Outcomes of a randomized quality improvement trial for high-risk Veterans in year two

Evelyn T Chang; Jean Yoon; Aryan Esmaeili; Donna M Zulman; Michael K Ong; Susan E Stockdale; Elvira E Jimenez; Karen Chu; David Atkins; Angela Denietolis; Steven M Asch; PACT Intensive Management (PIM) Demonstration Sites, PIM National Evaluation Center, and PIM Executive Committee

doi:10.1111/1475-6773.13674

Outcomes of a randomized quality improvement trial for high-risk Veterans in year two

Health Serv Res. 2021 Oct;56 Suppl 1(Suppl 1):1045-1056. doi: 10.1111/1475-6773.13674. Epub 2021 Jun 18.

Authors

Evelyn T Chang^{1

2

3}, Jean Yoon^{4

5}, Aryan Esmaeili⁴, Donna M Zulman^{6

7}, Michael K Ong^{2

3

8}, Susan E Stockdale^{1

9}, Elvira E Jimenez^{1

10}, Karen Chu¹, David Atkins¹¹, Angela Denietolis¹², Steven M Asch^{6

7}; PACT Intensive Management (PIM) Demonstration Sites, PIM National Evaluation Center, and PIM Executive Committee

Affiliations

¹ VA Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), Los Angeles, California, USA.
² Department of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA.
³ Department of Medicine, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California, USA.
⁴ VA Health Economics Resource Center (HERC), Menlo Park, California, USA.
⁵ Department of General Internal Medicine, UCSF School of Medicine, San Francisco, California, USA.
⁶ VA HSR&D Center for Innovation to Implementation, Menlo Park, California, USA.
⁷ Division of Primary Care and Population Health, Stanford University School of Medicine, Menlo Park, California, USA.
⁸ Department of Health Policy and Management, Fielding School of Public Health, University of California at Los Angeles, Los Angeles, California, USA.
⁹ Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, California, USA.
¹⁰ Behavioral Neurology, Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California, USA.
¹¹ VA Health Services Research and Development, Washington, District of Columbia, USA.
¹² VA Office of Primary Care, Washington, District of Columbia, USA.

Abstract

Objective: The Veterans Health Administration (VHA) conducted a randomized quality improvement evaluation to determine whether augmenting patient-centered medical homes with Primary care Intensive Management (PIM) decreased utilization of acute care and health care costs among patients at high risk for hospitalization. PIM was cost-neutral in the first year; we analyzed changes in utilization and costs in the second year.

Data sources: VHA administrative data for five demonstration sites from August 2013 to March 2019.

Data sources: Administrative data extracted from VHA's Corporate Data Warehouse.

Study design: Veterans with a risk of 90-day hospitalization in the top 10th percentile and recent hospitalization or emergency department (ED) visit were randomly assigned to usual primary care vs primary care augmented by PIM. PIM included interdisciplinary teams, comprehensive patient assessment, intensive case management, and care coordination services. We compared the change in mean VHA inpatient and outpatient utilization and costs (including PIM expenses) per patient for the 12-month period before randomization and 13-24 months after randomization for PIM vs usual care using difference-in-differences.

Principal findings: Both PIM patients (n = 1902) and usual care patients (n = 1882) had a mean of 5.6 chronic conditions. PIM patients had a greater number of primary care visits compared to those in usual care (mean 4.6 visits/patient/year vs 3.7 visits/patient/year, p < 0.05), but ED visits (p = 0.45) and hospitalizations (p = 0.95) were not significantly different. We found a small relative increase in outpatient costs among PIM patients compared to those in usual care (mean difference + $928/patient/year, p = 0.053), but no significant differences in mean inpatient costs (+$245/patient/year, p = 0.97). Total mean health care costs were similar between the two groups during the second year (mean difference + $1479/patient/year, p = 0.73).

Conclusions: Approaches that target patients solely based on the high risk of hospitalization are unlikely to reduce acute care use or total costs in VHA, which already offers patient-centered medical homes.

Keywords: Patient Care Team; Veterans Health Services; case management; multimorbidity.

Publication types

Research Support, U.S. Gov't, Non-P.H.S.

MeSH terms

Adult
Chronic Disease / economics*
Chronic Disease / therapy*
Female
Humans
Male
Middle Aged
Patient-Centered Care / organization & administration*
Primary Health Care / organization & administration*
Quality Improvement / organization & administration*
United States
United States Department of Veterans Affairs
Veterans Health Services / organization & administration*
Veterans*