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Rajan SS, Sarvepalli S, Wei L, Meyer AND, Murphy DR, Choi DT, Singh H. Medical Home Implementation and Follow-Up of Cancer-Related Abnormal Test Results in the Veterans Health Administration. JAMA Netw Open 2024; 7:e240087. [PMID: 38483392 PMCID: PMC10940951 DOI: 10.1001/jamanetworkopen.2024.0087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 12/18/2023] [Indexed: 03/17/2024] Open
Abstract
Importance Lack of timely follow-up of cancer-related abnormal test results can lead to delayed or missed diagnoses, adverse cancer outcomes, and substantial cost burden for patients. Care delivery models, such as the Veterans Affairs' (VA) Patient-Aligned Care Team (PACT), which aim to improve patient-centered care coordination, could potentially also improve timely follow-up of abnormal test results. PACT was implemented nationally in the VA between 2010 and 2012. Objective To evaluate the long-term association between PACT implementation and timely follow-up of abnormal test results related to the diagnosis of 5 different cancers. Design, Setting, and Participants This multiyear retrospective cohort study used 14 years of VA data (2006-2019), which were analyzed using panel data-based random-effects linear regressions. The setting included all VA clinics and facilities. The participants were adult patients who underwent diagnostic testing related to 5 different cancers and had abnormal test results. Data extraction and statistical analyses were performed from September 2021 to December 2023. Exposure Calendar years denoting preperiods and postperiods of PACT implementation, and the PACT Implementation Progress Index Score denoting the extent of implementation in each VA clinic and facility. Main Outcome and Measure Percentage of potentially missed timely follow-ups of abnormal test results. Results This study analyzed 6 data sets representing 5 different types of cancers. During the initial years of PACT implementation (2010 to 2013), percentage of potentially missed timely follow-ups decreased between 3 to 7 percentage points for urinalysis suggestive of bladder cancer, 12 to 14 percentage points for mammograms suggestive of breast cancer, 19 to 22 percentage points for fecal tests suggestive of colorectal cancer, and 6 to 13 percentage points for iron deficiency anemia laboratory tests suggestive of colorectal cancer, with no statistically significant changes for α-fetoprotien tests and lung cancer imaging. However, these beneficial reductions were not sustained over time. Better PACT implementation scores were associated with a decrease in potentially missed timely follow-up percentages for urinalysis (0.3-percentage point reduction [95% CI, -0.6 to -0.1] with 1-point increase in the score), and laboratory tests suggestive of iron deficiency anemia (0.5-percentage point reduction [95% CI,-0.8 to -0.2] with 1-point increase in the score). Conclusions and Relevance This cohort study found that implementation of PACT in the VA was associated with a potential short-term improvement in the quality of follow-up for certain test results. Additional multifaceted sustained interventions to reduce missed test results are required to prevent care delays.
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Affiliation(s)
- Suja S. Rajan
- Department of Management, Policy & Community Health, School of Public Health, The University of Texas Health Science Center at Houston
| | | | - Li Wei
- Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
| | - Ashley N. D. Meyer
- Department of Medicine, Baylor College of Medicine, Houston, Texas
- Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
| | - Daniel R. Murphy
- Department of Medicine, Baylor College of Medicine, Houston, Texas
- Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
| | - Debra T. Choi
- Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
| | - Hardeep Singh
- Department of Medicine, Baylor College of Medicine, Houston, Texas
- Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
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Rosland AM, Piette JD, Trivedi R, Lee A, Stoll S, Youk AO, Obrosky DS, Deverts D, Kerr EA, Heisler M. Effectiveness of a Health Coaching Intervention for Patient-Family Dyads to Improve Outcomes Among Adults With Diabetes: A Randomized Clinical Trial. JAMA Netw Open 2022; 5:e2237960. [PMID: 36374502 PMCID: PMC9664266 DOI: 10.1001/jamanetworkopen.2022.37960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
IMPORTANCE More than 75% of US adults with diabetes do not meet treatment goals. More effective support from family and friends ("supporters") may improve diabetes management and outcomes. OBJECTIVE To determine if the Caring Others Increasing Engagement in Patient Aligned Care Teams (CO-IMPACT) intervention improves patient activation, diabetes management, and outcomes compared with standard care. DESIGN, SETTING, AND PARTICIPANTS This randomized clinical trial was conducted from November 2016 to August 2019 among participants recruited from 2 Veterans Health Administration primary care sites. All patient participants were adults aged 30 to 70 years with diabetes who had hemoglobin A1c (HbA1c) levels greater than 8% of total hemoglobin (to convert to proportion of total hemoglobin, multiply by 0.01) or systolic blood pressure (SBP) higher than 150 mm Hg; each participating patient had an adult supporter. Of 1119 recruited, 239 patient-supporter dyads were enrolled between November 2016 and May 2018, randomized 1:1 to receive the CO-IMPACT intervention or standard care, and followed up for 12 to 15 months. Investigators and analysts were blinded to group assignment. INTERVENTIONS Patient-supporter dyads received a health coaching session focused on dyadic information sharing and positive support techniques, then 12 months of biweekly automated monitoring telephone calls to prompt dyadic actions to meet diabetes goals, coaching calls to help dyads prepare for primary care visits, and after-visit summaries. Standard-care dyads received general diabetes education materials only. MAIN OUTCOMES AND MEASURES Intent-to-treat analyses were conducted according to baseline dyad assignment. Primary prespecified outcomes were 12-month changes in Patient Activation Measure-13 (PAM-13) and UK Prospective Diabetes Study (UKPDS) 5-year diabetes-specific cardiac event risk scores. Secondary outcomes included 12-month changes in HbA1c levels, SBP, diabetes self-management behaviors, diabetes distress, diabetes management self-efficacy, and satisfaction with health system support for the involvement of family supporters. Changes in outcome measures between baseline and 12 months were analyzed using linear regression models. RESULTS A total of 239 dyads enrolled; among patient participants, the mean (SD) age was 60 (8.9) years, and 231 (96.7%) were male. The mean (SD) baseline HbA1c level was 8.5% (1.6%) and SBP was 140.2 mm Hg (18.4 mm Hg). A total of 168 patients (70.3%) lived with their enrolled supporter; 229 patients (95.8%) had complete 12-month outcome data. In intention-to-treat analyses vs standard care, CO-IMPACT patients had greater 12-month improvements in PAM-13 scores (intervention effect, 2.60 points; 95% CI, 0.02-5.18 points; P = .048) but nonsignificant differences in UKPDS 5-year cardiac risk (intervention effect, 1.01 points; 95% CI, -0.74 to 2.77 points; P = .26). Patients in the CO-IMPACT arm also had greater 12-month improvements in healthy eating (intervention effect, 0.71 d/wk; 95% CI, 0.20-1.22 d/wk; P = .007), diabetes self-efficacy (intervention effect, 0.40 points; 95% CI, 0.09-0.71 points; P = .01), and satisfaction with health system support for the family supporter participants' involvement (intervention effect, 0.28 points; 95% CI, 0.07-0.49 points; P = .009); however, the 2 arms had similar improvements in HbA1c levels and in other measures. CONCLUSIONS AND RELEVANCE In this randomized clinical trial, the CO-IMPACT intervention successfully engaged patient-supporter dyads and led to improved patient activation and self-efficacy. Physiological outcomes improved similarly in both arms. More intensive direct coaching of supporters, or targeting patients with less preexisting support or fewer diabetes management resources, may have greater impact. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02328326.
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Affiliation(s)
- Ann-Marie Rosland
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Department of Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - John D. Piette
- Department of Health Behavior and Health Education, School of Public Health, University of Michigan, Ann Arbor
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Ranak Trivedi
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, California
- Center for Innovation to Implementation, VA Palo Alto Healthcare System, Menlo Park, California
| | - Aaron Lee
- Department of Psychology, University of Mississippi, University
| | - Shelley Stoll
- Department of Internal Medicine and the Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Ada O. Youk
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania
| | - D. Scott Obrosky
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Department of Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Denise Deverts
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Department of Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Eve A. Kerr
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
- Department of Internal Medicine and the Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Michele Heisler
- Department of Health Behavior and Health Education, School of Public Health, University of Michigan, Ann Arbor
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
- Department of Internal Medicine and the Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
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Leung LB, Steers WN, Hoggatt KJ, Washington DL. Explaining racial-ethnic differences in hypertension and diabetes control among veterans before and after patient-centered medical home implementation. PLoS One 2020; 15:e0240306. [PMID: 33044984 PMCID: PMC7549758 DOI: 10.1371/journal.pone.0240306] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 09/23/2020] [Indexed: 11/18/2022] Open
Abstract
Patient-centered medical homes (PCMH) are primary care delivery models that improve care access and population-level health outcomes, yet they have not been observed to narrow racial-ethnic disparities in the Veteran Health Administration (VHA) or other health systems. We aimed to identify and compare underlying drivers of persistent hypertension and diabetes control differences between non-Hispanic Black (Black) and Hispanic versus non-Hispanic White (White) patients before and after PCMH implementation in the VHA. Among Black and Hispanic versus White VHA primary care patients in 2009 (nhypertension = 26,906; ndiabetes = 21,141) and 2014 (nhypertension = 83,809; ndiabetes = 38,887), we retrospectively examined hypertension control (blood pressure<140/90) and diabetes control (hemoglobin A1c <9) obtained through random chart abstraction of patient health records nationally via VHA's quality monitoring program. We fit linear probability regression models, adjusting for age, gender, comorbidity, and socioeconomic status (SES). Blinder-Oaxaca and Smith-Welch decomposition methods were used to parse out explained and unexplained contributors to health disparity between racial-ethnic groups pre- and post-PCMH implementation. Compared to White patients, hypertension and diabetes control remained significantly lower for Black (-6.2%[0.4%] and -3.1%[0.6%], respectively; p's<0.001) and Hispanic (-1.4%[0.8%] and -4.0%[1.0%], respectively; p's<0.001) patients following VHA PCMH implementation. Most racial-ethnic differences (55.7-92.3%; all p<0.05) were not attributed to age, gender, comorbidity, and SES. The contribution of explained versus unexplained factors did not significantly change over time. While many explanations for persistent racial-ethnic disparities in disease control among veterans exist, our study did not find that it was due to an influx of "sick" or "socioeconomically vulnerable" patients into the VHA following PCMH implementation. Instead, unexplained differences may be due to differential healthcare and community experiences (e.g., discrimination). Understanding underlying pathways leading to health disparities will better inform policy and clinical interventions to improve PCMH care delivery to racial-ethnic minority patients in health systems.
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Affiliation(s)
- Lucinda B. Leung
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation, & Policy (Health Equity-QUERI National Partnered Evaluation Center), VA Greater Los Angeles Healthcare System, Los Angeles, California, United States of America
- Division of General Internal Medicine and Health Services Research, Department of Medicine, UCLA David Geffen School of Medicine, Los Angeles, California, United States of America
| | - W. Neil Steers
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation, & Policy (Health Equity-QUERI National Partnered Evaluation Center), VA Greater Los Angeles Healthcare System, Los Angeles, California, United States of America
- Division of General Internal Medicine and Health Services Research, Department of Medicine, UCLA David Geffen School of Medicine, Los Angeles, California, United States of America
| | - Katherine J. Hoggatt
- San Francisco VA Health Care System, San Francisco, California, United States of America
- Department of Medicine, University of California, San Francisco, San Francisco, CA, United States of America
| | - Donna L. Washington
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation, & Policy (Health Equity-QUERI National Partnered Evaluation Center), VA Greater Los Angeles Healthcare System, Los Angeles, California, United States of America
- Division of General Internal Medicine and Health Services Research, Department of Medicine, UCLA David Geffen School of Medicine, Los Angeles, California, United States of America
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Hysong SJ, Amspoker AB, Hughes AM, Woodard L, Oswald FL, Petersen LA, Lester HF. Impact of team configuration and team stability on primary care quality. Implement Sci 2019; 14:22. [PMID: 30841926 PMCID: PMC6404317 DOI: 10.1186/s13012-019-0864-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Accepted: 01/30/2019] [Indexed: 12/02/2022] Open
Abstract
Background The science of effective teams is well documented; far less is known, however, about how specific team configurations may impact primary care team effectiveness. Further, teams experiencing frequent personnel changes (perhaps as a consequence of poor implementation) may have difficulty delivering effective, continuous, well-coordinated care. This study aims to examine the extent to which primary care clinics in the Veterans Health Administration have implemented team configurations consistent with recommendations based on the Patient-Centered Medical Home model and the extent to which adherence to said recommendations, team stability, and role stability impact healthcare quality. Specifically, we expect to find better clinical outcomes in teams that adhere to recommended team configurations, teams whose membership and configuration are more stable over time, and teams whose clinical manager role is more stable over time. Methods/design We will employ a combination of social network analysis and multilevel modeling to conduct a database review of variables extracted from the Veterans Health Administration’s Team Assignments Report (TAR) (one of the largest, most diverse existing national samples of primary care teams (nteams > 7000)), as well as other employee and clinical data sources. To ensure the examination of appropriate clinical outcomes, we will enlist a team of subject matter experts to select a concise set of clear, prioritized primary care performance metrics. We will accomplish this using the Productivity Measurement and Enhancement System, an evidence-based methodology for developing and implementing performance measurement. Discussion We are unaware of other studies of healthcare teams that consider team size, composition, and configuration longitudinally or with sample sizes of this magnitude. Results from this study can inform primary care team implementation policy and practice in both private- and public-sector clinics, such that teams are configured optimally, with adequate staffing, and the right mix of roles within the team. Trial registration Not applicable—this study does not involve interventions on human participants. Electronic supplementary material The online version of this article (10.1186/s13012-019-0864-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Sylvia J Hysong
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX, USA. .,Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey VA Medical Center, Houston, TX, USA.
| | - Amber B Amspoker
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX, USA.,Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey VA Medical Center, Houston, TX, USA
| | - Ashley M Hughes
- Department of Biomedical and Health Information Sciences, University of Illinois Chicago, Chicago, IL, USA
| | - Lechauncy Woodard
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX, USA.,Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey VA Medical Center, Houston, TX, USA
| | | | - Laura A Petersen
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX, USA.,Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey VA Medical Center, Houston, TX, USA
| | - Houston F Lester
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX, USA.,Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey VA Medical Center, Houston, TX, USA
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Stehno-Bittel L, VanHoose L. Capsule Commentary on Woodard et al., Impact of Patient-Centered Medical Home Implementation on Diabetes Control in the Veterans Health Administration. J Gen Intern Med 2018; 33:1384. [PMID: 29869140 PMCID: PMC6082186 DOI: 10.1007/s11606-018-4509-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
| | - Lisa VanHoose
- University of Kansas Medical Center, Kansas City, KS, USA
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