title: Quality and efficiency in small practices transitioning to patient centered medical homes: a randomized trial.
abstract: BACKGROUND
  There is growing evidence that even small and solo primary care practices can successfully transition to full Patient Centered Medical Home (PCMH) status when provided with support, including practice redesign, care managers, and a revised payment plan. Less is known about the quality and efficiency outcomes associated with this transition.
  
  
  OBJECTIVE
  Test quality and efficiency outcomes associated with 2-year transition to PCMH status among physicians in intervention versus control practices.
  
  
  METHODS
  Randomized Controlled Trial.
  
  
  METHODS
  Eighteen intervention practices with 43 physicians and 14 control practices with 24 physicians; all from adult primary care practices.
  
  
  METHODS
  Modeled on 2008 NCQA PPC®-PCMH™, intervention practices received 18 months of tailored practice redesign support; 2 years of revised payment, including up to $2.50 per member per month (PMPM) for achieving quality targets and up to $2.50 PMPM for PPC-PCMH recognition; and 18 months of embedded care management support. Controls received yearly participation payments.
  
  
  METHODS
  Eleven clinical quality indicators from the 2009 HEDIS process and health outcomes measures derived from patient claims data; Ten efficiency indicators based on Thomson Reuter efficiency indexes and Emergency Department (ED) Visit Ratios; and a panel of costs of care measures.
  
  
  RESULTS
  Compared to control physicians, intervention physicians significantly improved TWO of 11 quality indicators: hypertensive blood pressure control over 2 years (intervention +23 percentage points, control -2 percentage points, p =0.02) and breast cancer screening over 3 years (intervention +3.5 percentage points, control -0.4 percentage points, p =0.03). Compared to control physicians, intervention physicians significantly improved ONE of ten efficiency indicators: number of care episodes resulting in ED visits was reduced (intervention -0.7 percentage points, control + 0.5 percentage points, p = 0.002), with 3.8 fewer ED visits per year, saving approximately $1,900 in ED costs per physician, per year. There were no significant cost-savings on any of the pre-specified costs of care measures.
  
  
  CONCLUSIONS
  In a randomized trial, we observed that some indicators of quality and efficiency of care in general adult primary care practices transitioning to PCMH status can be significantly, but modestly, improved over 2 years, although most indicators did not improve and there were no cost-savings compared with control practices. For the most part, quality and efficiency of care provided in unsupported control practices remained unchanged or worsened during the trial.
authors: University of Connecticut Health Center, Farmington, CT, USA. fifield@nso1.uchc.edu
authors: Judith
authors: J
authors: Fifield
authors: Deborah Dauser
authors: DD
authors: Forrest
authors: Joseph A
authors: JA
authors: Burleson
authors: Melanie
authors: M
authors: Martin-Peele
authors: William
authors: W
authors: Gillespie
mesh_terms: D000328:Adult; D000368:Aged; D017598:Efficiency, Organizational; D005260:Female; D018166:Health Care Reform; D006801:Humans; D008297:Male; D008875:Middle Aged; D009936:Organizational Innovation; D010043:Outcome and Process Assessment, Health Care / Q000379:methods; D018802:Patient-Centered Care / Q000458:organization & administration* / Q000592:standards; D011320:Primary Health Care / Q000458:organization & administration* / Q000592:standards; D011785:Quality Assurance, Health Care / Q000379:methods; D011787:Quality of Health Care; D014481:United States