Medical home rating and quality of diabetes care in safety net clinics

Background: The patient-centered medical home (PCMH) is a promising model for improving quality of care among patients with chronic diseases such as diabetes.

Objective: This study examines whether medical home rating is associated with quality of diabetes care in safety net clinics.

Study Design: Cross-sectional study of 20 randomly selected clinics, stratified by state, from 65 clinics at baseline in a PCMH demonstration project in Colorado, Idaho, Massachusetts, Oregon, and Pennsylvania. Approximately 60 randomly selected patient charts per site were abstracted. Patient demographic information (age, gender, race/ethnicity, health insurance) and glycated hemoglobin (HbA1c) were abstracted. Clinic directors completed surveys to rate how well their clinic performs as a PCMH. Responses were scored with the Safety Net Medical Home Scale (SNMHS), which provides 0-100 scores for total PCMH score and six subscales: access and communication, patient registry/tracking, care management, test referral/tracking, quality improvement, and external coordination. We developed multivariate generalized estimating equation models accounting for clustering of patients within clinics. We modeled the odds of a patient HbA1c value <9.0%, once as a function of total PCMH score and covariates, and again as a function of PCMH subscales and covariates.

Population: Patients between the ages of 18 and 75 with a primary or secondary diagnosis of diabetes (ICD-9 code 250.xx) between June 1, 2008 and May 31, 2009.

Findings: To date, 14 of 20 clinics have completed chart abstraction, reflecting 856 patients. 27% were uninsured, 24% had Medicaid, and 9% were dually eligible for Medicare and Medicaid. Mean age was 53 years (SD=12). 54% were women, 21% were non-Hispanic Black, and 19% were Hispanic. Mean HbA1c in the study sample was 7.8% (SD=2.0%) and 78% of patients had an HbA1c <9.0%. Total PCMH score was not associated with HbA1c <9.0%. Among PCMH subscales, 10-point higher scores in test/referral tracking and quality improvement were associated with 0.77 (CI, 0.71-0.83) and 0.72 (CI, 0.52-1.00) odds of HbA1c <9.0%. 10-point higher scores in the access and communication subscale and the care management subscale were associated with 2.00 (CI, 1.69-2.36) and 1.24 (CI, 1.02-1.50) odds of HbA1c <9.0%.

Conclusions: Preliminary baseline results suggest that higher overall medical home rating is not associated with improved HbA1c control. However, certain features of the medical home, such as providing easy access and effective care management, may be particularly beneficial for diabetes care. Further study is warranted to understand what medical home interventions can increase quality of diabetes care.