Estimating Associations Between Medical Home Adoption, Utilization, and Quality: A Comparison of Evaluation Approaches
Methodological differences between evaluations of medical home adoption might complicate readers’ ability to draw conclusions across studies.Objectives:
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.Measurements:
Six utilization and 6 quality measures.Results:
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.Conclusions:
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.