Elements of the Veterans Health Administration Patient-Centered Medical Home are Associated with Greater Adherence to Oral Hypoglycemic Agents in Patients with Diabetes

The Patient-centered Medical Home as an Intervention Strategy for Diabetes Mellitus: A Systematic Review of the Literature

BACKGROUND

Poorly managed diabetes mellitus increases health care expenditures and negatively impacts health outcomes. There are 34 million people living with diabetes in the United States with a direct annual medical cost of $237 billion. The patient-centered medical home (PCMH) was introduced to transform primary care by offering team-based care that is accessible, coordinated, and comprehensive. Although the PCMH is believed to address multiple gaps in delivering care to people living with chronic diseases, the research has not yet reported clear benefits for managing diabetes.

OBJECTIVE

The study reviews the scientific literature about diabetes mellitus outcomes reported by PCMHs, and understands the impact of team-based care, interdisciplinary communication, and care coordination strategies on the clinical, financial, and health-related outcomes.

METHODS

The systematic review was performed according to the Cochrane method and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Eight databases were systematically searched for articles. The Oxford Centre for Evidence-based Medicine Levels of evidence and the Critical Appraisal Skills Programme systematic review checklist were used to evaluate the studies.

RESULTS

The search resulted in 596 articles, of which 24 met all the inclusion criteria. Care management resulted in more screenings and better preventive care. Pharmacy-led interventions and technology were associated with positive clinical outcomes, decreased utilization, and cost savings. Most studies reported decreased emergency room visits and less inpatient admissions.

CONCLUSION

The quality and strength of the outcomes were largely inconclusive about the overall effectiveness of the PCMH. Defining and comparing concepts across studies was difficult as universal definitions specific to the PCMH were not often applied. More research is needed to unpack the care model of the PCMH to further understand how the individual key components, such as care bundles, contribute to improved outcomes. Further evaluations are needed for team-based care, communication, and care coordination with comparisons to patient, clinical, health, and financial outcomes.

Patient-Centered Medical Home Activities Associated With Low Medicare Spending and Utilization

PURPOSE

To identify components of the patient-centered medical home (PCMH) model of care that are associated with lower spending and utilization among Medicare beneficiaries.

METHODS

Regression analyses of changes in outcomes for Medicare beneficiaries in practices that engaged in particular PCMH activities compared with beneficiaries in practices that did not. We analyzed claims for 302,719 Medicare fee-for-service beneficiaries linked to PCMH surveys completed by 394 practices in the Centers for Medicare & Medicaid Services' 8-state Multi-Payer Advanced Primary Care Practice demonstration.

RESULTS

Six activities were associated with lower spending or utilization. Use of a registry to identify and remind patients due for preventive services was associated with all 4 of our outcome measures: total spending was $69.77 less per beneficiary per month (PBPM) (P = 0.00); acute-care hospital spending was $36.62 less PBPM (P = 0.00); there were 6.78 fewer hospital admissions per 1,000 beneficiaries per quarter (P1KBPQ) (P = 0.003); and 11.05 fewer emergency department (ED) visits P1KBPQ (P = 0.05). Using a patient registry for pre-visit planning and clinician reminders was associated with $29.31 lower total spending PBPM (P = 0.05). Engaging patients with chronic conditions in goal setting and action planning was associated with 4.62 fewer hospital admissions P1KBPQ (P = 0.01) and 11.53 fewer ED visits P1KBPQ (P = 0.00). Monitoring patients during hospital stays was associated with $22.06 lower hospital spending PBPM (P = 0.03). Developing referral protocols with commonly referred-to clinicians was associated with 11.62 fewer ED visits P1KBPQ (P = 0.00). Using quality improvement approaches was associated with 13.47 fewer ED visits P1KBPQ (P =0.00).

CONCLUSIONS

Practices seeking to deliver more efficient care may benefit from implementing these 6 activities.

Components of the Patient-Centered Medical Home Associated with Perceived Access to Primary Care

BACKGROUND

Following implementation of the patient-centered medical home (PCMH) within the Department of Veterans Affairs (VA), access to primary care improved. However, understanding of how this occurred is lacking.

OBJECTIVE

To examine the association between organizational aspects of the PCMH model and access-related initiatives with patient perception of access to urgent, same-day, and routine care within the VA.

DESIGN

Cross-sectional PARTICIPANTS: Veterans who responded to the annual Survey of Healthcare Experiences of Patients in 2016 (N = 241,122 patients) and primary staff who responded to VA National Primary Care Provider and Staff Survey (N = 4815 staff).

MAIN MEASURES

Three outcomes of perception of access: percentage of patients responding in the highest category for same-day care (waiting ≤ 1 day), urgent care (always receiving care when needed), and routine care (always receiving checkups when desired). Predictors were staff-level report of access-related initiatives and organizational factors in the clinic. We used generalized estimating equations to model associations, adjusting for characteristics of patients and their respective clinics.

KEY RESULTS

Access was significantly better in clinics where staff reviewed performance reports (+ 0.9% in the highest perception of access for urgent care, P < 0.01; + 1.2% for routine care, P < 0.001), leadership was supportive of the PCMH (+ 1.6% for urgent care, P < 0.01), and initiatives to improve access included open access (+ 0.8% to + 1.7% across all outcomes, P < 0.01) and telehealth visits (+ 1.2% to + 1.4%, P < 0.001). Perceived access was worse in clinics with moderate staff burnout (- 1.1% to - 1.4%, P < 0.001), primary care provider turnover during the past year (- 1.0% to - 1.6%, P < 0.001), or medical support assistant turnover in the past year (- 0.9% to - 1.4%, P < 0.001).

CONCLUSIONS

Perception of access was strongly associated with identifiable organizational factors and access-related initiatives within VA primary care clinics that could be adopted by other health systems.

Shared decision making, satisfaction with care and medication adherence among patients with diabetes

OBJECTIVES

We examined factors associated with shared decision making and whether shared decision-making (SDM) was associated with satisfaction with care or with adherence to anti-diabetic medication.

METHODS

A retrospective study was conducted using 2011-2014 Medical Expenditure Panel Survey (MEPS) data. Inclusion criteria were 18 years or older and visit to a usual source of care during the prior 12 months. Exclusion criteria were reported cognitive limitation, proxy response, less than two prescription fills, or missing data on study variables. SDM was assessed using seven MEPS items. Satisfaction with care was assessed using a single MEPS item 12 months after SDM measurement. Adherence was assessed using Medication Possession Ratio in 12 months after SDM measurement.

RESULTS

The weighted sample of 797 respondents represented 15.6 million with diabetes. Being older, male, or uninsured were associated with low SDM. High SDM was associated with higher satisfaction (p < 0.0001). SDM was not associated with adherence.

CONCLUSIONS

Patients with higher SDM were more satisfied with their healthcare. We did not find association between SDM and adherence to antidiabetic medication.

PRACTICE IMPLICATIONS

Involvement in SDM is encouraged to improve patient satisfaction. Providers may consider age, sex and insurance status in facilitating communications to improve SDM.