Journal of General Internal Medicine

, Volume 34, Issue 8, pp 1546–1553 | Cite as

Patient-Reported Access in the Patient-Centered Medical Home and Avoidable Hospitalizations: an Observational Analysis of the Veterans Health Administration

  • Matthew R. AugustineEmail author
  • Karin M. Nelson
  • Stephan D. Fihn
  • Edwin S. Wong



The Patient-Centered Medical Home (PCMH) has emphasized timely access to primary care, often by using non-traditional modes of delivery, such as care in person after-hours or by phone during or after normal hours. Limited data exists on whether improving patient-reported access with these service types reduces hospitalization.


To examine the association of patient-reported access to primary care within the Veteran Health Administration (VHA) via five service types and hospitalizations for ambulatory care sensitive conditions (ACSCs).


Retrospective cohort study, using multivariable logistic regression adjusting for patient demographics, comorbidity, characteristics of patients’ area of residence, and clinic-level random effects.


A total of 69,710 VHA primary care patients who responded to the 2012 Survey of Healthcare Experiences of Patients (SHEP), PCMH module.

Main Measures

Survey questions captured patients’ ability to obtain care from VHA for five service types: routine care, immediate care, after-hours care, care by phone during regular office hours, and care by phone after normal hours. Outcomes included binary measures of hospitalization for overall, acute, and chronic ACSCs in 2013, identified in VHA administrative data and Medicare fee-for-service claims.

Key Results

Patients who reported “always” able to obtain after-hours care compared to “never” were less likely to be hospitalized for chronic ACSCs (OR 0.62, 95% CI 0.44–0.89, p = 0.009). Patients reporting “usually” getting care by phone during regular hours were more likely have a hospitalization for chronic ACSC (OR 1.49, 95% CI 1.03–2.17, p = 0.034). Experiences with routine care, immediate care, and care by phone after-hours demonstrated no significant association with hospitalization for ACSCs.


Improving patients’ ability to obtain after-hours care was associated with fewer hospitalizations for chronic ACSCs, while access to care by phone during regular hours was associated with more hospitalizations. Health systems should consider the benefits, including reduced hospitalizations for chronic ACSCs, against the costs of implementing each of these PCMH services.


access to care primary care veterans Health Services Research utilization 



This work was undertaken as part of the Veterans Health Administration’s Primary Care Analytics and Evaluation Unit, supporting and evaluating VHA’s transition to a PCMH. Funding for the Primary Care Analytics and Evaluation Unit is provided by the VHA Office of Primary Care. In addition, we worked in collaboration with the VHA’s Office of Performance Measurement for the use of data from the SHEP-PCMH. We thank the administrative staff and analytic teams within these organizations for their support and assistance. At the time of this research, Dr. Augustine was supported by a VHA HSR&D Physician Advanced Fellowship and is currently supported by the Department of Medicine at James J Peters VA Medical Center and the Empire Clinical Research Investigator Program awarded through the Department of Medicine at the Icahn School of Medicine at Mount Sinai. Dr. Wong was supported by VA HSR&D Career Development Award (CDA-13-024).

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they do not have a conflict of interest.


The views expressed in this paper are of the authors and do not necessarily reflect the position or policy of the United States Government, Department of Veterans Affairs, University of Washington, or Icahn School of Medicine at Mount Sinai.

Supplementary material

11606_2019_5060_MOESM1_ESM.pdf (399 kb)
ESM 1 (PDF 398 kb)


  1. 1.
    Fortney JC, Steffick DE, Burgess JF, Maciejewski ML, Petersen LA. Are primary care services a substitute or complement for specialty and inpatient services? Health Serv Res. 2005;40(5 Pt 1):1422–1442.CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q. 2005;83(3):457–502.CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    Schoen C, Osborn R, Squires D, Doty MM. Access, affordability, and insurance complexity are often worse in the United States compared to ten other countries. Health Affairs. 2013;32(12):2205–2215.CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Kilo CM, Wasson JH. Practice redesign and the patient-centered medical home: history, promises, and challenges. Health Affairs. 2010;29(5):773–778.CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Jackson GL, Powers BJ, Chatterjee R, et al. Improving patient care. The patient centered medical home. A Systematic Review. Ann Intern Med. 2013;158(3):169–178.CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Yoon J, Chow A, Rubenstein LV. Impact of medical home implementation through evidence-based quality improvement on utilization and costs. Med Care. 2016;54(2):118–125.CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Kehle SM, Greer N, Rutks I, Wilt T. Interventions to improve veterans’ access to care: a systematic review of the literature. J Gen Intern Med. 2011;26(S2):689–696.CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Institute of Medicine (US) Committee on Monitoring Access to Personal Health Care Services, Millman M. Access to Health Care in America; 1993.
  9. 9.
    Bindman AB, Grumbach K, Osmond D, et al. Preventable hospitalizations and access to health care. JAMA. 1995;274(4):305–311.CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    AHRQ QI, Version 4.5. Prevention Quality Indicators #90, Technical Specifications, Prevention Quality Overall Composite. Published 2013. Accessed March 5, 2017.
  11. 11.
    AHRQ. Potentially Avoidable Hospitalization. Published 2016. Accessed December 2, 2016.
  12. 12.
    Lin Y-H, Eberth JM, Probst JC. Ambulatory care-sensitive condition hospitalizations among medicare beneficiaries. Am J Prev Med. 2016;51(4):493–501.CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Ansari Z, Laditka JN, Laditka SB. Access to health care and hospitalization for ambulatory care sensitive conditions. Med Care Res Rev. 2006;63(6):719–741.CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Gibson OR, Segal L, McDermott RA. A systematic review of evidence on the association between hospitalisation for chronic disease related ambulatory care sensitive conditions and primary health care resourcing. BMC Health Serv Res. 2013;13:336.CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    Rosano A, Loha CA, Falvo R, et al. The relationship between avoidable hospitalization and accessibility to primary care: a systematic review. Eur J Public Health. 2013;23(3):356–360.CrossRefPubMedPubMedCentralGoogle Scholar
  16. 16.
    van Loenen T, van den Berg MJ, Westert GP, Faber MJ. Organizational aspects of primary care related to avoidable hospitalization: a systematic review. Fam Pract. 2014;31(5):502–516.CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    Oster A, Bindman AB. Emergency department visits for ambulatory care sensitive conditions: insights into preventable hospitalizations. Med Care. 2003;41(2):198–207.PubMedPubMedCentralGoogle Scholar
  18. 18.
    Schreiber S, Zielinski T. The meaning of ambulatory care sensitive admissions: urban and rural perspectives. J Rural Health. 1997;13(4):276–284.CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Culler SD, Parchman ML, Przybylski M. Factors related to potentially preventable hospitalizations among the elderly. Med Care. 1998;36(6):804–817.CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    Will JC, Yoon PW. Preventable hospitalizations for hypertension: establishing a baseline for monitoring racial differences in rates. Prev Chronic Dis. 2013;10:120165.CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    Blustein J, Hanson K, Shea S. Preventable hospitalizations and socioeconomic status. Health Aff (Millwood). 1998;17(2):177–189.CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    Pappas G, Hadden WC, Kozak LJ, Fisher GF. Potentially avoidable hospitalizations: inequalities in rates between US socioeconomic groups. Am J Public Health. 1997;87(5):811–816.CrossRefPubMedPubMedCentralGoogle Scholar
  23. 23.
    Bottle A, Millett C, Xie Y, Saxena S, Wachter RM, Majeed A. Quality of primary care and hospital admissions for diabetes mellitus in England. J Ambul Care Manage. 2008;31(3):226–238.CrossRefPubMedPubMedCentralGoogle Scholar
  24. 24.
    Nelson KM, Helfrich C, Sun H, et al. Implementation of the patient-centered medical home in the Veterans Health Administration: associations with patient satisfaction, quality of care, staff burnout, and hospital and emergency department use. JAMA Intern Med. 2014;174(8):1350–1358.CrossRefPubMedPubMedCentralGoogle Scholar
  25. 25.
    Yoon J, Liu C-F, Lo J, et al. Early changes in VA medical home components and utilization. Am J Manag Care. 2015;21(3):197–204.PubMedPubMedCentralGoogle Scholar
  26. 26.
    Fortney JC, Burgess JF, Bosworth HB, Booth BM, Kaboli PJ. A re-conceptualization of access for 21st century healthcare. J Gen Intern Med. 2011;26 Suppl 2:639–647.CrossRefPubMedPubMedCentralGoogle Scholar
  27. 27.
    Rosenstock IM, Strecher VJ, Becker MH. Social learning theory and the Health Belief Model. Health Educ Q. 1988;15(2):175–183.CrossRefPubMedPubMedCentralGoogle Scholar
  28. 28.
    CAHPS-CG. Patient-Centered Medical Home (PCMH) Item Set. Accessed August 23, 2016.
  29. 29.
    Scholle SH, Vuong O, Ding L, et al. Development of and field test results for the CAHPS PCMH Survey. Med Care. 2012;50 Suppl:S2-S10.CrossRefPubMedPubMedCentralGoogle Scholar
  30. 30.
    HRSA. Area Health Resources Files (AHRF). 2011 ed. Rockville, MD: Health Resources and Services Administration, Bureau of Health Workforce; 2012.Google Scholar
  31. 31.
    WWAMI Rural Health Resource Center. Rural-Urban Commuting Areas (RUCA) Data Version 2.0. 2007.
  32. 32.
    Hays RD, Berman LJ, Kanter MH, et al. Evaluating the psychometric properties of the CAHPS Patient-centered Medical Home survey. Clin Ther. 2014;36(5):689–696.e1.CrossRefPubMedPubMedCentralGoogle Scholar
  33. 33.
    Hausmann LRM, Gao S, Mor MK, Schaefer JH, Fine MJ. Understanding racial and ethnic differences in patient experiences with outpatient health care in Veterans Affairs Medical Centers. Med Care. 2013;51(6):532–539.CrossRefPubMedPubMedCentralGoogle Scholar
  34. 34.
    Jones AL, Mor MK, Cashy JP, et al. Racial/ethnic differences in primary care experiences in patient-centered medical homes among veterans with mental health and substance use disorders. J Gen Intern Med. 2016;31(12):1435–1443.CrossRefPubMedPubMedCentralGoogle Scholar
  35. 35.
    AHRQ QI, Version 4.5. Prevention Quality Indicators #91, Technical Specfications, Prevention Quality Acute Composite. Published 2013. Accessed March 5, 2017.
  36. 36.
    AHRQ QI, Version 4.5. Prevention Quality Indicators #92, Technical Specifications, Prevention Quality Chronic Composite. Published 2013. Accessed March 5, 2017.
  37. 37.
    Wong ES, Hebert PL, Hernandez SE, et al. Association between local area unemployment rates and use of Veterans Affairs outpatient health services. Med Care. 2014;52(2):137–143.CrossRefPubMedPubMedCentralGoogle Scholar
  38. 38.
    Wong ES, Hebert PL, Nelson KM, et al. Local area unemployment and the demand for inpatient care among veterans affairs enrollees. Med Care Res Rev. 2015;72(4):468–480.CrossRefPubMedPubMedCentralGoogle Scholar
  39. 39.
    Poverty Areas. U S Census Bureau. Published June 1, 1995. Accessed March 1, 2016.
  40. 40.
    Hynes DM, Koelling K, Stroupe K, et al. Veterans’ access to and use of Medicare and Veterans Affairs health care. Med Care. 2007;45(3):214–223.CrossRefPubMedPubMedCentralGoogle Scholar
  41. 41.
    Veterans Health Administration. Rurality Definition and Methods Work Group Report. Office for Health for Policy and Planning. Department of Veterans Affairs; 2013.Google Scholar
  42. 42.
    Maciejewski ML, Perkins M, Li Y-F, Chapko M, Fortney JC, Liu C-F. Utilization and expenditures of veterans obtaining primary care in community clinics and VA medical centers: an observational cohort study. BMC Health Serv Res. 2007;7:56.CrossRefPubMedPubMedCentralGoogle Scholar
  43. 43.
    Borowsky SJ, Nelson DB, Fortney JC, Hedeen AN, Bradley JL, Chapko MK. VA community-based outpatient clinics: performance measures based on patient perceptions of care. Med Care. 2002;40(7):578–586.CrossRefPubMedPubMedCentralGoogle Scholar
  44. 44.
    Fortney JC, Borowsky SJ, Hedeen AN, Maciejewski ML, Chapko MK. VA community-based outpatient clinics: access and utilization performance measures. Med Care. 2002;40(7):561–569.CrossRefPubMedPubMedCentralGoogle Scholar
  45. 45.
    Liu C-F, Chapko M, Bryson CL, et al. Use of outpatient care in Veterans Health Administration and Medicare among veterans receiving primary care in community-based and hospital outpatient clinics. Health Serv Res. 2010;45(5 Pt 1):1268–1286.CrossRefPubMedPubMedCentralGoogle Scholar
  46. 46.
    Andersen RM. Revisiting the behavioral model and access to medical care: does it matter? J Health Soc Behav. 1995;36(1):1–10.CrossRefPubMedPubMedCentralGoogle Scholar
  47. 47.
    Gagne JJ, Glynn RJ, Avorn J, Levin R, Schneeweiss S. A combined comorbidity score predicted mortality in elderly patients better than existing scores. J Clin Epidemiol. 2011;64(7):749–759.CrossRefPubMedPubMedCentralGoogle Scholar
  48. 48.
    Skinner HG, Coffey R, Jones J, Heslin KC, Moy E. The effects of multiple chronic conditions on hospitalization costs and utilization for ambulatory care sensitive conditions in the United States: a nationally representative cross-sectional study. BMC Health Serv Res. 2016;16(1):77.CrossRefPubMedPubMedCentralGoogle Scholar
  49. 49.
    Elixhauser A, Steiner C, Harris DR, Coffey RM. Comorbidity measures for use with administrative data. Med Care. 1998;36(1):8–27.CrossRefPubMedPubMedCentralGoogle Scholar
  50. 50.
    Romano PS, Roos LL, Jollis JG. Adapting a clinical comorbidity index for use with ICD-9-CM administrative data: differing perspectives. J Clin Epidemiol. 1993;46(10):1075–9 discussion1081–90.CrossRefPubMedPubMedCentralGoogle Scholar
  51. 51.
    Yoon J, Yano EM, Altman L, et al. Reducing costs of acute care for ambulatory care-sensitive medical conditions: the central roles of comorbid mental illness. Med Care. 2012;50(8):705–713.CrossRefPubMedPubMedCentralGoogle Scholar
  52. 52.
    Augustine MR, Nelson KM, Fihn SD, Wong ES. How are patients accessing primary care within the patient-centered medical home? results from the Veterans Health Administration. J Ambul Care Manage. 2018;41(3):194–203.CrossRefPubMedPubMedCentralGoogle Scholar
  53. 53.
    Huang G, Kim S, Gasper J, Xu Y, Bosworth T, May L. 2016 Survey of Veteran Enrollees’ Health and Use of Health Care. Rockville, MD; 2017:1–207.Google Scholar
  54. 54.
    Prentice JC, Davies ML, Pizer SD. Which outpatient wait-time measures are related to patient satisfaction? Am J Med Qual. 2014;29(3):227–235.CrossRefPubMedPubMedCentralGoogle Scholar
  55. 55.
    Prentice JC, Fincke BG, Miller DR, Pizer SD. Outpatient wait time and diabetes care quality improvement. Am J Manag Care. 2011;17(2):e43-e54.PubMedPubMedCentralGoogle Scholar
  56. 56.
    Kangovi S, Barg FK, Carter T, Long JA, Shannon R, Grande D. Understanding why patients of low socioeconomic status prefer hospitals over ambulatory care. Health Affairs. 2013;32(7):1196–1203.CrossRefPubMedPubMedCentralGoogle Scholar
  57. 57.
    Berkowitz SA, Meigs JB, DeWalt D, et al. Material need insecurities, control of diabetes mellitus, and use of health care resources: results of the Measuring Economic Insecurity in Diabetes study. JAMA Intern Med. 2015;175(2):257–265.CrossRefPubMedPubMedCentralGoogle Scholar
  58. 58.
    Lowe RA, Localio AR, Schwarz DF, et al. Association between primary care practice characteristics and emergency department use in a medicaid managed care organization. Med Care. 2005;43(8):792–800.CrossRefPubMedPubMedCentralGoogle Scholar
  59. 59.
    Sherman BW, Gibson TB, Lynch WD, Addy C. Health care use and spending patterns vary by wage level in employer-sponsored plans. Health Affairs. 2017;36(2):250–257.CrossRefPubMedPubMedCentralGoogle Scholar
  60. 60.
    Cowling TE, Harris M, Majeed A. Extended opening hours and patient experience of general practice in England: multilevel regression analysis of a national patient survey. BMJ Qual Saf. 2017;26(5):360–371.PubMedPubMedCentralGoogle Scholar
  61. 61.
    O’Malley AS. After-hours access to primary care practices linked with lower emergency department use and less unmet medical need. Health Affairs. 2013;32(1):175–183.CrossRefPubMedPubMedCentralGoogle Scholar
  62. 62.
    Campbell JL, Fletcher E, Britten N, et al. Telephone triage for management of same-day consultation requests in general practice (the ESTEEM trial): a cluster-randomised controlled trial and cost-consequence analysis. Lancet. 2014;384(9957):1859–1868.CrossRefPubMedPubMedCentralGoogle Scholar
  63. 63.
    Campbell JL, Fletcher E, Britten N, et al. The clinical effectiveness and cost-effectiveness of telephone triage for managing same-day consultation requests in general practice: a cluster randomised controlled trial comparing general practitioner-led and nurse-led management systems with usual care (the ESTEEM trial). Health Technol Assess. 2015;19(13):1–212–vii–viii.PubMedPubMedCentralGoogle Scholar
  64. 64.
    Yoon J, Cordasco KM, Chow A, Rubenstein LV. The relationship between same-day access and continuity in primary care and emergency department visits. PLoS ONE. 2015;10(9):e0135274.CrossRefPubMedPubMedCentralGoogle Scholar
  65. 65.
    Bunn F, Byrne G, Kendall S. Telephone consultation and triage: effects on health care use and patient satisfaction. Cochrane Database Syst Rev. 2004;(4):CD004180.Google Scholar
  66. 66.
    Rubin G, Bate A, George A, Shackley P, Hall N. Preferences for access to the GP: a discrete choice experiment. Br J Gen Pract. 2006;56(531):743–748.PubMedPubMedCentralGoogle Scholar
  67. 67.
    Turner D, Tarrant C, Windridge K, et al. Do patients value continuity of care in general practice? An investigation using stated preference discrete choice experiments. J Health Serv Res Policy. 2007;12(3):132–137.CrossRefPubMedPubMedCentralGoogle Scholar
  68. 68.
    Ajmera M, Wilkins TL, Sambamoorthi U. Dual Medicare and Veteran Health Administration use and ambulatory care sensitive hospitalizations. J Gen Intern Med. 2011;26 Suppl 2:669–675.CrossRefPubMedPubMedCentralGoogle Scholar
  69. 69.
    Cheraghi-Sohi S, Hole AR, Mead N, et al. What patients want from primary care consultations: a discrete choice experiment to identify patients’ priorities. Ann Fam Med. 2008;6(2):107–115.CrossRefPubMedPubMedCentralGoogle Scholar
  70. 70.
    Carret MLV, Fassa AG, Kawachi I. Demand for emergency health service: factors associated with inappropriate use. BMC Health Serv Res. 2007;7:131.CrossRefPubMedPubMedCentralGoogle Scholar
  71. 71.
    Rust G, Ye J, Baltrus P, Daniels E, Adesunloye B, Fryer GE. Practical barriers to timely primary care access: impact on adult use of emergency department services. Arch Intern Med. 2008;168(15):1705–1710.CrossRefPubMedPubMedCentralGoogle Scholar
  72. 72.
    Cheung PT, Wiler JL, Lowe RA, Ginde AA. National study of barriers to timely primary care and emergency department utilization among Medicaid beneficiaries. Ann Emerg Med. 2012;60(1):4–10.e2.CrossRefPubMedPubMedCentralGoogle Scholar
  73. 73.
    Davis K, Stremikis K, Squires D, Schoen C. Mirror, mirror on the wall, 2014 update: how the us health care system compares internationally. The Commonwealth Fund; 2014.Google Scholar
  74. 74.
    Aysola J, Rhodes KV, Polsky D. Patient-centered medical homes and access to services for new primary care patients. Med Care. 2015;53(10):857–862.PubMedPubMedCentralGoogle Scholar

Copyright information

© Society of General Internal Medicine (This is a U.S. government work and not under copyright protection in the U.S.; foreign copyright protection may apply) 2019

Authors and Affiliations

  • Matthew R. Augustine
    • 1
    • 2
    Email author
  • Karin M. Nelson
    • 3
    • 4
    • 5
  • Stephan D. Fihn
    • 3
    • 4
  • Edwin S. Wong
    • 4
    • 5
  1. 1.Department of Medicine James J Peters VA Medical CenterBronxUSA
  2. 2.Department of MedicineIcahn School of Medicine at Mount SinaiNew YorkUSA
  3. 3.Department of MedicineUniversity of WashingtonSeattleUSA
  4. 4.Department of Health ServicesUniversity of WashingtonSeattleUSA
  5. 5.Center of Innovation for Veteran-Centered and Value-Driven CareVA Puget Sound Health Care SystemSeattleUSA

Personalised recommendations