Implementation of Patient-Centered Medical Homes in Adult Primary Care Practices.

There has been relatively little empirical evidence about the effects of patient-centered medical home (PCMH) implementation on patient-related outcomes and costs. Using a longitudinal design and a large study group of 2,218 Michigan adult primary care practices, our study examined the following research questions: Is the level of, and change in, implementation of PCMH associated with medical surgical cost, preventive services utilization, and quality of care in the following year? Results indicated that both level and amount of change in practice implementation of PCMH are independently and positively associated with measures of quality of care and use of preventive services, after controlling for a variety of practice, patient cohort, and practice environmental characteristics. Results also indicate that lower overall medical and surgical costs are associated with higher levels of PCMH implementation, although change in PCMH implementation did not achieve statistical significance.

Dialing in: effect of telephonic wellness coaching on weight loss.

OBJECTIVE: To estimate the effect of telephonic wellness coaching on weight loss in a commercially insured population. STUDY DESIGN: Pre-post evaluation design. METHODS: Self-reported weight was obtained from 2 annual health assessment questionnaires administered during 2008 and 2010. Baseline (T1) information from these questionnaires was used to identify overweight/obese individuals and to determine targets for a 4-call wellness coaching program. Overweight/obese individuals identified at T1 were classified into following groups: (1) targeted for wellness coaching (N = 1448, including 1050 participants and 398 nonparticipants); (2) not targeted for wellness coaching, but targeted for other telephonic wellness care management (WCM) programs (N = 1270); (3) not targeted for any WCM programs (N = 7586). Weight reported on questionnaires a year later (T2) was used to calculate weight change between T1 and T2. Paired t-tests were used to detect significant weight changes over time. Multivariable linear regressions were used to compare weight changes between the groups. Stratified analysis was conducted to determine the effectiveness of telephonic wellness coaching for subgroups based on participants' selected health goals, intensity of the intervention received and initial stage of change. RESULTS: The group targeted for wellness coaching reported an average weight change of -0.44 kg (95% confidence interval [CI], -0.76 to -0.16) at T2, significantly more weight loss than reported by the group not targeted for any WCM programs. Participants who started in preparation stage and completed the program reported weight change of -1.43 kg (95% CI, -2.17 to -0.68), highest among program participants. CONCLUSIONS: Small weight loss was observed for obese/individuals targeted for telephonic wellness coaching.

Association between maternal preventive care utilization and adolescent vaccination: it's not just about Pap testing.

STUDY OBJECTIVE: To examine the association between maternal preventive care utilization and human papillomavirus (HPV) vaccine uptake by their adolescent daughters. DESIGN: A cross-sectional study using immunization records from administrative claims and the state health department's immunization information system from June 2006 through May 2011. PARTICIPANTS: Commercially-insured Michigan females aged 13-17 in May 2011 and their mothers. Mothers were identified using relationship information on the insurance contract. MAIN OUTCOME MEASURES: Using logistic regression, we investigated whether initiating and/or completing the HPV vaccine series were associated with maternal preventive care utilization (Papaniculou testing, mammograms, primary care office visits) independently and using a combined maternal preventive care utilization index. RESULTS: Among 38,604 mother-daughter pairs, 36% of daughters initiated and 22% completed the HPV vaccine series. Maternal utilization of each recommended service was modestly associated with both daughter's initiation and completion of the HPV vaccine. Effect estimates for receipt of Papaniculou test on vaccine initiation (OR = 1.07, 95% CI = 1.06-1.08) were not any higher than for mammograms (OR = 1.10, 95% CI = 1.08-1.11) or primary care office visits (OR = 1.07, 95% CI = 1.06-1.09). Using a maternal preventive care utilization index, vaccine uptake increased with an increasing number of received services. CONCLUSIONS: Maternal receipt of recommended preventive care, which may reflect general attitudes toward prevention, is as or more predictive of daughter's vaccination status than cervical cancer screening alone. Engaging women in broad routine preventive care practices may have additional positive effects on adolescent HPV vaccination beyond those achieved through cervical cancer prevention efforts alone.

Partial and incremental PCMH practice transformation: implications for quality and costs.

OBJECTIVE: To examine the associations between partial and incremental implementation of the Patient Centered Medical Home (PCMH) model and measures of cost and quality of care. DATA SOURCE: We combined validated, self-reported PCMH capabilities data with administrative claims data for a diverse statewide population of 2,432 primary care practices in Michigan. These data were supplemented with contextual data from the Area Resource File. STUDY DESIGN: We measured medical home capabilities in place as of June 2009 and change in medical home capabilities implemented between July 2009 and June 2010. Generalized estimating equations were used to estimate the mean effect of these PCMH measures on total medical costs and quality of care delivered in physician practices between July 2009 and June 2010, while controlling for potential practice, patient cohort, physician organization, and practice environment confounders. PRINCIPAL FINDINGS: Based on the observed relationships for partial implementation, full implementation of the PCMH model is associated with a 3.5 percent higher quality composite score, a 5.1 percent higher preventive composite score, and $26.37 lower per member per month medical costs for adults. Full PCMH implementation is also associated with a 12.2 percent higher preventive composite score, but no reductions in costs for pediatric populations. Incremental improvements in PCMH model implementation yielded similar positive effects on quality of care for both adult and pediatric populations but were not associated with cost savings for either population. CONCLUSIONS: Estimated effects of the PCMH model on quality and cost of care appear to improve with the degree of PCMH implementation achieved and with incremental improvements in implementation.

Assessment and measurement of patient-centered medical home implementation: the BCBSM experience.

PURPOSE: Our goal was to describe an approach to patient-centered medical home (PCMH) measurement based on delineating the desired properties of the measurement relative to assumptions about the PCMH and the uses of the measure by Blue Cross Blue Shield of Michigan (BCBSM) and health services researchers. METHODS: We developed and validated an approach to assess 13 functional domains of PCMHs and 128 capabilities within those domains. A measure of PCMH implementation was constructed using data from the validated self-assessment and then tested on a large sample of primary care practices in Michigan. RESULTS: Our results suggest that the measure adequately addresses the specific requirements and assumptions underlying the BCBSM PCMH program-ability to assess change in level of implementation; ability to compare across practices regardless of size, affiliation, or payer mix; and ability to assess implementation of the PCMH through different sequencing of capabilities and domains. CONCLUSIONS: Our experience illustrates that approaches to measuring PCMH should be driven by the measures' intended use(s) and users, and that a one-size-fits-all approach may not be appropriate. Rather than promoting the BCBSM PCMH measure as the gold standard, our study highlights the challenges, strengths, and limitations of developing a standardized approach to PCMH measurement.

Lower rates of preterm birth in women of Arab ancestry: an epidemiologic paradox--Michigan, 1993-2002.

OBJECTIVE: Preterm birth (PTB), <37 weeks gestation, occurs in 12.1% of live births annually and is associated with significant morbidity and mortality in the United States. Racial/ethnic subgroups are disproportionately affected by PTB. Michigan is home to one of the largest Arab-American communities in the country; however, little is known about PTB in this population. This study examined the maternal demographic profile and risk factors of preterm birth (PTB) among foreign-born and US-born women of Arab ancestry relative to US-born Whites in Michigan. METHODS: Using Michigan Vital Statistics data, we examined correlates of PTB for primiparous U.S.-born white (n = 205,749), U.S.-born Arab (n=1,697), and foreign-born Arab (n=5,997) women who had had a live-born singleton infant during 1993-2002. We examined variables commonly reported to be associated with PTB, including mother's age and education; insurance type; marital status of parents; receipt of prenatal care; mother's chronic hypertension, diabetes, and tobacco use; and infant sex. RESULTS: Foreign-born Arabs are less educated and more likely to be on Medicaid, and they receive less prenatal care than US-born Whites. Prevalence of PTB was 8.5, 8.0, and 7.5% for US-born Whites, US-born Arabs, and foreign-born Arabs, respectively. Pregnancy-related hypertension was the only predictor of PTB that these three groups had in common: Adjusted Odds Ratio (AOR)=2.1 (95% Confidence Interval (CI)=1.99, 2.21), AOR=2.6 (95% CI=1.24, 5.51), and AOR=2.6 (95% CI=1.55, 4.31) for US-born whites, US-born Arabs, and foreign-born Arabs, respectively. CONCLUSIONS: Foreign-born Arab women in Michigan have a higher-risk maternal demographic profile than that of their US-born white counterparts; however, their prevalence of PTB is lower, which is consistent with the epidemiologic paradox reported among foreign-born Hispanic women.