PACT Initiative Did Not Reduce Most Disparities in Improved Hypertension or Diabetes Control among VA Patients
Patient-centered medical homes have been developed and widely promoted across the United States as a primary care delivery model that achieves better patient outcomes. In 2010, VA began nationwide implementation of its own patient-centered medical home model known as the Patient Aligned Care Team (PACT) initiative. An early evaluation of VA PACTs found that sites with greater implementation of the care model had higher performance on most quality measures, including hypertension and diabetes control; however, it is unknown whether such improvements in quality measures extend to all racial/ethnic groups. Thus this study sought to determine whether PACTs helped mitigate national racial/ethnic disparities in VA clinical outcomes, after adjusting for variable implementation and social determinants of health. Investigators analyzed VA data for 2009 and 2014 – the year before and four years after the implementation of the PACT care model. The study sample included 146,698 Veterans with hypertension and 79,832 Veterans with diabetes who received healthcare from 140 VA healthcare facilities. Measures included hypertension control (BP <140/90 mmHg) and diabetes control (HbA1C of 9% or less). The main independent variable was race/ethnicity. Demographics also were assessed.
- Improvements in clinical outcomes for hypertension and diabetes control had not been achieved for whites or most racial/ethnic groups four years into VA's system-wide roll-out of the PACT initiative. Greater PACT implementation was associated with higher percentages of Veterans who achieved hypertension or diabetes control, but most racial/ethnic disparities in achieving control persisted.
- In 2014, compared with 2009, disparities in hypertension control were similar for blacks, had become smaller but remained significant for Hispanics, and were no longer significant for multiracial individuals, whereas disparities were now significant for American Indian/Alaska Natives (AI/ANs) and Native Hawaiians/other Pacific Islanders (NH/OPIs). By contrast, in 2014, disparities in diabetes control were similar for AI/ANs, blacks, and Hispanics, and were no longer significant for NH/OPIs.
- To promote health equity, healthcare innovations such as patient-centered medical homes should incorporate tailored strategies that account for determinants of racial/ethnic variations.
- The relatively small size of the AI/AN, Asian, multi-race, and NH/OPI samples in this study may have precluded identification as significant a change in disparities that could be clinically relevant.
- Investigators were not able to adjust for facility-level variations in the implementation of patient-centered medical homes specific to racial/ethnic groups.
This study was funded by VA's Office of Health Equity and HSR&D's Quality Enhancement Research Initiative (QUERI). Drs. Washington, Steers, and Huynh are part of HSR&D's Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP) in Los Angeles, CA.
Washington DL, Steers WN, Huynh A, et al. Racial and Ethnic Disparities Persist at Veterans Health Administration Patient-Centered Medical Homes. Health Affairs. June 2017;36(6):1086-94.