Blog | Friday, September 13, 2013

QD: News Every Day--PCMH pilot reduced ambulatory care-sensitive emergency visits

A pilot program of a patient-centered medical home in Rhode Island was associated after two years with a significant reduction in ambulatory care-sensitive emergency department visits, with a downward trend (but not significance) in emergency department visits and inpatient admissions, a study found.

Researchers at Harvard and the RAND Corporation reviewed claims data two years before and after October 2008 to assess the Rhode Island Chronic Care Sustainability Initiative, a pilot program among five independent primary care practices and three private insurers. Another 34 practices were used for comparison.

Researchers assessed changes in hospital admissions, emergency department visits, and six measures of quality of care: three for diabetes and three for colon, breast and cervical cancer screening. Results appeared online Sept. 9 at JAMA Internal Medicine.

Although estimates of the emergency department visits and inpatient admissions of patients in the pilot practices trended toward lower utilization, the only significant difference was a lower rate of ambulatory care sensitive emergency department visits in the pilot practices, approximately 0.8 per 1,000 member months or approximately 11.6% compared with the baseline rate of 6.9 for emergency department visits per 1,000 member months (P=.002).

There were downward trends but no significant reductions for overall emergency department visits, inpatient admissions or ambulatory care-sensitive inpatient admissions for pilot practices compared with control practices, the study found. Also, there were no changes in primary care or specialist visits, or for prescription drug use. There were no significant improvements for diabetes and cancer screening quality measures, although there were positive trends for some diabetes quality measures.

The authors wrote that two years may not be long enough to generate the expected benefits from a patient-centered medical home. “Our interviews suggest that only after 2 years did the practices build the foundation for the care coordination and high-risk care management efforts that may be necessary for broader and more substantial improvements in hospital and emergency department utilization and patient outcomes.”

An editorial noted that studying efficacy of practice transformations isn’t like seeking FDA approval for a new drug. “To evaluate practice interventions, such as the patient-centered medical home, researchers often must capitalize on natural experiments over which they have little control. A consequence of evaluating a natural experiment is that studies are frequently underpowered to detect clinically important effects, as was the case in Rhode Island. ... 2 years of follow-up may have been too short for full implementation of the intervention and for evaluating the intervention’s effects on outcomes. No doubt Rosenthal et al would have preferred to study more than 5 practices and to continue the evaluation beyond 2 years of follow-up.”