diabetes is the seventh leading cause of death in the u.s . and is widely considered a forthcoming global epidemic ( 1 ) .
it is more prevalent in certain vulnerable subgroups , particularly in african americans and latinos and those of lower socioeconomic status ( ses ) . additionally , there are significant racial / ethnic and ses disparities in diabetes care , management , and health outcomes ( 2 ) .
african americans and latinos , for example , have two to four times the rate of related renal disease , blindness , amputation , and amputation - related mortality compared with non - hispanic whites ( 3 ) .
disparities in diabetes outcomes are the product of multiple interacting factors , including individual , family , neighborhood , and community factors .
disparities in outcomes are also likely due to poorer - quality diabetes care received by vulnerable populations . as evidence of this
, the agency for healthcare research and quality has reported disparities of up to 20% in the receipt of preventive services for diabetes across race / ethnicity , income , and education groups ( 4 ) .
other studies have found that differences in diabetes care vary according to characteristics of primary care practices ( 5,6 ) .
individuals with diabetes receive the majority of their care in a primary care setting ( 7 ) .
thus it is imperative to understand health care factors that influence care in this setting , especially with the advent of changes to the primary care environment .
a medical home reflects an accessible , ongoing source of primary care that delivers or coordinates the majority of a patient s care .
medical - home definitions vary considerably across organizations , but there is consensus on at least four key features : first - contact care , continuity , comprehensiveness , and coordination ( 8,9 )
. other features sometimes include aspects of community - oriented care , family - centered care , and cultural competence .
the evidence cited to promote the medical home is derived almost wholly from the literature on primary care delivery ( 10 ) .
there is a substantive literature demonstrating the benefits of primary care to equity and efficiency and in health care ( 11 ) , and primary care is a cornerstone of health system efforts to reduce disparities ( 12 ) .
most of these studies assess the general population in need of preventive care , not those from vulnerable populations who have chronic conditions , such as diabetes .
thus we undertook this study to evaluate whether patient - reported indicators of care that are consistent with the medical - home model are associated with patient - reported receipt of recommended preventive diabetes services for adults considered vulnerable .
we hypothesized that patients with physicians who are reported to function more like a medical home will be more likely to report better preventive diabetes care ( including both recommended screening and patient education ) .
the data for this analysis are from a cross - sectional survey of patients aged 1963 years with type 2 diabetes and medicaid ( medi - cal ) health insurance in los angeles county .
first , primary care physicians ( i.e. , family medicine , internal medicine , and general practice ) were identified through publicly available network data for one of the largest medicaid plans in the county . from a list of 471 eligible physicians ,
they were randomly drawn and recruited until we reached our target sample size of 100 ( n = 104 ; 75% response rate ) .
random selection of physicians was accomplished on a rolling basis through a random cell selection algorithm in our spreadsheet software .
second , all physicians were asked to refer a minimum of 10 patients with type 2 diabetes who met the study criteria  aged 18 to 63 years and having medi - cal health insurance  using one of two methods : retrospective or prospective referrals . the retrospective referral method involved referring all eligible patients who had visited the physician , working from most recent up to the past 6 months . before referral , the offices called the patients using a study - provided script that offered a chance to opt out of being referred .
physicians referred all eligible patients visiting the office for up to the next 6 months or until a minimum of 10 referrals were made . in this case , a flier was provided to each patient about the study by the office staff , allowing the patient an opportunity to opt out of being referred .
both methods received an institutional review board  approved waiver of health insurance portability and accountability act authorization by the university of southern california office for the protection of research subjects . in both approaches , the potential for physicians to hand - select patients is reduced by the requirement that all patients meeting the criteria be referred .
a total of 1.8% of patients opted out of being referred , accounted for in the study response rate . from the referrals , we then randomly selected patients ( again on a rolling basis using a random cell selection algorithm in our spreadsheet software ) until we reached a goal of 5 patients per physician .
there were no significant differences in opt - out rates , response rates , or demographics between referral methods .
we used the primary care assessment tools ( pcat ) adult expanded to assess patient - reported indicators of medical - home quality ( 13,14 ) .
the pcat has good reliability and validity and consists of 96 questions that evaluate 7 features : 1 ) first - contact care , 2 ) continuity of care , 3 ) comprehensiveness , 4 ) coordination , 5 ) community - oriented care , 6 ) family - centered care , and 7 ) cultural competence .
each question is scored using a likert - type response scale as follows :  definitely not 
( 1 point ) ,  probably not  ( 2 points ) ,  probably  ( 3 points ) , and  definitely  ( 4 points ) . missing values in any of the pcat items
were assigned the average score of 2.5 . a total medical - home score averages the responses across all of the features .
the first four features have two subcomponents each : one based on the structure indicating the capacity to practice as a medical home and one based on the process indicating actual care delivery .
first - contact care refers to the concept that care is available and first sought from the medical home when a new health or medical need arises , reflecting that services are accessible ( structure ) and utilization occurs when a need arises ( process ) .
continuity of care refers to the use of a regular source of care over time , including tracking a defined population ( structure ) and the perceived ongoing patient - provider relationship ( process ) .
comprehensiveness refers to the range of services offered ( structure ) and the recognition of problems and their appropriate delivery ( process ) .
coordination refers to arranging for and following up on specialist health services , including effective information systems ( structure ) and use of that information as it bears on current needs for integration of all patient care ( process ) .
these include community - oriented care that refers to the concept that all primary care is delivered in the context of the community , such that providers recognize the common health needs of the community and strive to be aware of , and oriented to , providing services to address those needs .
family - centered care refers to the recognition of the family as a major participant in the diagnosis , treatment , and recovery of patients .
providers must be aware of the family context , learn about the family history of illness and health risks , and work to incorporate the family as needed into care .
cultural competence refers to provision of care that respects the language , beliefs , and attitudes of people as they influence health .
providers should be prepared to address language barriers and account for cultural beliefs and practices in working to promote health .
we asked patients when they had their last hba1c test (  when was your last hba1c test ?
this is a test that measures your average blood sugar level over the past 2 or 3 months .  ) and dilated eye exam (  when was the last time that you had an eye exam during which the doctor put drops in your eyes that made your pupils large ?
you may have been unable to see enough to drive or had to wear dark glasses afterward .  ) .
responses were dichotomized at 6 months for last hba1c test and at 1 year for last eye exam .
patients were asked if their physician gave them a plan to manage their own care at home , if they have had diabetes education outside of their usual doctor or nurse visits , and whether they had met with a dietitian ( defined for them as  a person who teaches others what foods to eat to help you manage diabetes  ) .
patients were asked if in the past 6 months their physician had discussed any of nine topics with them : when and how to take insulin or diabetes pills , when and how to check blood glucose , how to time their meals , what to eat , how to check and care for their feet , how to increase their physical activity , how to make changes in medications , how to deal with the emotional demands of diabetes , and where to find community resources to help with diabetes .
responses to each item were dichotomous ( yes / no ) and are reported in this study as the total number of items discussed ( 0 to 9 ) .
descriptive statistics were first obtained for demographic characteristics , including race , education , employment , marital status , self - reported health status , medical - home scores for each feature and total score , as well as diabetes care and diabetes education received .
next , bivariate analysis was conducted to examine the differences in medical - home scores and demographics among different diabetes care and diabetes education received . to test the significance of differences , t tests or anova
finally , logistic regression of total medical - home score on diabetes care and linear regression of total medical - home score on diabetes education received were conducted , controlling for demographics .
seven people had one or more missing values in the study covariates and were dropped in the regression analyses .
the data for this analysis are from a cross - sectional survey of patients aged 1963 years with type 2 diabetes and medicaid ( medi - cal ) health insurance in los angeles county .
first , primary care physicians ( i.e. , family medicine , internal medicine , and general practice ) were identified through publicly available network data for one of the largest medicaid plans in the county . from a list of 471 eligible physicians ,
they were randomly drawn and recruited until we reached our target sample size of 100 ( n = 104 ; 75% response rate ) .
random selection of physicians was accomplished on a rolling basis through a random cell selection algorithm in our spreadsheet software .
second , all physicians were asked to refer a minimum of 10 patients with type 2 diabetes who met the study criteria  aged 18 to 63 years and having medi - cal health insurance  using one of two methods : retrospective or prospective referrals . the retrospective referral method involved referring all eligible patients who had visited the physician , working from most recent up to the past 6 months . before referral , the offices called the patients using a study - provided script that offered a chance to opt out of being referred .
physicians referred all eligible patients visiting the office for up to the next 6 months or until a minimum of 10 referrals were made . in this case , a flier was provided to each patient about the study by the office staff , allowing the patient an opportunity to opt out of being referred .
both methods received an institutional review board  approved waiver of health insurance portability and accountability act authorization by the university of southern california office for the protection of research subjects . in both approaches , the potential for physicians to hand - select patients is reduced by the requirement that all patients meeting the criteria be referred .
a total of 1.8% of patients opted out of being referred , accounted for in the study response rate . from the referrals , we then randomly selected patients ( again on a rolling basis using a random cell selection algorithm in our spreadsheet software ) until we reached a goal of 5 patients per physician .
there were no significant differences in opt - out rates , response rates , or demographics between referral methods .
we used the primary care assessment tools ( pcat ) adult expanded to assess patient - reported indicators of medical - home quality ( 13,14 ) .
the pcat has good reliability and validity and consists of 96 questions that evaluate 7 features : 1 ) first - contact care , 2 ) continuity of care , 3 ) comprehensiveness , 4 ) coordination , 5 ) community - oriented care , 6 ) family - centered care , and 7 ) cultural competence .
each question is scored using a likert - type response scale as follows :  definitely not 
( 1 point ) ,  probably not  ( 2 points ) ,  probably  ( 3 points ) , and  definitely  ( 4 points ) . missing values in any of the pcat items were assigned the average score of 2.5 . a total medical - home score averages the responses across all of the features .
the first four features have two subcomponents each : one based on the structure indicating the capacity to practice as a medical home and one based on the process indicating actual care delivery .
first - contact care refers to the concept that care is available and first sought from the medical home when a new health or medical need arises , reflecting that services are accessible ( structure ) and utilization occurs when a need arises ( process ) .
continuity of care refers to the use of a regular source of care over time , including tracking a defined population ( structure ) and the perceived ongoing patient - provider relationship ( process ) .
comprehensiveness refers to the range of services offered ( structure ) and the recognition of problems and their appropriate delivery ( process ) .
coordination refers to arranging for and following up on specialist health services , including effective information systems ( structure ) and use of that information as it bears on current needs for integration of all patient care ( process ) .
these include community - oriented care that refers to the concept that all primary care is delivered in the context of the community , such that providers recognize the common health needs of the community and strive to be aware of , and oriented to , providing services to address those needs .
family - centered care refers to the recognition of the family as a major participant in the diagnosis , treatment , and recovery of patients .
providers must be aware of the family context , learn about the family history of illness and health risks , and work to incorporate the family as needed into care .
cultural competence refers to provision of care that respects the language , beliefs , and attitudes of people as they influence health .
providers should be prepared to address language barriers and account for cultural beliefs and practices in working to promote health .
we asked patients when they had their last hba1c test (  when was your last hba1c test ?
this is a test that measures your average blood sugar level over the past 2 or 3 months .  ) and dilated eye exam (  when was the last time that you had an eye exam during which the doctor put drops in your eyes that made your pupils large ? you may have been unable to see enough to drive or had to wear dark glasses afterward .
responses were dichotomized at 6 months for last hba1c test and at 1 year for last eye exam .
patients were asked if their physician gave them a plan to manage their own care at home , if they have had diabetes education outside of their usual doctor or nurse visits , and whether they had met with a dietitian ( defined for them as  a person who teaches others what foods to eat to help you manage diabetes  ) .
patients were asked if in the past 6 months their physician had discussed any of nine topics with them : when and how to take insulin or diabetes pills , when and how to check blood glucose , how to time their meals , what to eat , how to check and care for their feet , how to increase their physical activity , how to make changes in medications , how to deal with the emotional demands of diabetes , and where to find community resources to help with diabetes . responses to each item
were dichotomous ( yes / no ) and are reported in this study as the total number of items discussed ( 0 to 9 ) .
we used the primary care assessment tools ( pcat ) adult expanded to assess patient - reported indicators of medical - home quality ( 13,14 ) .
the pcat has good reliability and validity and consists of 96 questions that evaluate 7 features : 1 ) first - contact care , 2 ) continuity of care , 3 ) comprehensiveness , 4 ) coordination , 5 ) community - oriented care , 6 ) family - centered care , and 7 ) cultural competence .
each question is scored using a likert - type response scale as follows :  definitely not 
( 1 point ) ,  probably not  ( 2 points ) ,  probably  ( 3 points ) , and  definitely  ( 4 points ) . missing values in any of the pcat items were assigned the average score of 2.5 . a total medical - home score averages the responses across all of the features .
the first four features have two subcomponents each : one based on the structure indicating the capacity to practice as a medical home and one based on the process indicating actual care delivery .
first - contact care refers to the concept that care is available and first sought from the medical home when a new health or medical need arises , reflecting that services are accessible ( structure ) and utilization occurs when a need arises ( process ) .
continuity of care refers to the use of a regular source of care over time , including tracking a defined population ( structure ) and the perceived ongoing patient - provider relationship ( process ) .
comprehensiveness refers to the range of services offered ( structure ) and the recognition of problems and their appropriate delivery ( process ) .
coordination refers to arranging for and following up on specialist health services , including effective information systems ( structure ) and use of that information as it bears on current needs for integration of all patient care ( process ) .
these include community - oriented care that refers to the concept that all primary care is delivered in the context of the community , such that providers recognize the common health needs of the community and strive to be aware of , and oriented to , providing services to address those needs .
family - centered care refers to the recognition of the family as a major participant in the diagnosis , treatment , and recovery of patients .
providers must be aware of the family context , learn about the family history of illness and health risks , and work to incorporate the family as needed into care .
cultural competence refers to provision of care that respects the language , beliefs , and attitudes of people as they influence health .
providers should be prepared to address language barriers and account for cultural beliefs and practices in working to promote health .
we asked patients when they had their last hba1c test (  when was your last hba1c test ? this is a test that measures your average blood sugar level over the past 2 or 3 months .  ) and dilated eye exam (  when was the last time that you had an eye exam during which the doctor put drops in your eyes that made your pupils large ? you may have been unable to see enough to drive or had to wear dark glasses afterward .  ) .
responses were dichotomized at 6 months for last hba1c test and at 1 year for last eye exam .
patients were asked if their physician gave them a plan to manage their own care at home , if they have had diabetes education outside of their usual doctor or nurse visits , and whether they had met with a dietitian ( defined for them as  a person who teaches others what foods to eat to help you manage diabetes  ) .
patients were asked if in the past 6 months their physician had discussed any of nine topics with them : when and how to take insulin or diabetes pills , when and how to check blood glucose , how to time their meals , what to eat , how to check and care for their feet , how to increase their physical activity , how to make changes in medications , how to deal with the emotional demands of diabetes , and where to find community resources to help with diabetes .
responses to each item were dichotomous ( yes / no ) and are reported in this study as the total number of items discussed ( 0 to 9 ) .
descriptive statistics were first obtained for demographic characteristics , including race , education , employment , marital status , self - reported health status , medical - home scores for each feature and total score , as well as diabetes care and diabetes education received .
next , bivariate analysis was conducted to examine the differences in medical - home scores and demographics among different diabetes care and diabetes education received . to test the significance of differences , t tests or anova
finally , logistic regression of total medical - home score on diabetes care and linear regression of total medical - home score on diabetes education received were conducted , controlling for demographics .
seven people had one or more missing values in the study covariates and were dropped in the regression analyses .
a total of 540 patient interviews were completed by telephone in spanish ( 55.3% ) , english ( 43.7% ) , and mandarin or armenian ( 1% ) . the most conservative response rate ( 56.9% ) is calculated as the total completed patient interviews ( n = 540 ) out of all patients sampled ( n = 949 ) .
approximately one - fifth of all patients sampled had an incorrect phone number and address ( n = 165 ) and were not considered usable . the response rate among just the usable listings ( n = 784 ) was 68.9% . among patients that we reached and spoke with ( n = 635 ) , the response rate was 85.0% .
table 1 provides a listing of the descriptive details of the 540 patients surveyed . of note ,
77% were hispanic , 56% had less than a high school education , and 72% were unemployed .
medical - home performance measurements yielded an average score of 2.85  0.29 ( based on a 14 scale , with 4 representing the highest level of care ) .
the lowest score was for community orientation ( 2.10  0.61 ) and the highest for first - contact utilization ( 3.81  0.40 )
. with regards to diabetes care , a majority ( 83% ) reported having their hba1c level measured within the past 6 months , while only 58% recollected having had a dilated ophthalmologic examination within the past year .
descriptive statistics ( n = 540 ) for medical - home measures , all 88 , 99 , and missing values were coded as 2.5 . for last hba1c test
, 31 observations of  do nt know  were coded as 6 months . for last eye exam
, 14 observations of  do nt know  were coded as 1 year . for diabetes education , 
education score equals the number saying  yes  to the nine education items with minimum of 0 and maximum of 9 .
e / vg / g , excellent / very good / good . table 2 provides a bivariate comparison between measures of diabetes care and medical - home performance .
higher medical - home performance was reported among patients who had received more timely and thorough diabetes care .
for example , the first - contact access feature score was higher among patients who had an hba1c test in the past 6 months compared with those who had the test longer ago ( 2.38 vs. 2.25 ; p < 0.05 ) and an eye exam in the past year compared with an eye exam longer ago ( 2.39 vs. 2.31 ; p < 0.05 ) .
similar patterns were found for all measures of medical - home performance except the comprehensiveness - services available feature .
interestingly , none of the sociodemographic variables , except health status , were found to be associated with any of the diabetes care measures .
bivariate analysis of medical - home measures , covariates , and diabetes care mean medical - home score ranges from 14 , with 4 = best .
. table 3 shows the relationship between overall medical - home performance and the diabetes care measures after adjustment for sociodemographics and health status .
we show the total medical - home performance score that summarizes all of the features here ( rather than the individual features ) because they were nearly all associated with the diabetes care measures in table 2 .
this table shows that total medical - home score ( on a scale from 1 to 4 ) is associated with improvements in each of the diabetes care measures .
for example , a 1-point increase in total medical - home performance is associated with 4.53 higher odds of reporting they had an hba1c test in the past 6 months and 1.88 higher odds of having an eye exam in the past year .
also , a 1-point increase in total medical - home performance was associated with a 5.66-point increase in our tally of diabetes education items received ( on a scale of 19 items ) .
regressions of diabetes care on medical - home total score controlling for demographics data are odds ratio / coefficient ( 95% ci ) .
the concept of a patient - centered medical home is becoming an accepted model for the delivery and coordination of care for patients in primary care settings .
this study is one of the first to specifically target diabetes in relationship to medical - home performance .
diabetes is one of our greatest emerging health care problems , and it is particularly suited for this sort of analysis given the availability of clearly defined preventive care guidelines .
in addition , the treatment of diabetes involves engagement of patients regarding lifestyle behaviors , which may benefit from the ongoing patient - provider relationship and other features in the primary care medical home .
indeed , this study found that among individuals with medicaid insurance , there was a relationship between patient - reported indicators of the medical - home model and better patient - reported diabetes care . in bivariate analysis ,
medical - home features nearly across the board were associated with better diabetes care . when summarized as a total score in multivariate analysis ,
medical - home performance was more predictive of diabetes care than any sociodemographic measures in our analysis .
this is somewhat expected given that the study is limited to medicaid patients ( limiting heterogeneity ) , but this also provides evidence that medical - home performance may lead to improvements in patient - reported diabetes care , even in this lower ses population .
the overall pcat score reported by this population was slightly lower than generally found for privately insured patients in hmo settings ( 15 ) .
many projects have been developed to enhance primary care practices , and some may be adaptable to practices predominantly serving medicaid or otherwise low - ses patients .
one review identified more than 40 medical - home transformation projects nationwide , with 8 reporting measures of diabetes care or outcomes ( 16 ) .
absent randomized controlled trials , before and after data in these pilots suggested the potential for improvements in diabetes care , outcomes , and costs .
if medical - home performance as shown in this study is indeed important for patients with diabetes , then the challenge will be to enable more practices to adopt at least some of these features ( 17,18 ) .
second , the data were collected from an important and growing , but unique , population ( mostly hispanic medicaid - insured patients in los angeles ) , and so the results may not be fully generalized to other vulnerable groups .
third , features in the pcat to assess medical - home quality align closely , but not perfectly , with the other measures of medical home ( such as those by the national committee for quality assurance ) .
the national committee for quality assurance measures are different in that they are reported by physicians and include elements of reimbursement not included in the pcat
fourth , an element of endogeneity may exist in the results because the independent and dependent measures were reported by the same individual .
for example , an individual who has a positive outlook on their medical care in general may report positive responses on both medical - home quality and diabetes care . while we can not rule out this potential endogeneity , it is reduced by the use of more reporting measures ( e.g. , do you have to wait more than 30 min before you are seen by a doctor or nurse ? ) rather than rating measures that tend to be based on more evaluative or subjective satisfaction measures ( e.g. , how satisfied are you with the wait time to be seen ? ) .
lastly , the diabetes quality measures were obtained by patient self - report and thus may be neither accurate measures of either medical - home performance nor complete and objective measures of clinical care .
previous work suggests the level of concordance between patient self - report and medical record or administrative data are only fair ( 5565% ) , with patients tending to overreport ( rather than underreport ) diabetes services ( 1921 ) .
these data reflect the patient s understanding of their condition and their perceived health care needs and thus likely influence care - seeking behaviors ( 22 ) .
the findings should , however , be confirmed with medical record or administrative data , but even those sources are not considered fully accurate and unbiased ( 20,23 ) . despite these limitations , this study adds important evidence to the value of the primary care medical home for patients with chronic disease .
the study also adds to the literature on how patients perceive the medical - home model and its impact on perceptions of chronic disease care . in our analysis , features consistent with higher medical - home performance were related to improvements in patient - reported diabetes care measures .
this adds to the literature on how patients perceive the medical - home model and suggest that the results may be particularly important , given that this study was conducted among a medicaid ( low - ses ) population where the prevalence of diabetes is higher , the potential for poor outcomes is greater , and resources dedicated to primary care tend to be fewer .
 objectivethe patient - centered medical home has gained much traction . 
 little is known about the relationship between the model and specific health care processes for chronic diseases such as diabetes . 
 this study assesses the impact of features of a medical home on diabetes care.research design and methodsa cross - sectional survey of 540 patients with medicaid ( medi - cal ) health insurance and type 2 diabetes in los angeles county was performed . 
 the primary care assessment tools was used to measure seven features of medical - home performance.resultsthe response rate of the patient survey was 68.9% . 
 patient - reported medical - home performance averaged a score of 2.85  0.29 ( on a 14 scale , with 4 equaling the best care ) . 
 patients who received more timely and thorough diabetes care reported higher medical - home performance in every feature except for the comprehensiveness - services available . 
 for example , the first - contact access feature score was higher among patients who had an hba1c test in the past 6 months versus those who did not ( 2.38 vs. 2.25 ; p < 0.05 ) . before and after adjusting for sociodemographics and health status , 
 total medical - home performance was positively associated with each diabetes care measure . a 1-point increase in total medical - home score 
 was associated with 4.53 higher odds of an hba1c test in the past 6 months and 1.88 higher odds of an eye exam in the past year.conclusionsfeatures consistent with higher medical - home performance are associated with improvements in patient - reported diabetes care process measures , even in this low socioeconomic status setting . 
 the patient - centered medical - home model may help in caring for people with type 2 diabetes . 
Introduction
Research Design and Methods
Study Sample
Measures
Medical-Home Total Score and Its Features
Diabetes Care Received
Diabetes Education Received
Analysis
Results
Conclusions