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    Original Investigation
    Health Policy
    February 5, 2020

    Association of High-Cost Health Care Utilization With Longitudinal Changes in Patient-Centered Medical Home Implementation

    Author Affiliations
    • 1Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington
    • 2VA Puget Sound Health Care System, Seattle, Washington
    • 3Department of Medicine, School of Medicine, University of Washington, Seattle
    • 4Department of Health Services, School of Public Health, University of Washington, Seattle
    JAMA Netw Open. 2020;3(2):e1920500. doi:10.1001/jamanetworkopen.2019.20500
    Key Points español 中文 (chinese)

    Question  Is a change in patient-centered medical home implementation associated with changes in high-cost health care utilization in the US Veterans Health Administration health care system?

    Findings  In this cohort study including 1 650 976 veterans, neither improvement nor decline in patient-centered medical home implementation was consistently associated with changes in the numbers of emergency department visits, ambulatory care–sensitive condition hospitalizations, or all-cause hospitalizations.

    Meaning  This finding highlights key challenges in measuring patient-centered medical home implementation over time.

    Abstract

    Importance  In 2010, the US Veterans Health Administration (VHA) implemented one of the largest patient-centered medical home (PCMH) models in the United States, the Patient Aligned Care Team initiative. Early evaluations demonstrated promising associations with improved patient outcomes, but limited evidence exists on the longitudinal association of PCMH implementation with changes in health care utilization.

    Objective  To determine whether a change in PCMH implementation is associated with changes in emergency department (ED) visits, hospitalizations for ambulatory care–sensitive conditions (ACSCs), or all-cause hospitalizations.

    Design, Setting, and Participants  This cohort study used national patient-level data from the VHA and Centers for Medicare & Medicaid Services between October 1, 2012, and September 30, 2015. A total of 1 650 976 patients from 897 included clinics were divided 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.

    Exposures  Clinics were categorized on improvement or decline in PCMH implementation based on their Patient Aligned Care Team implementation progress index (Pi2) score.

    Main Outcomes and Measures  Change in the number of ED visits, ACSC hospitalizations, and all-cause hospitalizations among patients at each clinic site.

    Results  The study included a total of 1 650 976 patients, of whom 581 167 (35.20%) were younger than 65 years (mean [SD] age, 49.03 [10.28] years; 495 247 [85.22%] men) and 1 069 809 (64.80%) were 65 years or older (mean [SD] age, 74.64 [7.41] years; 1 050 110 [98.16%] men). Among patients younger than 65 years, there were 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. There were no associations of change in Pi2 scores with all-cause hospitalizations or ACSC hospitalizations among patients younger than 65 years. In patients 65 years or older, 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. There was no association between change in Pi2 score with ACSC hospitalizations among patients 65 years or older.

    Conclusions and Relevance  There were no consistent associations of change in Pi2 score with high-cost health care utilization. This finding highlights the key differences in measuring PCMH implementation longitudinally compared with cross-sectional study designs.

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