Association of the Implementation of the Patient-Centered Medical Home with Quality of Life in Patients with Multimorbidity
The patient-centered medical home (PCMH) has clinical benefits for chronic disease care, but the association with patient-reported outcomes such as health-related quality of life (HRQoL) is unexplored in patients with multimorbidity (two or more chronic diseases).
To examine if greater clinic-level PCMH implementation was associated with higher HRQoL in multimorbid adults.
A retrospective cohort study.
Twenty-two thousand ninety-five multimorbid patients who received primary care at 944 Veterans Health Administration (VHA) clinics.
Our exposure was the Patient Aligned Care Team Implementation Progress Index (PI2) for the clinic in 2012, a previously validated composite measure of PCMH implementation. Higher PI2 scores indicate better performance within eight PCMH domains. Outcomes were patient-reported HRQoL measured by the physical and mental component scores (PCS and MCS) from the Short Form-12 patient experiences survey in 2013–2014. Interaction of the outcomes with total hospitalizations and primary care visit count was also examined. Generalized estimating equations were used for main models after adjusting for patient and clinic characteristics.
The cohort average age was 68 years, mostly male (96%), and had an average of 4.4 chronic diagnoses. Compared with patients seen at the lowest scoring clinics for PCMH implementation, care in the highest scoring clinics was associated with a higher adjusted marginal mean PCS (42.3 (95% CI 41.3–43.4) versus 40.3 (95% CI 39.1–41.5), P = 0.01), but a lower MCS (35.2 (95% CI 34.4–36.1) versus 36.0 (95% CI 35.3–36.8), P = 0.17). Patients with prior hospitalizations seen in clinics with higher compared with lower PI2 scores had a 2.7 point greater MCS (95% CI 0.6–4.8; P = 0.01).
Multimorbid patients seen in clinics with greater PCMH implementation reported higher physical HRQoL, but lower mental HRQoL. The association between PCMH implementation and mental HRQoL may depend on complex interactions with disease severity and prior hospitalizations.
KEY WORDSvulnerable populations quality of life primary care patient-centered outcomes research comorbidity
Our thanks to the Office of Reporting, Analytics, Performance, Improvement, and Deployment (RAPID) within the Veterans Health Administration for the access to the SHEP data. Additional thanks to Evelyn Chang, Matt Maciejewski, Lisa Rubenstein, Donna Zulman, Paul Hebert, and members of the VHA Primary Care Analytics Team and High-Risk Investigator Network for the insights and comments on the manuscript. Leslie Taylor and Philip Sylling provided invaluable statistical and coding assistance. This work was undertaken as part of the national evaluation of PACT funded by the VHA Office of Primary Care. Support for the primary author was from a VHA HSR&D Advanced Physician Fellowship. ES Wong was supported by a VHA HSR&D Career Development Award (No. 13-024).
Compliance with Ethical Standards
Conflict of Interest
The authors have no additional conflicts of interest, financial or otherwise, to disclose.
Funding agencies had no role in the study’s design, conduct, or reporting. The views expressed are those of the authors and do not necessarily reflect the position of the affiliated institutions.
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