Our study found a beneficial relationship between numerous health outcomes and the medical home in children without special health care needs. Although some of the effect sizes were modest, the health care utilization outcomes (preventive visits, outpatient sick visits, and ED sick visits) were robust (~30%).
Children without special health care needs compose the majority of the pediatric population (>80% in this national dataset). The AAP has long promoted the medical home for all children,4
and the Affordable Care Act of 2009 promotes the patient-centered medical home; this study provides further evidence supporting these policies. Our findings are significant given that studies to date have focused primarily on CSHCN. Although some studies have included all children, it was unclear if the positive associations found were due solely to the effect of CSHCN in the study populations, or if they exist independent of CSHCN.12,30–41
Our findings suggest that the benefits of the medical home for children without special health care needs mirror those experienced by CSHCN.
Our study broadened the outcomes measures assessed. Previous studies have focused on clinical outcomes such as ED utilization5,6,32,34,37
The medical home concept, however, is explicitly designed to provide care for all aspects of a child’s health and well-being.1
We therefore selected health-promoting behavior outcomes previously demonstrated to be positively associated with child health.21,23–28
The presence of a medical home was associated with health-promoting behaviors such as family reading, sleep hygiene, helmet use, and decreased screen time. Although the effects are modest, the near-universal reach of health care for children suggests that there may be a significant public health impact. We believe that future studies examining the impact of the medical home should consider reporting similar health-promoting behaviors.
Our findings have several implications for public policy and the delivery of primary care. Our study supports previous findings which suggest that having a medical home may decrease unnecessary child health care utilization (eg, ED visits), leading to overall health care savings. Studies have estimated that care inappropriately received in the ED costs 2 to 3 times as much as the same care in the appropriate setting.42,43
A reduction in ED utilization for sick visits of close to 30% would therefore represent a significant cost savings. Furthermore, our data demonstrated that preadolescents, who are more likely to have inappropriate ED utilization than adolescents or adults,44
may benefit the most from having a medical home. Thus, although further studies are needed, promoting the medical home among children without special health care needs presents a promising avenue for additional cost savings and improved health.
Our findings are consistent with those among the CSHCN and entire pediatric populations that disparities exist in children’s access to medical homes. We found that non-white children without special health care needs were less likely to have a medical home than white children. In addition, we found gradients with respect to socioeconomic status measures such as household income and parental education. Given the associations demonstrated in our study between the medical home and beneficial health care utilization patterns, increasing access to the medical home for these families may yield downstream reductions in other health care disparities.
The study has a number of limitations. First, the operationalization of the definition of the medical home is not validated. Although the definition has been agreed upon,45
measurement of it has not, which has prevented establishment of a validated questionnaire and limits comparison between studies. As used in our study, the definition of the medical home did not capture the continuity component defined by the AAP.1
In addition, the presence of a medical home was measured from the family’s perspective; this operationalization is therefore different from the systems-centered approach as espoused by the National Committee for Quality Assurance.46
However, this operationalization has been used by previous investigators who have analyzed this national dataset.15
Second, the data may not reflect the promotion of the medical home that has occurred since 2003. We chose these data instead of the 2007 NSCH as the latter did not measure ED and outpatient sick visits. Our data are the most recent available for these key outcome measures, and we therefore believe that our findings remain relevant to current policy and practice. Additional studies using more recent data, such as the forthcoming 2011 NSCH, will be useful. Third, the data were collected by self-report and were not validated, with the exception of CSHCN status.14
Fourth, this was a cross-sectional study, and therefore we cannot determine causality. Finally, although results were adjusted to account for the racial and socioeconomic disparities discussed here, it is possible that there were other unmeasured differences between the populations that may account for some of the differences attributed to medical home status. Further prospective studies examining the causal relationships between the medical home and health outcomes in children without special health care needs are needed.