title: Patient-centered medical home implementation and use of preventive services: the role of practice socioeconomic context.
abstract: OBJECTIVE
  The patient-centered medical home (PCMH) model of primary care is being implemented in a wide variety of socioeconomic contexts, yet there has been little research on whether its effects differ by context. Clinical preventive service use, including cancer screening, is an important outcome to assess the effectiveness of the PCMH within and across socioeconomic contexts.
  
  
  OBJECTIVE
  To determine whether the relationship between the PCMH and cancer screening is conditional on the socioeconomic context in which a primary care physician practice operates.
  
  
  METHODS
  A longitudinal study spanning July 1, 2009, through June 30, 2012, using data from the Blue Cross Blue Shield of Michigan Physician Group Incentive Program was conducted. Michigan nonpediatric primary care physician practices that participated in the Physician Group Incentive Program (5452 practice-years) were included. Sample size and outlier exclusion criteria were applied to each outcome. We examined the interaction between practices' PCMH implementation scores and their socioeconomic context. The implementation of a PCMH was self-reported by the practice's affiliated physician organizations and was measured as a continuous score ranging from 0 to 1. Socioeconomic context was calculated using a market-based approach based on zip code characteristics of the practice's patients and by combining multiple measures using principal components analysis.
  
  
  METHODS
  Breast, cervical, and colorectal cancer screening rates for practices' Blue Cross Blue Shield of Michigan patients.
  
  
  RESULTS
  The implementation of a PCMH was associated with higher breast, cervical, and colorectal cancer screening rates across most market socioeconomic contexts. In multivariable models, the PCMH was associated with a higher rate of screening for breast cancer (5.4%; 95% CI, 1.5% to 9.3%), cervical cancer (4.2%; 95% CI, 1.4% to 6.9%), and colorectal cancer (7.0%; 95% CI, 3.6% to 10.5%) in the lowest socioeconomic group but nonsignificant differences in screening for breast cancer (2.6%; 95% CI, -0.1% to 5.3%) and cervical cancer (-0.5%; 95% CI, -2.7% to 1.7%) and a higher rate of colorectal cancer (4.5%; 95% CI, 1.8% to 7.3%) screening in the highest socioeconomic group. Because PCMH implementation was associated with larger increases in screening in lower socioeconomic practice settings, models suggest reduced disparities in screening rates across these contexts. For example, the model-predicted disparity in breast cancer screening rates between the highest and lowest socioeconomic contexts was 6% (77.9% vs 72.2%) among practices with no PCMH implementation and 3% (80.3% vs. 77.0%) among practices with full PCMH implementation.
  
  
  CONCLUSIONS
  In our study, the PCMH model was associated with improved cancer screening rates across contexts but may be especially relevant for practices in lower socioeconomic areas.
authors: Department of Clinical Epidemiology and Biostatistics, Blue Cross Blue Shield of Michigan, Ann Arbor2Department of Epidemiology, Harvard School of Public Health, Harvard University, Boston, Massachusetts.
authors: Amanda R
authors: AR
authors: Markovitz
authors: Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor.
authors: Jeffrey A
authors: JA
authors: Alexander
authors: Department of Health Policy, Milken Institute School of Public Health, George Washington University, Washington, DC.
authors: Paula M
authors: PM
authors: Lantz
authors: Department of Clinical Epidemiology and Biostatistics, Blue Cross Blue Shield of Michigan, Ann Arbor.
authors: Michael L
authors: ML
authors: Paustian
mesh_terms: D000328:Adult; D000368:Aged; D001943:Breast Neoplasms / Q000191:economics / Q000517:prevention & control; D015179:Colorectal Neoplasms / Q000191:economics / Q000517:prevention & control; D055088:Early Detection of Cancer / Q000191:economics* / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D007348:Insurance, Health; D008297:Male; D008824:Michigan; D008875:Middle Aged; D018802:Patient-Centered Care / Q000191:economics / Q000706:statistics & numerical data*; D010816:Physician Incentive Plans; D010818:Practice Patterns, Physicians' / Q000191:economics / Q000706:statistics & numerical data*; D011314:Preventive Health Services / Q000191:economics / Q000706:statistics & numerical data*; D011320:Primary Health Care / Q000191:economics / Q000706:statistics & numerical data*; D017149:Private Sector; D012052:Reimbursement, Incentive; D012959:Socioeconomic Factors; D002583:Uterine Cervical Neoplasms / Q000191:economics / Q000517:prevention & control