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Wong ES, Rosland AM, Fihn SD, Nelson KM. Implementation of the Patient Aligned Care Team Initiative and Primary Care Use: Differences by Patient Comorbidity Burden. Paper presented at: VA HSR&D / QUERI National Meeting; 2015 Jul 10; Philadelphia, PA.
Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA; 2Department of Health Services, University of Washington, Seattle, WA; 3Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI; 4Department of Internal Medicine, University of Michigan, Ann Arbor, MI; 5Office of Analytics and Business Intelligence, Veterans Health Administration, Seattle, WA; 6Department of Medicine, University of Washington, Seattle, WA; Objective: In April 2010, VA began to establish patient-centered medical homes (PCMHs) at all primary care (PC) clinics nationwide as part of the Patient Aligned Care Team (PACT) initiative. Because PCMH was developed using the chronic care model, PACT may be more helpful for Veterans with higher comorbidity burden. We sought to determine whether complex patients had larger increases in PC visits attributable to PACT implementation relative to other patients. Methods: Using the Corporate Data Warehouse, we identified 2.7 million elderly VA users between October 2003 and September 2013. VA PC use was defined as the number of face-to-face visits with PC providers in a given quarter. Veterans with a Gagne comorbidity score 2 were considered complex, a cutoff corresponding to the 75th percentile. We applied interrupted time-series models to estimate long-run trends in PC use and estimated potential deviations from long-run trends following PACT implementation. We modeled time trends in quarterly PC use using negative binomial regression, adjusting for demographics, comorbidity and local economic conditions. We used these trends to estimate the predicted difference in quarterly PC visits with (i.e., observed) and without PACT (i.e., projected) and assessed differences by patient complexity. Results: For complex Veterans, PACT was associated with greater PC use starting 4 quarters following initial implementation (7 visits per 1,000 Veterans, p = 0.01). The positive association increased over time to study end (24 visits per 1,000 Veterans, p = 0.03). For non-complex Veterans, PACT was associated with greater PC use starting 8 quarters following implementation (4 visits per 1,000 Veterans, p = 0.01) to study end (12 visits per 1,000 Veterans, p = 0.02). Differences in PC use associated with PACT were statistically significant in all quarters. Conclusion: Greater PC use attributable to PACT materialized over time. The positive association between PACT and PC use was significantly larger for complex Veterans who have greater need for face-to-face PC. Impact: Greater integration of PCMH elements such as increased PC staffing by VA clinics that have been less effective at implementing PACT to date may improve access to PC for elderly VA users, particularly complex patients.