Adherence to guideline-recommended care for patients with chronic disease: the impacts of registration with a regular provider, enrollment in a patient-entered medical home, and multiple comorbidities

Following guideline-recommended processes of care is considered an indicator of quality of care. Patient-centered medical homes (PCMH) have been promoted as an organizational innovation that can improve quality, notably among patients with one or more chronic conditions who may be expected to benefit from improved coordination of care. Key characteristics of the PCMH model include multidisciplinary team-based practice, patient enrollment, and financial incentives for providers.

We evaluated the effects of Quebec’s PCMH model, Family Medicine Groups (FMGs), on adherence to guideline-recommended processes of care for patients with three prevalent chronic conditions: diabetes, chronic obstructive pulmonary disease, and heart failure. In the Quebec context, the absence of pay-for-performance-style initiatives enabled us to separate the contributions of team-based practice and patient enrollment from the influence of financial incentives. We also considered the appropriateness and feasibility of guideline adherence among patients with more complicated morbidity, comparing diabetic patients with concordant comorbidities (hypertension or high cholesterol) to those with discordant comorbidities (e.g., arthritis, asthma, depression).

We use insurance billing records from Quebec’s provincial insurer which covers 96% of the province’s population. The data include patient demographics, all physician services, hospital admissions, ED use, and prescriptions filled. We chose the index conditions of diabetes, COPD, and heart failure because in these data we are able to observe adherence to relevant guidelines which specify specialist consultations, taking certain prescription drugs, or screening tests.  Our sample includes 135,119 patients, of whom 20,228 enroll in FMGs and 114,891 are enrolled in traditional primary care practice. Patients are followed over a period of 7 years, 2 years prior to enrollment and 5 years after. We constructed indicators of adherence to specific guidelines for each chronic disease, as well as composite indicators to compare patterns for prescription drug- and visit-related guidelines across conditions. We use propensity score weighting to address selection bias and difference-in-differences models to estimate the effects of FMGs on adherence to clinical guidelines. For diabetic patients, we describe how adherence to guidelines changes after enrollment with a family physician, and how that relationship is modified as a function of the level and type of multimorbidity.

Our results indicate that all groups of patients experience small increases in adherence rates after enrollment with a family physician.  This increase is not modified by level and type of multimorbidity for diabetic patients.  There is also generally no evidence that FMGs have a positive effect on adherence to clinical guidelines. In fact, patients enrolled in FMGs improve adherence to prescription drug recommendations less than patients registered with a non-FMG physician (DD [95% CI] = - 2.83 % [-4.08 %, - 1.58 %]). There is no evidence of an FMG effect on adherence to guidelines related to consultations: (DD [95% CI] = - 0.24 % [- 2.24 %; 1.75 %]). We find no evidence that FMGs led to increased adherence to the clinical recommendations evaluated in our study. Our data suggest that enrollment with a physician may improve adherence regardless of the organizational model.