
Institute for Families in Society, University of South Carolina, Columbia, South Carolina, United States of America.
PLoS One. 2022 Sep 6;17(9):e0273805. doi: 10.1371/journal.pone.0273805. eCollection 2022.
Previous studies have found a mixed association between Patient-Centered Medical Home (PCMH) designation and improvements in primary care quality indicators, including avoidable pediatric emergency department (ED) encounters. Whether these associations persist after accounting for the geographic locations of providers relative to where patients reside is unknown.
To examine the association between geographic proximity to primary care providers versus hospitals and risk of avoidable and potentially avoidable ED visits among children with pre-existing diagnosis of attention-deficit/hyperactivity disorder or asthma.
Retrospective cohort study of a panel of pediatric Medicaid claims data from the South Carolina from 2016-2018 for 2,959 beneficiaries having a pre-existing diagnosis of attention-deficit/hyperactivity disorder (ADD, ages 6-12) and 6,390 beneficiaries with asthma (MMA, ages 5-18), as defined using Healthcare Effectiveness Data and Information Set (HEDIS) performance measures. We calculated differences in avoidable and potentially avoidable ED visits by the beneficiary's PCMH attribution type and in relation to differences in proximity to their primary care providers versus hospitals. Outcomes were defined using the New York University Emergency Department Algorithm (NYU-EDA). Differences in ED visit risk were assessed using generalized estimation equations and compared using marginal effects models.
The 2.4 percentage point reduction in risk of avoidable ED visits among children in the ADD cohort who attended a PCMH versus those who did not increased to 3.9 to 7.2 percentage points as relative proximity to primary care providers versus hospitals improved (p < 0.01). Children in the ADD and MMA cohorts that were enrolled in a medical home, but did not attend one for primary care services exhibited a 5.4 and 3.0 percentage point increase in avoidable ED visit compared to children who were unenrolled and did not attend medical homes (p < 0.05), but these differences were only observed when geographic proximity to hospitals was more convenient than primary care providers. Mixed findings were observed for potentially avoidable visits.
In several health care performance evaluations, patient-centered medical homes have not been found to reduce differences in hospital utilization for conditions that are treatable in primary care settings among children with chronic illnesses. Analytical approaches that also consider geographic proximity to health care services can identify performance benefits of medical homes. Expanding risk-adjustment models to also include geographic data would benefit ongoing quality improvement initiatives.
先前的研究发现，患者为中心的医疗之家（PCMH）的指定与初级保健质量指标的改善之间存在混合关联，包括可避免的儿科急诊部（ED）就诊。在考虑到提供者相对于患者居住地的地理位置之后，这些关联是否仍然存在尚不清楚。
检查相对于医院而言，与初级保健提供者的地理位置接近程度与患有先前诊断的注意力缺陷/多动障碍或哮喘的儿童的可避免和潜在可避免的 ED 就诊之间的关联。
这是一项来自南卡罗来纳州的 2016-2018 年的 Medicaid 儿科索赔数据的回顾性队列研究，该研究针对 2959 名患有先前诊断的注意力缺陷/多动障碍（ADD，年龄 6-12 岁）的受益人和 6390 名患有哮喘（MMA，年龄 5-18 岁）的受益人均定义了使用医疗保健效果数据和信息集（HEDIS）绩效指标。我们根据受益人的 PCMH 归属类型以及与他们的初级保健提供者与医院的接近程度的差异，计算了可避免和潜在可避免的 ED 就诊次数的差异。使用纽约大学急诊部门算法（NYU-EDA）定义结局。使用广义估计方程评估 ED 就诊风险的差异，并使用边际效应模型进行比较。
与未参加 PCMH 的 ADD 队列中的儿童相比，参加 PCMH 的儿童的可避免 ED 就诊风险降低了 2.4 个百分点，而随着与初级保健提供者相对于医院的相对接近程度的提高，该风险降低了 3.9 至 7.2 个百分点（p <0.01）。参加医疗之家但未参加初级保健服务的 ADD 和 MMA 队列中的儿童的可避免 ED 就诊率分别增加了 5.4 和 3.0 个百分点，而未参加且未参加医疗之家的儿童则增加了 5.4 和 3.0 个百分点（p <0.05），但仅当医院的地理位置比初级保健提供者更方便时，才观察到这些差异。潜在可避免的就诊存在混合发现。
在多项医疗保健绩效评估中，对于患有慢性病的儿童，患者为中心的医疗之家并未发现可减少在初级保健环境中可治疗的疾病的医院利用方面的差异。考虑到医疗服务地理位置的分析方法可以确定医疗之家的绩效优势。将风险调整模型扩展到还包括地理数据将有益于正在进行的质量改进计划。
