FROM JAMA

The value of the patient-centered medical home model has become a little bit clearer thanks to results from a randomized clinical trial that showed improved outcomes and lower costs for high-risk children treated in the patient-centered medical home setting, although more work is needed to understand the broad implications.

The trial focused on high-risk children with chronic illness and measured a variety of outcomes for those receiving comprehensive care (105 patients) versus those receiving usual care (95 patients), with a secondary outcome of the trial focused on the cost to treat these patients. Results were published Dec. 23 in JAMA (2014;312:2640-8 [ doi:10.1001/jama.2014.16419 ]).

Comprehensive care was provided at the University of Texas, Houston High-Risk Children’s Clinic, which served as the medical home. It included treatment from primary care clinicians and specialists in the same clinic with multiple features to promote prompt, effective care. Usual care was provided locally in private offices or in the university general pediatrics clinic without modification.

In an intent-to-treat analysis, the rate of serious illness among children receiving comprehensive care was 10 per 100 child-years, compared with 22 for children receiving usual care (rate ratio, 0.45). Hospital and clinic costs for the comprehensive care group also were lower – $16,523 per child year, compared with $26,781 for the usual care group (cost ratio, 0.58).

Other outcomes that were improved for the comprehensive care group versus the usual care group were total serious illness (16 per 100 child-years vs. 44), emergency department visits (90 vs. 190), hospitalizations (69 vs. 131), number of days in the hospital (276 vs. 635), ICU admissions (9 vs. 26) and days in the ICU (28 vs. 103). However, deaths were not significantly reduced in the comprehensive care arm (2 per 100 child-years vs. 3; P = .40).

Researchers attributed cost savings in the comprehensive care group to lower hospital costs.

“The benefits and cost savings we identified with comprehensive care seem likely to be achievable only in high-risk populations treated in major academic centers with the subspecialists, resources, and clinician commitment to provide such care,” Dr. Ricardo A. Mosquera a pediatrician at the University of Texas in Houston, and his colleagues wrote. “These findings from a single site of selected patients with a limited number of clinicians require study in larger, broader populations before conclusion about generalizability to other settings can be reached.”

gtwachtman@frontlinemedcom.com

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