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Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet].

The patient-centred medical home: a systematic review

GL Jackson, BJ Powers, R Chatterjee, J Prvu Bettger, AR Kemper, V Hasselblad, RJ Dolor, RJ Irvine, BL Heidenfelder, AS Kendrick, R Gray, and JW Williams.

Review published: 2013.

Link to full article: [Journal publisher]

CRD summary

The authors concluded that the patient-centred medical home could improve the experiences of patients and staff, but more evidence was needed to determine whether these improvements translated into improved clinical outcomes or economic benefit. The review process was generally satisfactory, but the data synthesis was not always easy to consolidate, making it difficult to comment on reliability.

Authors' objectives

To assess the effects of a patient-centred medical home, as a care model, on patient and staff experiences, the process of care, and the clinical and economic outcomes.

Searching

PubMed, Cochrane Database of Systematic Reviews and CINAHL were searched through to June 2012 for peer-reviewed articles in English. The search strategy was reported. Citations from key primary and review articles were manually searched.

Study selection

Eligible for inclusion were randomised controlled trials (RCTs) or comparative longitudinal observational studies. Eligible studies had to assess the effects of the patient-centred medical home (as defined by the Agency for Healthcare Research and Quality) in primary care for adults or children with multiple conditions. Interventions that did not use the term "medical home", but met the definition were categorised as "functional patient-centred medical home". The outcomes of interest were patient and staff experiences, the process of care, and clinical and economic outcomes. Follow-up had to be at least six months.

Most studies were of older adults, with multiple chronic conditions, in the USA. Study outcomes and the measures used varied widely. With the exception of one study, all compared the patient-centred medical home with usual care.

Two reviewers independently screened studies for inclusion. Disagreements were resolved through discussion.

Assessment of study quality

The risk of bias in each study was assessed by one reviewer and checked by a second reviewer, using Agency for Healthcare Research and Quality (AHRQ) criteria. Studies were rated as being good, fair, or poor quality.

The strength of the evidence for effectiveness outcomes was assessed, using AHRQ guidelines, which cover the risk of bias, consistency, directness, and precision of the results. Two reviewers rated outcomes as high, moderate, or low strength of evidence, or insufficient, where a decision was not possible.

Data extraction

The numbers of hospitalisations and emergency department visits were extracted from RCTs to calculate risk ratios and 95% confidence intervals. Risk differences or standardised mean differences were calculated for other outcomes, along with 95% confidence intervals.

One reviewer extracted the outcome data and a second reviewer checked them for accuracy. Disagreements were resolved through consensus or by referral to a third reviewer.

Methods of synthesis

A random-effects model was used to calculate summary estimates of effect from RCTs for hospitalisations and emergency department visits. For other outcomes, the authors reported a narrative synthesis and presented the median and range of effect sizes.

Results of the review

Nineteen comparative studies were included in the review; nine were RCTs, one of which had a crossover design, (46,559 patients) and 10 were observational studies (900,780 patients). Five studies were good quality, 13 were fair, and one was poor. Follow-up ranged from six months to 5.5 years. Seven studies explicitly evaluated the patient-centred medical home and 12 evaluated functional patient-centred medical home interventions.

Patient and staff experiences: Moderate strength evidence suggested that the patient-centred medical home was associated with small improvements in patient experiences (effect size median 0.27, range -0.36 to 0.42, five RCTs; 0.13, three observational studies). There was low strength evidence showing small-to-moderate positive effects from the patient-centred medical home on staff experiences (effect size median 0.18, range 0.14 to 0.22, two RCTs; 0.49, range 0.32 to 0.61, one observational study).

Process of care: There was moderate strength of evidence showing small-to-moderate positive effects on preventive services (RD median 1.3%, range -0.4 to 7.7, three RCTs; 14.2%, range 5.6 to 20.6, three observational studies). There was insufficient evidence on chronic illness care services (three RCTs; three observational studies).

Clinical outcomes: There was insufficient evidence on clinical outcomes (three RCTs; four observational studies). The patient-centred medical home did not statistically significantly affect admissions (RR 0.96, 95% CI 0.84 to 1.10), but there was a small reduction in emergency department visits (RR 0.81, 95% CI 0.67 to 0.98); five RCTs.

No studies reported the unintended consequences and other harms.

Cost information

With the exception of one sub-analysis, no studies reported statistically significant cost savings with the patient-centred medical home at six to 24 months follow-up. One good quality trial and one fair quality observational study reported higher total costs with the patient-centred medical home.

Authors' conclusions

The patient-centred medical home could improve the experiences of patients and staff, but more evidence was needed to determine whether these improvements translated into improved clinical outcomes or economic benefit.

CRD commentary

The review question and supporting criteria were clearly stated. Three electronic databases were searched, but this was restricted to peer-reviewed studies in English and potentially relevant data may have been missed. Each stage of the review was performed in duplicate, reducing the potential for reviewer error and bias. Study quality was assessed using appropriate criteria, which indicated that the studies were generally of fair quality.

The authors acknowledged the wide variability in the patient-centred medical home interventions, outcomes, and study populations. They went some way towards accounting for study variability, and appropriately reported the results separately for different study designs. It was unclear whether combining the studies was appropriate, and the results were not always easy to follow.

The authors’ conclusions were fairly conservative and they acknowledged that the evidence on the clinical outcomes was insufficient and should be considered preliminary. With the exception of possible missed studies, the review process was well conducted, but the results and synthesis were not always easy to consolidate, which makes it difficult to comment on the reliability of the findings.

Implications of the review for practice and research

Practice: The authors did not state any implications for practice.

Research: The authors stated that further research was needed to determine the benefits of the patient-centred medical home.

Funding

Funded by the Agency for Healthcare Research and Quality.

Bibliographic details

Jackson GL, Powers BJ, Chatterjee R, Prvu Bettger J, Kemper AR, Hasselblad V, Dolor RJ, Irvine RJ, Heidenfelder BL, Kendrick AS, Gray R, Williams JW. The patient-centred medical home: a systematic review. Annals of Internal Medicine 2013; 158(3): 169-178. [PubMed: 24779044]

Other publications of related interest

Agency for Healthcare Research and Quality. Closing the quality gap: revisiting the state of the science - series overview. Rockville, MD, USA: Agency for Healthcare Research and Quality. Evidence Report/Technology Assessment; 208. 2012.

Indexing Status

Subject indexing assigned by CRD

MeSH

Patient-Centered Care; Humans; Primary Health Care

AccessionNumber

12012055341

Database entry date

05/12/2012

Record Status

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.

CRD has determined that this article meets the DARE scientific quality criteria for a systematic review.

Copyright © 2014 University of York.

PMID: 24779044

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