RESUMO
BACKGROUND: Methodological differences between evaluations of medical home adoption might complicate readers' ability to draw conclusions across studies. OBJECTIVES: To study whether associations between medical home adoption and patient care are affected by methodological choices. DESIGN, SETTING, AND SUBJECTS: Among 71 practices participating in the Pennsylvania Chronic Care Initiative (a medical home pilot), we estimated cross-sectional and longitudinal associations between 4 definitions of "medical home adoption" [National Committee on Quality Assurance (NCQA) recognition in year 3, Medical Home Index scores at baseline and 3, and within-practice changes in Medical Home Index scores between baseline and year 3] and utilization and quality. MEASUREMENTS: Six utilization and 6 quality measures. RESULTS: In cross-sectional analyses at year 3, NCQA recognition was associated with higher rates of nephropathy monitoring (7.23 percentage points; confidence interval, 0.45-14.02), breast cancer screening (7.48; 2.11-12.86), and colorectal cancer screening (8.43; 2.44-14.42). In longitudinal analyses, NCQA recognition was associated with increases in hospitalization rates (2.75 per 1000 patient-months; 0.52-4.98). In baseline cross-sectional analyses, higher Medical Home Index scores were associated with fewer ambulatory care-sensitive hospitalizations (-0.61 per 1000 patient per month; -1.11 to -0.11), all-cause emergency department visits (-6.80; -12.28 to -1.32), and ambulatory care-sensitive emergency department visits (-5.60; 10.32 to -0.88). There were no statistically significant associations between any other measure of medical home adoption and quality or utilization. CONCLUSIONS: The findings of medical home evaluations are sensitive to methodological choices. Meta-analyses, narrative reviews, and other syntheses of medical home studies should consider subdividing their findings by analytic approach.
Assuntos
Hospitalização/estatística & dados numéricos , Assistência Centrada no Paciente/estatística & dados numéricos , Assistência Centrada no Paciente/normas , Garantia da Qualidade dos Cuidados de Saúde/métodos , Assistência Ambulatorial/estatística & dados numéricos , Estudos Transversais , Serviço Hospitalar de Emergência/estatística & dados numéricos , Humanos , Estudos Longitudinais , PennsylvaniaRESUMO
OBJECTIVE: To study the association between hospital nurse staffing and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores. DATA SOURCES: State hospital financial and utilization reports, Healthcare Cost and Utilization Project State Inpatient Databases, HCAHPS survey, and American Hospital Association Annual Survey of Hospitals. STUDY DESIGN: Retrospective study using cross-sectional and longitudinal models to estimate the effect of nurse staffing levels and skill mix on seven HCAHPS measures. DATA COLLECTION/EXTRACTION METHODS: Hospital-level data measuring nurse staffing, patient experience, and hospital characteristics from 2009 to 2011 for 341 hospitals (977 hospital years) in California, Maryland, and Nevada. PRINCIPAL FINDINGS: Nurse staffing level (i.e., number of licensed practical nurses and registered nurses per 1,000 inpatient days) was significantly and positively associated with all seven HCAHPS measures in cross-sectional models and three of seven measures in longitudinal models. Nursing skill mix (i.e., percentage of all staff who are registered nurses) was significantly and negatively associated with scores on one measure in cross-sectional models and none in longitudinal models. CONCLUSIONS: After controlling for unobserved hospital characteristics, the positive influences of increased nurse staffing levels and skill mix were relatively small in size and limited to a few measures of patients' inpatient experience.