More Patient-Aligned Care Team Components Translates to Improved Quality of Care for Veterans with Chronic Disease
In 2010, VA launched the Patient Aligned Care Teams (PACT) initiative nationwide. This retrospective study examined whether the extent to which clinics had implemented PACT components was associated with improvements in the quality of care for Veterans with chronic conditions over a four year period. Investigators assessed PACT implementation using 53 PCMH measures derived from clinical encounter data and patient and staff surveys, assessing 8 domains such as continuity, coordination, team-based care, comprehensiveness of care, and self-management support. Change was assessed over 4 years (2009-2013) in 15 VA outpatient care quality measures related to coronary artery disease (CAD), diabetes (DM), and hypertension (HTN) from 808 VA primary care clinics nationwide that implemented PACT. Clinical outcomes included LDL<100 among patients with CAD, HbA1c<9% among patients with DM, and BP<160/100 and BP<140/90 among patients with HTN, while process measures included aspirin prescription among patients with CAD, as well as HbA1c measured in the last year and ACE-inhibitor/ARB prescription among patients with DM.
- Over four years concurrent with PACT implementation, primary care clinics with the most PACT components in place (n=77) had greater improvements in 5 of 7 chronic disease intermediate clinical outcome and 2 of 8 chronic disease process measures when compared to clinics with the least PACT components in place (n=69).
- Quality measures that improved more among the clinics with highest PACT implementation included LDL< 100 in CAD and DM patients, and BP < 160/100 in DM and HTN patients. Improvements in percentage of clinic patient population meeting clinical outcome quality measures over four years in the high PACT implementation clinics ranged from 1.3% to 5.2%.
- There were very few statistically significant differences in quality measure changes between clinics with moderate levels of PACT implementation and clinics with the least PACT implementation.
- VA primary care clinics may be able to achieve improved quality of care for patients with common chronic conditions through patient-centered medical home-aligned changes in care delivery across all patients, if those changes are extensively implemented.
- There was no control group of clinics that were not asked to implement PACT, so investigators conducted a within-clinic analysis of change controlling for pre-PACT quality levels.
- Some of the quality measures in this study have been updated, e.g., therapy targeted to specific LDL levels has been replaced with guidelines emphasizing cardiac risk based statin therapy.
This study was supported by the VA PACT Demo Lab Coordinating Center and funded by VA's Office of Primary Care Operations. Drs. Wong and Maciejewski are supported by HSR&D Career Development and Research Career Scientist Awards, respectively. Dr. Rosland is part of HSR&D's Center for Health Equity Research and Promotion; Dr. Wong is part of HSR&D's Center for Innovation for Veteran-Centered and Value-Driven Care; and Dr. Maciejewski is part of HSR&D's Center for Health Services Research in Primary Care. Drs. Fihn and Nelson are part of the operationally-funded national Pact Evaluation Initiative.
Rosland AM, Wong E, Maciejewski M, Zulman D, Piegari R, Fihn S, and Nelson, K. Patient-Centered Medical Home Implementation and Improved Chronic Disease Quality: A Longitudinal Observational Study. Health Services Research. November 20, 2017;e-pub ahead of print.