Relationship Between High Utilization and Changes in PCMH Implementation

Changes in patient-centered medical home (PCMH) implementation had no consistent association with changes in high cost health care utilization, according to a study results published in JAMA Network Open.

“In 2010, the US Veterans Health Administration (VHA) implemented one of the largest PCMH models in the United States, the Patient Aligned Care Team (PACT) initiative,” Ashok Reddy, MD, MSc, Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA and colleagues explained in the study, noting that limited evidence exists examining the longitudinal association between implementation and utilization.

Researchers observed no consistent change in PCMH capabilities associated with changes in emergency department (ED) visits, hospitalization visits for ambulatory care-sensitive conditions (ACSC), or all-cause hospitalizations.

Dr Reddy and colleagues said that these results were surprising as previous data showed that PCMH implementation in care delivery, like team-based care and care continuity, decreased high-cost acute health care utilization rates.

The cohort study used patient-level data for 1,650,976 veterans at 897 clinic sites, from the VHA and Centers for Medicare & Medicaid Services, from October 1, 2012 and September 30, 2015 and divided patients into 2 cohorts, “patients younger than 65 years who received primary care at VHA sites affiliated with a VHA ED and patients 65 years or older who were enrolled in both VHA and Medicare services.”

Changes in improvement were measured by each clinics PACT implementation progress index (Pi²) score. Results were as follows:

• Patients younger than 65-years: fewer ED visits among patients seen at clinics that had improved PCMH implementation (110.8 fewer visits per 1000 patients; P<.001) and clinics that had somewhat worse implementation (69.0 fewer visits per 1000 patients; P<.001) compared with clinics that had no change in Pi² score.
• Patients older than 65-years: those seen at clinics that had somewhat worse PCMH implementation experienced fewer ED visits (20.1 fewer visits per 1000 patients; P=.002) and all-cause hospitalizations (12.4 fewer hospitalizations per 1000 patients; P=.007) compared with clinics with no change in Pi² score.

Neither cohort observed associations between change in Pi² score with ACSC hospitalizations.

“These findings lead to additional questions that are critical for PCMH evaluations in and outside the VHA,” said Dr Reddy and colleagues. “For example, do certain functions or domains of the PCMH have a threshold effect? If that is the case, improvement in certain PCMH capabilities would not lead to additional improvement in outcomes.”

Study authors explained that it could be that PCMH might be more important for improving care for various, specific groups of patients, such as those with multiple chronic conditions who benefit more from continuity than interventions to improve access to care, and added that more research is needed. —Edan Stanley