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

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 1650976 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 1650976 patients, of whom 581167 (35.20%) were younger than 65 years (mean [SD] age, 49.03 [10.28] years; 495247 [85.22%] men) and 1069809 (64.80%) were 65 years or older (mean [SD] age, 74.64 [7.41] years; 1050110 [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