A challenge for the primary care medical home model (PCMH) is incorporating care from specialties. In this study, Elrashidi et al explored the impact of integrating a neurologist into the Mayo Clinic PCMH by comparing aspects of care delivered by the integrated neurologist with matched visits from the pre-integration time period. The integrated neurologist worked 0.6 FTE, had a staff of 3 FTE registered nurses, 3 clinical assistants, and a specified work plan — 3-4 scheduled patients per half day, in addition to curbsides, e-consults, follow-up, and additional acute same-day consults. Over a 12-month period of patient follow-up, patients seen by the integrated neurologist had fewer subsequent neurologist visits (0.62, p=0.001), EMGs (OR 0.64, p=0.009), and brain MRIs (0.60, p<0.001), but not total subsequent outpatient visits (0.92, p=0.21), ED visits (0.83, p=0.20), or hospitalizations (0.96, p=0.83) compared with the pre-integration visits. The integrated neurologist also did not lower the time to neurologist appointment (p=0.83), despite presumably reducing referrals because of curbsides and e-consults.
This is a provocative idea, but unfortunately the study has too many limitations to render a judgment on the effect of integrating neurologists into PCMHs. There are simply too many potential confounders relating to the study’s design. The major design limit is the evaluation of only one integrated neurologist. Potential confounders include differences in salaries, staff support, volumes of patients, time with patients, and unmeasured patient factors (e.g., severity, care preferences). It would have been more informative to quantify how this one neurologist’s practice changed after the integration, although that addresses only one limitation. Realizing however that it is not feasible for most organizational changes to undergo large randomized trials, is there some data from this work that could better inform the potential effects of an integrated neurologist? This is a circumstance where semi-structured interviews with key persons (the neurologist, office staff, primary care providers, and patients) and qualitative analysis might provide important insights. For example, I would be interested in the key stakeholders description of their practice experience before and after integration.