The Transforming Outcomes for Patients Through Medical Home Evaluation and reDesign (TOPMED) Cluster Randomized Controlled Trial Cost and Utilization Results

Background: Primary CareMedical Home (PCMH) redesign efforts are intended to enhance primary care's ability to improve population health and well-being. PCMH transformation that is focused on "high-value elements"(HVEs) for cost and utilization may improve effectiveness. Objectives: The objective of this study was to determine if a focus on achieving HVEs extracted from successful primary care transformation models would reduce cost and utilization as compared with a focus on achieving PCMH quality improvement goals. Research Design: A stratified, cluster randomized controlled trial with 2 arms. All practices received equal financial incentives, health information technology support, and in-person practice facilitation. Analyses consisted of multivariable modeling, adjusting for the cluster, with difference-in-difference results. Subjects: Eight primary care clinics that were engaged in PCMH reform. Measures: We examined: (1) total claims payments; (2) emergency department (ED) visits; and (3) hospitalizations among patients during baseline and intervention years. Results: In total, 16,099 patients met the inclusion criteria. Intervention clinics had significantly lower baseline ED visits (P=0.02) and claims paid (P=0.01). Difference-in-difference showed a decrease in ED visits greater in control than intervention (ED per 1000 patients: +56; 95% confidence interval: +96, +15) with a trend towards decreased hospitalizations in intervention (-15; 95% confidence interval: -52, +21). Costs were not different. In modeling monthly outcome means, the generalized linear mixed model showed significant differences for hospitalizations during the intervention year (P=0.03). Discussion: The trial had a trend of decreasing hospitalizations, increased ED visits, and no change in costs in the HVE versus quality improvement arms.