Study Suggests Adoption of PACT Features is Significantly Associated with Lower Risk of Avoidable Hospitalization

BACKGROUND:
In 2010, VA began implementing the patient-centered medical home, called the Patient-Aligned Care Team (PACT), in its primary care clinics. Benefits of improving ambulatory care with PACT may include reducing unnecessary and expensive acute care. This study measured the baseline adoption of medical home features by VA primary care clinics prior to widespread PACT implementation to determine if these features were associated with lower risk and costs of potentially avoidable hospitalizations. Using VA data, investigators identified 2,853,030 Veterans who received care in 814 VA primary care clinics in FY09. Patient and clinic factors in the baseline year (FY09) were then used to predict patient outcomes in the follow-up year (FY10). The primary outcome measured in this study was potentially avoidable hospitalizations for ambulatory care sensitive conditions (ACSC) that included: asthma, angina without procedure, pneumonia, dehydration, COPD, congestive heart failure, complications related to diabetes, hypertension, perforated appendix, and urinary tract infection. In addition, the total number and costs of ACSC hospitalizations were measured for each Veteran during the 12-month follow-up period. The main independent variable — adoption of medical home features — came from a survey of all VA primary care clinics in 11/09, and included 7 components: access and scheduling, care coordination and transitions in care, organization of practice, patient-centered care and communication, population management, quality and performance improvement, and use of technology.

FINDINGS:

• Greater adoption of medical home features by VA primary care clinics was found to be significantly associated with lower risk of avoidable hospitalizations. Veterans in clinics with the highest medical home adoption had significantly lower ACSC rates (20 per 1,000) compared to Veterans in clinics with the lowest (25 per 1,000) and medium (26 per 1,000) adoption of medical home features.
• If clinics were transformed from the mean level of medical home adoption to the maximum level, the reduction in hospitalization costs in an average-sized clinic with 3,500 Veterans could be as much as $83,000 annually.
• Two PACT features were independently related to lower risk of ACSC hospitalization: access and scheduling, and care coordination/transitions in care. For example, Veterans in clinics with the highest scores on access and scheduling had 17% lower odds of having an ACSC admission compared to the lowest scoring clinics.

LIMITATIONS:

• The survey used to determine adoption of medical home features was a self-report instrument.
• Because of the cross-sectional design of this study, investigators were unable to determine a causal relationship between clinic medical home components and patients' risk for hospitalization.

AUTHOR/FUNDING INFORMATION:
This study was funded by HSR&D (IIR 09-082). Dr. Yoon is part of HSR&D's Health Economics Resource Center (HERC) in Palo Alto, CA.

Yoon J, Rose D, Canelo I, et al. Medical Home Features of VHA Primary Care Clinics and Avoidable Hospitalizations. Journal of General Internal Medicine March 26, 2013;e-pub ahead of print.