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2015 HSR&D/QUERI National Conference Abstract

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1076 — Do Patient Aligned Medical Team Models of Care Impact VA's Clinical Learning Environments?

Kashner TM, Office of Academic Affiliations, Department of Veterans Affairs, Washington, DC; Byrne JM, Jerry L. Pettis Memorial VA Medical Center, Loma Linda, CA; Gilman SC, Office of Academic Affiliations, Department of Veterans Affairs, Washington, DC; Wicker AB, Jerry L. Pettis Memorial VA Medical Center, Loma Linda, CA; Bernett DS, Office of Academic Affiliations, VA Medical Center, St. Louis, MO; Aron DC, Louis Stokes Cleveland VA Medical Center, Cleveland, OH; Brannen JL, Office of Academic Affiliations, Department of Veterans Affairs, Washington, DC; Cannon GW, George E. Wahlen VA Medical Center, Salt Lake City, UT; Chang BK, Office of Academic Affiliations, Department of Veterans Affairs, Washington, DC; Hettler DL, Office of Academic Affiliations, Department of Veterans Affairs, Washington, DC

Objectives:
We assessed the impact of VA's Patient Aligned Care Team (PACT) model of care, implemented in FY2011, on the clinical, learning, and working experiences of VHA's physician trainees (medical students, residents, fellows) using Office of Academic Affiliations' Learners' Perceptions Survey (LPS) data. Annually, 41,000 physician residents and 22,000 medical students rotate through VA medical centers. Assessing the impact of PACT on VA trainee experiences has consequences for medical education, staff recruitment, and quality of patient care in VA clinical teaching settings.

Methods:
The current study assessed PACT using a before (2008-2010) - after (2012-2014) design, with 2011 serving as a transition year, for n = 28,386 physician trainee respondents to the LPS. Following PACT implementation, OAA redesigned the LPS beginning in 2012 to measure trainee PACT experiences. Identifying "control" facilities for traditional difference-in-differences computations was impractical because reported PACT experiences failed to cluster by facility (ICC = .19 CI95%[.17-.20]). Instead, our novel approach identifies "control" respondents in the post-period based on their reported PACT experiences, and pre-period as a Missing-At-Random problem (observable reporting year) using robust multiple imputation from post-period data. PACT effect sizes were computed from the coefficient to a time period x PACT experience interaction term. Robust estimates were computed for missing value and outcome models following exhaustive searches of possible models (searching 13,496 models to impute missing values and 9,192 outcome models) with the best Generalized Akaike Information Criteria accounting for model misspecification, unobservable temporal confounders, response biases, facility nesting, multicollinearity, and ordinal outcomes after 10-fold cross validation.

Results:
PACT implementation was associated (p < .001) with improved physician trainee satisfaction in the following: systems handling medical errors (O.R. = 2.4), care quality (O.R. = 1.6), learning (O.R. = 1.9) and working (O.R. = 2.1) environments, personal experiences (O.R. = 2.1), and quality (O.R. = 1.9) and availability (O.R. = 1.9) of clinical support services. No changes were observed for faculty preceptors or physical environment.

Implications:
VA's PACT care models were associated with favorable clinical, learning, and working experiences of VA physician residents and medical students.

Impacts:
Study findings support OAA's efforts to expand patient-centered and interprofessional education models for its physician residents, with possible implications for physician staff recruitment and perceived care quality.