Study: PCMH needs better evaluation tools

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Although the patient-centered medical home (PCMH) is a promising innovation, rigorous evaluations and comprehensive implementation analyses are needed to assess effectiveness and refine the model to meet stakeholders’ needs, according to an article in the February edition of the American Journal of Managed Care.

Deborah Peikes, PhD, from Mathematica Policy Research, and colleagues systematically reviewed current evidence on PCMH, which aims to reinvigorate primary care and achieve the triple aim of better quality, improved experience and lower costs.

Out of 498 studies published or disseminated from January 2000 to September 2010 on U.S.-based interventions, 14 evaluations of 12 interventions met the inclusion criteria: Tested a practice-level intervention with three or more of five key PCMH components and conducted a quantitative study of one of the triple aim outcomes or of healthcare professional experience.

The interventions most often cited to support the medical home can be viewed as precursors to the medical home. Evaluations of six of these interventions provided rigorous evidence on one or more outcomes. This evidence indicates some favorable effects on all three triple aim outcomes, a few unfavorable effects on costs and many inconclusive results.

“This review highlights opportunities to improve the evidence base on the PCMH going forward,” the authors wrote. They suggested:

Use of stronger evaluation designs and methods: Evaluators of PCMH interventions have a huge opportunity to fill the current knowledge gap and contribute to the ongoing learning on PCMH effectiveness. The challenge is to make sure the practices and patients in the intervention and comparison groups are comparable at baseline to distinguish effects of the medical home model from preexisting differences between the intervention and comparison groups. Evaluations also should use rigorous analytical methods, including adjusting analyses for clustering of patients within practices.

Conduct comprehensive implementation analyses: “We found that most evaluations did not report how the intervention was implemented,” they wrote. “While undertaking an implementation study requires additional expertise and resources, it adds tremendous value in identifying barriers and facilitators to improving outcomes, how findings might generalize to other contexts and ways to refine the model. Implementation evaluations can provide powerful insights on their own, as well as when combined with quantitative outcome studies (that is, a mixed-methods approach). A mixed-methods approach is particularly informative when evaluating the PCMH model.”

Follow outcomes for longer periods of time: Evaluations examined outcomes for one to three years, with most following patients for two years, according to the authors. “While most decision makers are eager to obtain results, given the dramatic changes many practices need to undergo to become medical homes, short-term results may be misleading.”

Improve reporting and documentation: Many evaluations were not documented well enough to assess the strength of their methods. To allow objective assessment of the evidence, evaluation results—even preliminary results or results from pilot studies—should be accompanied by a detailed description of the methods used.

Examine a core set of outcome measures and develop standardized measures of PCMH components: Estimating effects on a standard list of outcome measures would enable a meta-analysis of findings across different interventions. “Such an analysis can dramatically improve the power to detect effects compared with individual evaluations, which are often underpowered. The body of evidence would also be improved if researchers used detailed, standardized measures of PCMH components and processes,” the authors wrote.

“Findings from future evaluations will help guide the substantial efforts practices and payors invest to adopt the PCMH with the goal of achieving the triple aim outcomes,” the authors concluded.