Tuesday, April 12, 2011

The Patient Centered Medical Home and Diabetes: A Timely Review of the Evidence

Where's that evidence?
After last week's Disease Management Care ACO-Blog-Fest (which catapulted the DMCB onto a highly coveted 'first page' Google "search" status for "Accountable Care Organization"), the DMCB turns its attention back to the Patient Centered Medical Home (PCMH), thanks to this timely hot-off-the-presses review by Trajko Bojadzievski and Robert Gabbay of the Penn State College of Medicine

Anyone pondering the many promises of the PCMH is likely to eventually focus on diabetes mellitus.  The condition is not only highly prevalent and costly, but its quite measurable.  Patients with diabetes are readily identified in most healthcare databases and it's relatively easy to measure the frequency of recommended tests and treatments over time.  It could also be argued that diabetes is a "bell weather" for overall quality for providers and insurers.  Solve diabetes and you solve the health care conundrum.

With that as background, Drs. Bojadzievski and Gabbay asked a simple question: what is the evidence that the PCMH reduces costs or increases quality for patients with diabetes?

The authors assembled peer-reviewed published papers as well as all the web-based reports on the PCMH and its impact on diabetes. They identified 41 programs and pilots; three were excluded because of their small size and focus on converting from usual care to a medical home practice, leaving 38. 

Unsurprisingly, the authors found that common ingredients for the PCMH include payment reform (with additional money to pay for new infrastructure, patient coordination and quality bonuses), care management, patient registries, electronic records and expert consultation support. They provide succinct summaries (including a well organized table) of the what the DMCB is coming to refer to as the "Top Eight" PCMH pilots: Community Care of North Carolina, Geisinger Health System, the Pennsylvania Chronic Care Initiative, Group Health, the Rhode Island Initiative, Health Partners, the Colorado PCMH pilot, and the PCMH National Demonstration Pilot.

While their review showed the PCMH was associated with impressive quality gains, the authors' answer to the question poised above was telling:

"Although randomized trials have yet to be performed, the eight Medical Home initiatives reported provide encouraging “before and after” results to support the PCMH as a viable mechanism to improve the quality and costs of diabetes." 

"Before and after?" Once again, the DMCB is left wondering if the enthusiasm for the PCMH will ever be matched by its evidence base.  Recall the following quote from a past 2007 article from the American Journal of Managed Care that critically examined "disease management":

"However, the vendor-run assessments typically do not meet the requirements of peer-reviewed research in terms of the comparison strategy, and adequate control for selection bias and regression to the mean."

Fortunately for the DM industry, they responded by adopting approaches that meet many of the rigor and plausibility requirements of peer reviewed research. The good news for the PCMH is that they can do that also as better data from the pilots are released the coming months.  That being said, the DMCB is also coming to believe that the uptake of the medical home may ultimately hinge less on the pilots than on how well it supports the success of ACOs.  Unfortunately for advocates of the PCMH, that ACO evidence base - and it prospects for profitability - remains an even bigger question mark.

One last important point from the authors was that expert "practice transformation coaches" and "learning collaboratives (meetings to explore and exchange ideas) are a common feature of the PCMH.  If that is one of the factors leading to "before and after" success described above, ACOs that are building medical homes in their networks may be well advised to tap into that kind of expertise.

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