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