Tribal implementation of a patient-centred medical home model in Alaska accompanied by decreased hospital use.

BACKGROUND: Between 1995 and 1998, tribally owned Southcentral Foundation (SCF) incrementally assumed responsibility from the Indian Health Service (IHS) for primary care services on the Alaska Native Medical Center (ANMC) campus in Anchorage, Alaska. In 1999, SCF began implementing components of a Patient-Centered Medical Home (PCMH) model to improve access and continuity of care. OBJECTIVE: To evaluate hospitalisation trends before, during and after PCMH implementation. DESIGN: Time series analysis of aggregated medical record data. METHODS: Regression analysis with correlated errors was used to estimate trends over time for the percent of customer-owners hospitalised overall and for specific conditions during 4 time periods (March 1996-July 1999: SCF assumes responsibility for primary care; August 1999-July 2000: PCMH implementation starts; August 2000-April 2005: early post-PCMH implementation; May 2005-December 2009: later post-PCMH implementation). Analysis was restricted to individuals residing in Southcentral Alaska and receiving health care at ANMC. RESULTS: The percent of SCF customer-owners hospitalised per month for any reason was steady before and during PCMH implementation, declined steadily immediately following implementation and subsequently stabilised. The percent hospitalised per month for unintentional injury or poisoning also declined during and after the PCMH implementation. Among adult asthma patients, the percent hospitalised annually for asthma declined prior to and during implementation and remained lower thereafter. The percent of heart failure patients hospitalised annually for heart failure remained relatively constant throughout the study period while the percent of hypertension patients hospitalised for hypertension shifted higher between 1999 and 2002 compared to earlier and later years. CONCLUSION: Implementation of PCMH at SCF was accompanied by decreases in the percent of customer-owners hospitalised monthly for any reason and for unintentional injury and in the percent of asthma patients hospitalised annually for asthma. Increased accessibility to empanelled care teams may have contributed to decreased need for hospitalisation.

Process and outcomes of patient-centered medical care with Alaska Native people at Southcentral Foundation.

PURPOSE: This study describes key elements of the transition to a patient-centered medical home (PCMH) model at Southcentral Foundation (SCF), a tribally owned and managed primary care system, and evaluates changes in emergency care use for any reason, for asthma, and for unintentional injuries, during and after the transition. METHODS: We conducted a time series analyses of emergency care use from medical record data. We also conducted 45 individual, in-depth interviews with PCMH patients (customer-owners), primary care clinicians, health system employees, and tribal leaders. RESULTS: Emergency care use for all causes was increasing before the PCMH implementation, dropped during and immediately after the implementation, and subsequently leveled off. Emergency care use for adult asthma dropped before, during, and immediately after implementation, subsequently leveling off approximately 5 years after implementation. Emergency care use for unintentional injuries, a comparison variable, showed an increasing trend before and during implementation and decreasing trends after implementation. Interview participants observed improved access to primary care services after the transition to the PCMH tempered by increased staff fatigue. Additional themes of PCMH transformation included the building of relationships for coordinated, team-based care, and the important role of leadership in PCMH implementation. CONCLUSIONS: All reported measures of emergency care use show a decreasing trend after the PCMH implementation. Before the implementation, overall use and use for unintentional injuries had been increasing. The combined quantitative and qualitative results are consistent with decreased emergency care use resulting from a decreased need for emergency care services due to increased availability of primary care services and same-day appointments.

Chronic disease risk factors among Alaska Native and American Indian people, Alaska, 2004-2006.

INTRODUCTION: The Alaska Education and Research Towards Health (EARTH) Study is being conducted to determine the prevalence of clinically measured chronic disease risk factors in a large population of American Indian/Alaska Native people (AI/AN). We report these estimates and compare them with those for the overall US population, as assessed by the National Health and Nutrition Examination Survey (NHANES). METHODS: We measured blood pressure, height, weight, and fasting serum lipids and glucose in a prospective cohort of 3,822 AI/AN participants who resided in Alaska during 2004 through 2006. We categorized participants as having chronic disease risk factors if their measurements exceeded cutoffs that were determined on the basis of national recommendations. We analyzed the prevalence of risk factors by sex and age and compared the age-adjusted prevalence with 1999-2004 NHANES measurements. RESULTS: EARTH participants were significantly more likely than NHANES participants to be overweight or obese and to have impaired fasting glucose, low high-density lipoprotein cholesterol, high low-density lipoprotein cholesterol, and hypertension. The prevalence of high total cholesterol and triglycerides was not significantly different between the 2 study populations. CONCLUSION: We provide baseline clinical measurements for chronic disease risk factors for a larger study sample than any previous study of AI/AN living in Alaska. The prevalence of most risk factors measured exceeded national rates. These data can be used to tailor health interventions and reduce health disparities.

The impact of hormone therapy on health-related quality of life: longitudinal results from the Study of Women's Health Across the Nation.

OBJECTIVE: To determine the impact of hormone therapy (HT) on health-related quality of life (HRQOL) during the menopausal transition and to examine variation based on menopausal symptom status. DESIGN: The Study of Women's Health Across the Nation is a multisite, multiethnic study of mid-life women without baseline HT use. Women completed annual questionnaires including HT use, menstrual bleeding, symptoms, and HRQOL (Medical Outcomes Study Short Form-36). We compared baseline characteristics of women who initiated HT during follow-up with noninitiators. We examined the effect of HRQOL on the likelihood of initiating HT using survival analysis and the relationship between HT initiation and subsequent HRQOL using longitudinal random effects models. Among HT initiators, we compared change in HRQOL between women with frequent (>or=6 d/wk) and infrequent symptoms. RESULTS: Of the 3,102 participants, 813 initiated HT during the 6-year follow-up period. At baseline, women who subsequently initiated HT were more likely to report poor role physical functioning, higher socioeconomic status, and frequent symptoms and to be white. In longitudinal analyses, women reporting poor role emotional and physical functioning at the visit before initiation were less likely to subsequently initiate (hazard ratio [95% CI]: 0.76 [0.62-0.91] and 0.58 [0.47-0.71]; P<0.01 and <0.0001, respectively), and initiation was associated with subsequent poorer role physical functioning (odds ratio [95% CI]: 1.26 [1.02-1.56]; P=0.03). Among HT initiators, frequent symptom reporters showed improvements in vitality (+2.7) compared with other initiators (-2.9) (P<0.01). CONCLUSIONS: Poor HRQOL does not increase the likelihood of initiating HT, nor is HT use associated with HRQOL improvements. The exception is women reporting frequent symptoms who report improved vitality after initiation. Future studies may employ more frequent HRQOL measures to further discern this trend.