The effectiveness of patient-centred medical home model versus standard primary care in chronic disease management: protocol for a systematic review and meta-analysis of randomised and non-randomised controlled trials

The health burden from non-communicable diseases including major depressive disorder, diabetes, stroke, ischaemic heart disease, chronic obstructive pulmonary disease (COPD), lung cancer, and musculoskeletal disorders has risen in recent decades [1]. Consequently, the growing burden of multiple chronic medical conditions (multimorbidity) presents significant challenges on health systems worldwide and emphasises the need to explore better strategies towards chronic disease management [2, 3]. Patients with multimorbidity have complex health care needs that are challenging to manage in primary care for a range of reasons [4, 5]. These patients often experience poor health-rated quality of life, physical, and mental health, as well as increased risk of mortality [6, 7]. Furthermore, multimorbidity is associated with an increased risk of hospitalisations and inappropriate polypharmacy [8, 9]. Interventions and strategies that improve the quality and performance of general practice could lead to better patient outcomes and yield significant reductions in avoidable health care utilisation and overall health care costs [4].

Health care systems in high-income countries typically focus on the ‘single-disease framework’, where the delivery of primary care for the management of multimorbidity is often fragmented, lacking integration, and continuity of care [10]. Paradoxically, primary care is ideally placed to facilitate coordinated and continuous care in the management and possibly prevention of chronic diseases [11]. Strategies for effective management and prevention of multimorbidity should include integrated, multidisciplinary team (MDT), and long-term chronic disease approaches to adequately address the complex care needs of these patients [12].

The patient-centred medical home (PCMH) care model, initially introduced as “medical home” by the American Academy of Paediatrics in 1967, has been considered to conceptually provide highest quality of primary care for patients with multimorbidity [13]. Although definitions vary and there have been calls for changes [14, 15], the PCMH model typically includes a general practitioner (GP) and MDT working together to provide coordinated and patient-centred care that promotes long-term patient engagement using a long-term chronic disease approach [15, 16]. There is a small but growing body of evidence including a systematic review published in 2013 [13] suggesting that the PCMH primary care model is more effective than standard care for improving clinical outcomes in patients [17, 18], quality of care [19, 20], and reducing hospital admissions [21, 22]. Although the previous review [13] provided a comprehensive synthesis of relevant studies on the effectiveness of PCMH model of care at the time, the authors included studies in patients with multimorbidity only, thereby studies in patients with single chronic disease were excluded and studies in non-primary care settings (tertiary care services) reporting results favouring the effectiveness of the PCMH [23, 24] which may have partially biased their overall positive results and conclusions. Further, additional studies evaluating the effectiveness of the PCMH care model have been published since [25‐27].

Guidelines released by the Royal Australian College of General Practitioners (RACGP) include a vision of equitable access to high-quality health care based on the PCMH [16]. Similarly, the Australian Medical Association (AMA) recognises the potential of the PCMH model of care to enable an integrated MDT approach for the management of multimorbidity [15]. Since the advocacy and implementation of the PCMH model of primary care are rapidly growing in Australia and worldwide [12, 13, 28], a current review is timely and warranted. Our searching of electronic databases and registries (PROSPERO, CDSR, JBI database for systematic reviews, and DARE) in December 2017 confirmed the absence of any newly completed or ongoing relevant systematic reviews. Therefore, the proposed systematic review described in this study protocol will aim to summarise the best available evidence on the effectiveness of PCMH models of primary care compared to standard care in chronic disease management.

The systematic review outlined in this protocol paper aims to identify, assess, and synthesise the best available evidence on the effectiveness of the PCMH model of primary care for chronic diseases management. We anticipate that the proposed systematic review will be the most comprehensive evidence summary to date and believe that the findings of our systematic review will provide the most conclusive evidence (high quality) [36] on the effectiveness of PCMH care model in chronic disease management. We expect that our findings will inform patients, primary care providers, and public health administrators and policy-makers on the benefits and risks of the PCMH model in chronic disease management in primary care.

The proposed review will provide reliable information on the benefits of the PCMH model such as improving quality of care, clinical outcomes, and reducing hospital and ED admissions [17, 19, 21]. This knowledge could potentially empower patients to take proactive action and work with their GP to better self-manage their chronic conditions [37]. Empowered patients are more likely to seek better quality of care from their GPs or shop for GPs providing PCMH care, where they can be partners and not just bystanders in making decisions about their health care management [38].

We anticipate that our findings will be useful to GPs and primary care providers also, which may lead to transformational organisational changes in their structures and practices. This may encourage primary care services to be efficient in better targeting of health services according to the needs of the local community [39]. Providers will also be informed about current practices that have adopted the core PCMH principles in providing coordinated care through MDT approaches which have resulted in improved job satisfaction, burnout rates, and patient-provider relationship [40, 41].

Finally, the proposed systematic review findings might help policy-makers and health ministries in understanding health and economic benefits associated with the PCMH model of care [42, 43]. This will help direct scarce health care resources towards improvements in general practice service delivery. In addition, we also believe that the findings of this review will impact current practice, policy, and implementation guidelines [28, 44], which might result in efficiency gains in health systems in Australia and possibly other similar countries.

In summary, the proposed systematic review aims to address existing knowledge gaps by providing the highest level of evidence on the effectiveness of PCMH in chronic disease management. We expect that our findings will better inform patients, primary care providers, and policy makers on the benefits and risks associated with the PCMH model of care. In addition, the proposed systematic review may provide perspectives in achieving efficiency gains in health systems and future research opportunities.