Elements of the Veterans Health Administration Patient-Centered Medical Home are Associated with Greater Adherence to Oral Hypoglycemic Agents in Patients with Diabetes

Abstract

In 2010, Veterans Health Administration (VHA) primary care clinics adopted a patient-centered medical home (PCMH) model. This study sought to examine the association between the organizational features related to adoption of PCMH and the level of adherence to oral hypoglycemic agents (OHAs) among patients with diabetes. This retrospective cohort study involved 757 VA clinics that provide primary care to 440,971 patients with diabetes who were taking OHAs in fiscal year 2012. One-year refill-based medication possession ratios (MPRs) were calculated at the patient level. Clinic-level adherence was defined as the proportion of clinics with MPR ≥80%. Risk adjustment of adherence was performed using logistic regression to account for differences in patient populations at clinics. Eight domains of the PCMH model (ie, access, continuity, coordination, teamwork, comprehensive care, self-management, communication, shared decision making) were assessed using items from a previously validated index. Multivariate linear regression was applied to identify PCMH components associated with clinic-level adherence. Patients with diabetes per clinic ranged from 100 to 5011. The average level of adherence to OHAs among clinics ranged from 52.8% to 61.9% (interquartile range = 57.9% to 59.4%). In multivariate analysis, organizational features associated with higher clinic-level adherence included access to routine care (standardized beta [Sβ] = .21, P = .004), having a respectful office staff (Sβ = 0.21, P = .002), and utilization of telephone encounters (Sβ = 0.23, P < .001). Among a national cohort of veterans with diabetes, overall PCMH implementation did not significantly increase adherence to oral hypoglycemic agents, although aspects of implementation were associated with increased adherence. Measures of access to care appear the most significant.

Patient-Centered Medical Home Activities Associated With Low Medicare Spending and Utilization

“…Some researchers have begun to explore thisisolating relationships between particular PCMH capabilities and outcomes for veterans, 6,7 persons with diabetes, [8][9][10] veterans with diabetes, 11 persons with diabetes served by safety-net clinics, 12 and children with chronic conditions. 13,14 Studies have also looked at different health care settings, such as federally qualified health centers [15][16][17] and NCQA Level 3 PCMHs in Minnesota.…”

Components of the Patient-Centered Medical Home Associated with Perceived Access to Primary Care

“…Better primary care access is associated with higher patient satisfaction, lower mortality, and improved medication adherence. [1][2][3] However, not all strategies to increase access are equally effective and may have unintended consequences when interacting. When implemented in isolation, some strategies such as open (i.e., advanced) access may lead to improved wait times without clear benefit for health outcomes or utilization.…”