Health Services Research & Development, VA Puget Sound Health Care System, 1660 South Columbian Way, Seattle, WA, 98108, USA.
Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA.
J Gen Intern Med. 2020 Oct;35(10):2932-2938. doi: 10.1007/s11606-020-06076-7. Epub 2020 Aug 6.
The patient-centered medical home (PCMH) was established in part to improve chronic disease management, yet evidence is limited for effects on patients with multimorbidity.
To examine the association of Patient-Aligned Care Team (PACT) implementation, the Veterans Health Administration (VA) PCMH model, and care quality for multimorbid patients enrolled in VA primary care from 2012 to 2014.
Retrospective cohort.
318,764 multimorbid (> 3 chronic diseases) patients receiving care in 917 clinics.
PCMH implementation was measured using the PACT Implementation Progress Index (PI) for clinics in 2012. The PI is a validated composite measure of administrative and survey data with higher scores associated with greater care quality. Quality outcomes from 2013 to 2014 were assessed from External Peer Review Program (EPRP) metrics. Outcomes included preventative care, chronic disease management, and mental health and substance use metrics. We used generalized estimating equations to model associations adjusting for patient and clinic characteristics. We also examined associations for a subgroup with > 5 chronic diseases.
For one-third of metrics (5/15), greater implementation of PACT in 2012 was associated with higher predicted probability of meeting the quality metric in 2013-2014. This association persisted for only two metrics (diabetic glycemic control, P < 0.001; lipid control in ischemic heart disease, P = 0.02) among patients with > 5 chronic diseases.
Multimorbid patients engaged in care from clinics with higher PCMH implementation received higher quality care across several quality domains, but this association was reduced in patients with > 5 chronic diseases.
以患者为中心的医疗之家（PCMH）的建立部分是为了改善慢性病管理，但目前关于其对多病种患者的影响的证据有限。
本研究旨在探讨 2012 年至 2014 年期间，患者对齐护理团队（PACT）的实施、退伍军人事务部（VA）PCMH 模式与 VA 初级保健中多病种患者的护理质量之间的关系。
回顾性队列研究。
917 个诊所中 318764 名患有多种慢性病（>3 种慢性疾病）的患者。
2012 年，采用 PACT 实施进展指数（PI）对诊所的 PCMH 实施情况进行测量。PI 是一种经过验证的行政和调查数据综合衡量指标，得分越高，护理质量越高。2013 年至 2014 年的质量结果来自外部同行评审计划（EPRP）指标。结果包括预防保健、慢性病管理以及心理健康和物质使用指标。我们使用广义估计方程来调整患者和诊所特征后对关联进行建模。我们还检查了>5 种慢性疾病患者亚组的关联。
在 15 项指标中有 1/3（5/15），2012 年 PACT 的实施程度越高，与 2013-2014 年更高质量指标的预测概率之间存在正相关关系。在患有>5 种慢性疾病的患者中，这种关联仅在两个指标中持续存在（糖尿病血糖控制，P<0.001；缺血性心脏病患者的血脂控制，P=0.02）。
参与具有更高 PCMH 实施程度的诊所护理的多病种患者在多个质量领域获得了更高质量的护理，但在患有>5 种慢性疾病的患者中，这种关联有所减少。
