Lampman Michelle A, Steffensmeier Kenda R Stewart, Reisinger Heather Schacht, Sarrazin Mary Vaughan, Steffen Melissa J A, Solimeo Samantha L, Stewart Greg L, Mueller Keith J
Primary Care Analytics Team (PCAT) and the Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, Iowa.
Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota.
J Rural Health. 2021 Mar;37(2):426-436. doi: 10.1111/jrh.12490. Epub 2020 Jul 6.
To assess differences in Patient Aligned Care Team (PACT) performance between rural and urban primary care clinics within the Veterans Health Administration (VHA).
An Explanatory Sequential Mixed Methods design was conducted using VHA administrative data to assess performance of a national sample of 891 VHA primary care clinics. Generalized Estimating Equations with repeated measures were used to estimate associations between rurality and process-oriented endpoints including: chronic disease management through telehealth; use of telephone visits, group visits or secured messaging; same-day access; continuity with primary care provider; and postdischarge follow-up. Qualitative data collected during on-site visits with 5 clinics were used to provide insights into PACT processes from the perspectives of staff in rural and urban clinics.
After adjusting for patient- and practice-level characteristics, clinics located in large rural or small/isolated rural areas demonstrated difficulty enhancing access through use of telephone visits, group visits, or secured messaging and completing postdischarge follow-up calls, compared to urban clinics. Qualitative analysis indicated that staff from both rural and urban clinics reported similar barriers implementing these PACT processes. Both patient and staff behaviors and preferences impact implementation of these processes. Distance to care and access to high-speed Internet were also reported as barriers.
This study contributes to the understanding of PACT performance in rural settings by highlighting ways contextual and behavioral factors relate to performance. Increasing implementation of patient-centered medical home (PCMH) models, such as PACT, will require additional attention to the complex relationships between the practice and surrounding context.
评估退伍军人健康管理局（VHA）内农村和城市初级保健诊所的患者协作护理团队（PACT）绩效差异。
采用解释性序列混合方法设计，利用VHA行政数据评估891家VHA初级保健诊所全国样本的绩效。使用重复测量的广义估计方程来估计农村地区与以流程为导向的终点之间的关联，这些终点包括：通过远程医疗进行慢性病管理；使用电话问诊、小组问诊或安全消息传递；当日就诊；与初级保健提供者的连续性；以及出院后随访。在对5家诊所进行实地考察期间收集的定性数据，用于从农村和城市诊所工作人员的角度深入了解PACT流程。
在对患者和机构层面的特征进行调整后，与城市诊所相比，位于大型农村或小型/偏远农村地区的诊所，在通过使用电话问诊、小组问诊或安全消息传递来增加就诊机会以及完成出院后随访电话方面存在困难。定性分析表明，农村和城市诊所的工作人员报告了在实施这些PACT流程时存在类似的障碍。患者和工作人员的行为及偏好都会影响这些流程的实施。就医距离和高速互联网接入也被报告为障碍。
本研究通过强调背景因素和行为因素与绩效的关联方式，有助于理解农村地区的PACT绩效。增加以患者为中心的医疗之家（PCMH）模式（如PACT）的实施，将需要更多关注机构与周边环境之间的复杂关系。
