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Rosland A, Wong ES, Zulman D, Piegari R, Prenovost K, Fihn SD, Nelson KM. Higher Level of Patient-Centered Medical Home Implementation Associated with Larger Improvements in Clinical Quality in the PACT Initiative. Paper presented at: VA HSR&D / QUERI National Meeting; 2015 Jul 10; Philadelphia, PA.
Abstract Text: Research Objective: In 2010, the Veterans Health Administration (VHA) began to establish patient centered medical homes (PCMH) at all primary care (PC) clinics nationwide as part of the Patient Aligned Care Teams (PACT) initiative. PACT focuses on whole-clinic improvements in patient-centered care delivery, such as increased continuity and access, and multi-disciplinary team-based care. PACT does not explicitly focus on care for specific medical conditions or patient populations. However, effective implementation of PCMH may have beneficial effects on chronic illness care. This study examined whether extent of PACT implementation at individual VHA PC clinics by 2012 was associated with changes in chronic illness care between 2009 (pre-PACT) and 2013. Study Design: Pre-post observational study of VHA's 955 PC clinics (serving > 5 million patients). Using multivariate linear regression, we examined the association between clinics' PACT implementation and clinic-level change in 15 individual clinical quality indicators (CQI). CQI were collected by VHA's External Peer Review Program, in which external contractors manually abstract electronic health records to assess clinical performance using standardized criteria. Each indicator is expressed as the % of a clinic's qualifying patients who received guideline adherent care. PACT implementation was measured using the previously developed PI2 score, an 53 variable index representing 8 PCMH domains, ranging from -8 (least extensive implementation) to +8 (most extensive). All models were adjusted for clinics' baseline value of the CQI measure, community vs. hospital-based clinic, rural vs. urban location, and area unemployment levels. Results are reported as model-based predictions for 2009-2013 change in proportion of patients receiving guideline adherent care, for clinics with the least PACT implementation (PI2 < -4) vs. those with the most (PI2 > +4). Population Studied: VA PC patients with diabetes (DM), hypertension (HTN), ischemic heart disease (IHD), and heart failure (HF). Principal Findings: Overall, clinical quality was high. However, more extensive PACT implementation was significantly associated with larger improvements in 5 quality measures at p < 0.05 and in 2 additional measures at p < 0.06. Specifically, clinics with the most PACT implementation had significantly greater improvements than clinics with the least PACT implementation in: annual LDL measurement in IHD (2009- 13 predicted change +2.4% for high Pi2 vs. 0% for low Pi2, p < 0.01), LDL < 100 in IHD (+7.8% vs. +2.7%, p < 0.01) and DM (+3.1% vs. +0.09%, p = 0.06), ACE inhibitor or ARB prescription for recent IHD with EF < 40% (+0.03% vs. -0.02%, p < 0.01), blood pressure < 160/100 in HTN (+0.8% vs. -0.9%, p < 0.001) and DM (+0.2% vs. -1.1%, p = 0.03), and annual HbA1c measurement in DM (+1.3% vs. +0.5%, p = 0.06). Measures for which change over time was unassociated with PI2score were: aspirin prescription in CVD or DM; HbA1c < 9 in DM; regular foot, retinal or renal function checks in DM; and HF with EF < 40% with ACE inhibitor/ARB prescription. Submission Completed 1/15/15, 1:05 PM https://academyhealth.confex.com/academyhealth/2015arm/general/pa.88andEntryTable = Paperandstep = 6andStepEntry = 5-Paper4188andpassword = 565987 Page 2 of 4 Conclusions: Over the period of initial PACT implementation, clinics with PACT most extensively in place by 2012 had significantly larger improvements in almost half of the chronic disease process and outcome quality measures examined. Implications for Policy or Practice: This study suggests that focusing resources on PCMH-aligned changes in care delivery across all patients may result in downstream improvements in quality of care and clinical outcomes for patients with specific chronic diseases.