Variability in Transitional Care Outcomes Across Hospitals Discharging Veterans to Skilled Nursing Facilities.

BACKGROUND: The period after transition from hospital to skilled nursing facility (SNF) is high-risk, but variability in outcomes related to transitions across hospitals is not well-known. OBJECTIVES: Evaluate variability in transitional care outcomes across Veterans Health Administration (VHA) and non-VHA hospitals for Veterans, and identify characteristics of high-performing and low-performing hospitals. RESEARCH DESIGN: Retrospective observational study using the 2012-2014 Residential History File, which concatenates VHA, Medicare, and Medicaid data into longitudinal episodes of care for Veterans. SUBJECTS: Veterans aged 65 or older who were acutely hospitalized in a VHA or non-VHA hospital and discharged to SNF; 1 transition was randomly selected per patient. MEASURES: Adverse "transitional care" outcomes were a composite of hospital readmission, emergency department visit, or mortality within 7 days of hospital discharge. RESULTS: Among the 365,942 Veteran transitions from hospital to SNF across 1310 hospitals, the composite outcome rate ranged from 3.3% to 23.2%. In multivariable analysis adjusting for patient characteristics, hospital discharge diagnosis and SNF category, no single hospital characteristic was significantly associated with the 7-day adverse outcomes in either VHA or non-VHA hospitals. Very few high or low-performing hospitals remained in this category across all 3 years. The increased odds of having a 7-day event due to being treated in a low versus high-performing hospital was similar to the odds carried by having an intensive care unit stay during the index admission. CONCLUSIONS: While variability in hospital outcomes is significant, unmeasured care processes may play a larger role than currently measured hospital characteristics in explaining outcomes.

Patient and Partner Feedback Reports to Improve Statin Medication Adherence: A Randomized Control Trial.

BACKGROUND: Simple nudges such as reminders and feedback reports to either a patient or a partner may facilitate improved medication adherence. OBJECTIVE: To test the impact of a pill bottle used to monitor adherence, deliver a daily alarm, and generate weekly medication adherence feedback reports on statin adherence. DESIGN: Three-month, three-arm randomized clinical trial (ClinicalTrials.gov identifier: NCT02480530). PARTICIPANTS: One hundred and twenty-six veterans with known coronary artery disease and poor adherence (medication possession ratio <80 %). INTERVENTION: Patients were randomized to one of three groups: (1) a control group (n = 36) that received a pill-monitoring device with no alarms or feedback; (2) an individual feedback group (n = 36) that received a daily alarm and a weekly medication adherence feedback report; and (3) a partner feedback group (n = 54) that received an alarm and a weekly feedback report that was shared with a friend, family member, or a peer. The intervention continued for 3 months, and participants were followed for an additional 3 months after the intervention period. MAIN MEASURES: Adherence as measured by pill bottle. Secondary outcomes included change in LDL (mg/dl), patient activation, and social support. KEY RESULTS: During the 3-month intervention period, medication adherence was higher in both feedback arms than in the control arm (individual feedback group 89 %, partner feedback group 86 %, control group 67 %; p < 0.001 and = 0.001). At 6 months, there was no difference in medication adherence between either of the feedback groups and the control (individual feedback 60 %, partner feedback 52 %, control group 54 %; p = 0.75 and 0.97). CONCLUSIONS: Daily alarms combined with individual or partner feedback reports improved statin medication adherence. While neither an individual feedback nor partner feedback strategy created a sustainable medication adherence habit, the intervention itself is relatively easy to implement and low cost.

Primary care staff perspectives on a virtual learning collaborative to support medical home implementation.

BACKGROUND: Many organizations rely on quality improvement collaboratives (QICs) to facilitate Patient-Centered Medical Home (PCMH) implementation, and there is a trend toward conducting QIC activities virtually to reduce costs and expand their reach. However, the evidence base for QICs is limited; questions remain about how QICs operate, why they succeed or fail, and how they are experienced by participants. OBJECTIVE: We surveyed participants in an innovative Virtual Collaborative (VC) designed to support PCMH implementation within one Veterans Integrated Service Network, to understand why and for whom the VC was more/less effective and identify opportunities for improvement. DESIGN: This anonymous online survey was designed to assess participants' views on the VC's usefulness, impact, and acceptability, and to explore variations by role, practice setting, prior training, and overall engagement in VC activities. PARTICIPANTS: Respondents were 353 primary care staff, including providers, nurses, and support staff. MEASURES/APPROACH: The survey comprised 32 structured and three free-response items. Structured items assessed participation in and perceived usefulness of VC activities; perceived acceptability of the training format; overall perceived impact; and basic demographics. Responses were dichotomized and compared using Chi-square tests. Free-response items inviting constructive criticism of the VC were coded and summarized to identify themes and illustrative quotes. RESULTS: The VC most benefited respondents with prior PCMH training and those who fully participated in VC activities. Respondents especially valued the opportunity to share experiences with other teams. Non-providers and those new to PCMH felt learning content did not meet their needs. Reported barriers to full participation included staffing constraints, insufficient and/or unprotected time, and inadequate leadership support. CONCLUSIONS: Our study offers practical lessons for others considering a virtual collaborative model for PCMH spread. Findings contribute to the evidence base for QICs overall and virtual QICs in particular, highlighting the value of seeking input from "the trenches."

Primary care access and emergency room use among older veterans.

BACKGROUND: Patient access to primary care is often noted to be poor. Improving access may reduce emergency room (ER) visits. OBJECTIVE: To examine the relationship between primary care access and ER use and to test whether this relationship is moderated by having a continuous relationship with a Primary Care Provider (PCP) (or if the PCP is the near-sole provider of care for patients). DESIGN AND PATIENTS: A longitudinal retrospective study of 627,276 patients receiving primary care from 6,398 primary care providers (PCPs) nationally within the Veterans Health Administration (VHA) in 2009. We tracked weekly changes in PCP-level appointment availability. MEASUREMENTS: The number of a PCP's patients who went to the ER in a given week. RESULTS: Among all PCPs, being absent from patient care for the week had no effect on whether that PCP's patients used the ER in that week (incident rate ratio (IRR) 0.997, p = 0.70). However, among PCPs who were near-sole providers of care, a PCP's absence for a week or more had a statistically significant effect on ER visits (IRR 1.04, p = 0.01). The percentage of a PCP's weekly appointment slots that were fully booked (booking density) had no significant effect on whether their patients used the ER in that week among all PCPs. However, among near-sole providers of care, a 10-percentage point increase in the booking density changed the IRR of ER visits in that week by 1.005 (p = 0.08) and by 1.006 on weekdays (p = 0.07). CONCLUSIONS: Patients' access to their PCP had a small effect on whether those patients used the ER among PCPs whose patients rarely saw another PCP. Among other PCPs, there was no effect of PCP access on ER use. These results suggest that sharing patient-care responsibilities across PCPs may be effective in improving access to care and decreasing unnecessary ER use.

Association of Discharge to Home vs Institutional Postacute Care With Outcomes After Lower Extremity Joint Replacement.

Importance: Changes in financial incentives have led to more patients being discharged home than to institutional forms of postacute care, such as skilled nursing facilities (SNFs), after elective lower extremity total joint replacement (LEJR). Objective: To evaluate the association of this change with hospital readmissions, surgical complications, and mortality. Design, Setting, and Participants: This cohort study used cross-temporal propensity-matching to identify 104 828 adult patients who were discharged home following LEJR between 2016 and 2018 (after changes in financial incentives) and 84 121 adult patients discharged to institutional forms of postacute care (eg, SNFs) between 2011 and 2013 (before changes in financial incentives). A difference-in-differences design was used to compare differences in outcomes between these groups to a propensity-matched group of patients discharged to institutional postacute care in both periods. Data were collected from Pennsylvania all-payer claims database, which includes all surgical procedures and hospitalizations across payers and hospitals in Pennsylvania. Data were analyzed between August 2019 and February 2020. Exposures: Type of postacute care (home, including home with home health vs institutional postacute care, including SNF, inpatient rehabilitation facilities, and long-term acute care hospitals). Main Outcomes and Measures: Main outcomes were 30- and 90-day hospital readmissions, LEJR complication rates, and mortality rates. Results: Of 189 949 patients, 113 981 (60.0%) were women, and 83 444 (43.9%) were aged 40 to 64 years. The rate of discharge home increased from 63.6% (54 097 of 85 121) in 2011 to 2013 to 78.4% (82 199 of 104 828) in 2016 to 2018. In the adjusted difference-in-differences comparison, matched patients discharged home in 2016 to 2018 had significantly lower 30-day (difference, -2.9%; 95% CI, -4.2% to -1.6%) and 90-day (difference, -3.9%; 95% CI, -5.8% to -2.0%) readmission rates compared with similar patients sent to institutional postacute care in 2011 to 2013. Surgical complication and mortality rates were unchanged. Results were similar across payers and across hospital bundled payment participation status. Conclusions and Relevance: In this cohort study, increases in discharges home following LEJR surgery did not seem to be associated with increased harm during a period in which changes in financial incentives likely spurred observed changes in postacute care.

External Validation of the Skilled Nursing Facility Prognosis Score for Predicting Mortality, Hospital Readmission, and Community Discharge in Veterans.

BACKGROUND/OBJECTIVES: Prognostic tools are needed to identify patients at high risk for adverse outcomes receiving post-acute care in skilled nursing facilities (SNFs) and provide high-value care. The SNF Prognosis Score was developed in a Medicare sample to predict a composite of long-term SNF stay, hospital readmission, or death during the SNF stay. Our goal was to evaluate the score's performance in an external validation cohort. DESIGN: Retrospective observational analysis. SETTING: We used a Veterans Administration (VA) Residential History File that concatenates VA, Medicare, and Medicaid claims to identify care trajectories across settings and payers for individual veterans. PARTICIPANTS: Previously community-dwelling veterans receiving post-acute care in a SNF after hospitalization from January 1, 2012, to December 31, 2014. Both VA and non-VA hospitals and SNFs were included. MEASUREMENTS: We calculated the five-item SNF Prognosis Score for all eligible veterans in our sample and determined its discrimination (using a receiver operating characteristic curve) and calibration (plotting observed and expected events). RESULTS: The 386,483 veterans in our sample had worse physical function, more comorbidities, and were more likely to be treated for heart failure, but they had shorter index hospital lengths of stay and fewer catheters than the original Medicare cohort. The SNF Prognosis Score had similar discrimination (C-statistic = .70; .75 in the derivation cohort) and calibration at low to moderate levels of risk; at high levels, calibration was poorer with the score overestimating risks of adverse events. CONCLUSION: The SNF Prognosis Score has reasonable discrimination and calibration, and it is simple to calculate using an admission SNF assessment and a nomogram. Future work embedding the score into practice is needed to determine real-world feasibility, acceptability, and effectiveness.

Effect of Peer Mentors in Diabetes Self-management vs Usual Care on Outcomes in US Veterans With Type 2 Diabetes: A Randomized Clinical Trial.

Importance: Diabetes is a substantial public health issue. Peer mentoring is a low-cost intervention for improving glycemic control in patients with diabetes. However, long-term effects of peer mentoring and creation of sustainable models are not well studied. Objective: Assess the effects of a peer support intervention for improving glycemic control in patients with diabetes and evaluate a model in which former mentees serve as mentors. Design, Setting, and Participants: A randomized clinical trial was conducted from September 27, 2012, to March 21, 2018, at the Corporal Michael J. Crescenz Medical Center. US veterans with type 2 diabetes aged 30 to 75 years with hemoglobin A1C (HbA1c) greater than 8% received support over 6 months from peers with prior poor glycemic control but who had achieved HbA1c less than or equal to 7.5% (phase 1). Phase 1 mentees were then randomized to become a mentor or not to new randomly assigned participants in phase 2. Outcomes were assessed at 6 and 12 months. Data were analyzed from October 5, 2016, to September 4, 2018. Interventions: Mentors who received an initial training session and monthly reinforcement training were assigned 1 mentee and given $20 for each month they contacted their mentee at least weekly. Main Outcomes and Measures: Primary outcome was HbA1c change at 6 months. Secondary outcomes included HbA1c change at 12 months and change in low-density lipoprotein, blood pressure, diabetes quality of life, and depression symptoms at 6 and 12 months. Results: The study enrolled 365 participants into phase 1 and 122 participants into phase 2. Most participants were Black (341 [66%]) and male (454 [96%]), with a mean (SD) age of 60 (7.5) years. Mean phase 1 HbA1c change at 6 months for usual care was -0.20% (95% CI, -0.46% to 0.06%) vs -0.52% (95% CI, -0.76% to -0.29%) for mentees (P = .06). Mean phase 2 HbA1c change at 6 months for usual care was -0.46% (95% CI, -1.02% to 0.10%) vs 0.08% (95% CI, -0.42% to 0.57%) for mentees (P = .16). There were no differences in secondary outcomes or HbA1c levels at 12 months. There was no benefit to past mentees who became mentors. Conclusions and Relevance: In this randomized clinical trial, a peer mentor intervention did not improve 6-month HbA1c levels and did not have sustained benefits. Trial Registration: ClinicalTrials.gov Identifier: NCT01651117.

Transitional Care Outcomes in Veterans Receiving Post-Acute Care in a Skilled Nursing Facility.

BACKGROUND: As the veteran population ages, more veterans are receiving post-acute care in skilled nursing facilities (SNFs). However, the outcomes of these transitions across Veterans Affairs (VA) and non-VA settings are unclear. OBJECTIVE: To measure adverse outcomes in veterans transitioning from hospital to SNF in VA and non-VA hospitals and SNFs. DESIGN: Retrospective observational study using the 2012 to 2014 Residential History File, which concatenates VA, Medicare, and Medicaid data into longitudinal episodes of care for veterans. SETTING: VA and non-VA hospitals and SNFs in four categories: non-VA SNFs, VA-contracted SNFs, VA Community Living Centers (CLCs), and State Veterans Homes. PARTICIPANTS: Veterans, aged 65 years or older, who were acutely hospitalized and discharged to an SNF; one transition was randomly selected per patient. MEASUREMENTS: Adverse "transitional care" outcomes were a composite of hospital readmission, emergency department visit, or mortality within 7 days of hospital discharge. RESULTS: More than four in five veteran transitions (81.7%) occurred entirely outside the VA system. The overall 7-day outcome rate was 10.7% in the 388 339 veterans included. Adverse outcomes were lowest in VA hospital-CLC transitions (7.5%; 95% confidence interval [CI] = 7.1%-7.8%) and highest in non-VA hospital to VA-contracted nursing home transitions (17.5%; 95% CI = 16.0%-18.9%) in unadjusted analysis. In multivariate analyses adjusted for patient and hospital characteristics, VA hospitals had lower adverse outcome rates than non-VA hospitals (odds ratio [OR] = 0.80; 95% CI = 0.74-0.86). In comparison to VA hospital-VA CLC transitions, non-VA hospital to VA-contracted nursing homes (OR = 2.51; 95% CI = 2.09-3.02) and non-VA hospital to CLC (OR = 2.25; 95% CI = 1.81-2.79) had the highest overall adverse outcome rates. CONCLUSION: Most veteran hospital-SNF transitions occur outside the VA, although adverse transitional care outcomes are lowest inside the VA. These findings raise important questions about the VA's role as a provider and payer of post-acute care in SNFs. J Am Geriatr Soc 67:1820-1826, 2019.

Association between Continuity and Team-Based Care and Health Care Utilization: An Observational Study of Medicare-Eligible Veterans in VA Patient Aligned Care Team.

OBJECTIVE: It remains unknown whether high-functioning teams can compensate for poor continuity of care to support important patient outcomes. DATA SOURCE: Linked VA administrative and Medicare claims data to measure the relationship of team-based care and continuity of care with high-cost utilization. STUDY DESIGN: Retrospective cohort study of 1.2 million VA-Medicare dual eligible Veterans assigned to a VA primary care provider (PCP) in 2012. Continuity was the proportion of primary care visits to the assigned VA provider of care. Clinics were categorized as low, average, or high-team functioning based on survey data. Our primary outcomes were the number of all-cause hospitalizations, ambulatory care sensitive (ACSC) hospitalizations, and emergency department (ED) visits in 2013. PRINCIPAL FINDINGS: A 10-percentage point increase in continuity with a VA PCP was associated with 4.5 fewer hospitalizations (p < .001), 3.2 fewer ACSC hospitalizations (p < .001), and 2.6 more ED visits (p = .07) per 1,000 patients. Team-based care was not significantly associated with any high-cost utilization category. Associations were heterogeneous across VA-reliant and nonreliant Veterans. Finally, the interaction results demonstrated that the quality of team-based care functioning could not compensate for poor continuity on hospitalizations, ACSC hospitalizations, or ED visits. CONCLUSIONS: In Veterans who were reliant on the VA for services, increasing continuity with a VA PCP and high-functioning team-based care clinics was associated with fewer ED visits and hospitalizations. Furthermore, leveraging combined data from VA and Medicare allowed to better measure continuity and assess high-cost utilization among Veterans who are and are not reliant on the VA for services.

Mortality among patients in VA hospitals in the first 2 years following ACGME resident duty hour reform.

CONTEXT: Limitations in duty hours for physicians-in-training in the United States were established by the Accreditation Council for Graduate Medical Education (ACGME) and implemented on July 1, 2003. The association of these changes with mortality among hospitalized patients has not been well established. OBJECTIVE: To determine whether the change in duty hour regulations was associated with relative changes in mortality in hospitals of different teaching intensity within the US Veterans Affairs (VA) system. DESIGN, SETTING, AND PATIENTS: An observational study of all unique patients (N = 318 636) admitted to acute-care VA hospitals (N = 131) using interrupted time series analysis with data from July 1, 2000, to June 30, 2005. All patients had principal diagnoses of acute myocardial infarction (AMI), congestive heart failure, gastrointestinal bleeding, or stroke or a diagnosis related group classification of general, orthopedic, or vascular surgery. Logistic regression was used to examine the change in mortality for patients in more vs less teaching-intensive hospitals before (academic years 2000-2003) and after (academic years 2003-2005) duty hour reform, adjusting for patient comorbidities, common time trends, and hospital site. MAIN OUTCOME MEASURE: All-location mortality within 30 days of hospital admission. RESULTS: In postreform year 1, no significant relative changes in mortality were observed for either medical or surgical patients. In postreform year 2, the odds of mortality decreased significantly in more teaching-intensive hospitals for medical patients only. Comparing a hospital having a resident-to-bed ratio of 1 with a hospital having a resident-to-bed ratio of 0, the odds of mortality were reduced for patients with AMI (odds ratio [OR], 0.48; 95% confidence interval [CI], 0.33-0.71), for the 4 medical conditions together (OR, 0.74; 95% CI, 0.61-0.89), and for the 3 medical conditions excluding AMI (OR, 0.79; 95% CI, 0.63-0.98). Compared with hospitals in the 25th percentile of teaching intensity, there was an absolute improvement in mortality from prereform year 1 to postreform year 2 of 0.70 percentage points (11.1% relative decrease) and 0.88 percentage points (13.9% relative decrease) in hospitals in the 75th and 90th percentile of teaching intensity, respectively, for the combined medical conditions. CONCLUSIONS: The ACGME duty hour reform was associated with significant relative improvement in mortality for patients with 4 common medical conditions in more teaching-intensive VA hospitals in postreform year 2. No associations were identified for surgical patients.

Racial and Ethnic Minority Concentration in Veterans Affairs Facilities and Delivery of Patient-Centered Primary Care.

Despite patient-centered medical home implementation by the Veterans Health Administration (VHA), delivery of patient-centered care varies across VHA facilities. Facility characteristics underlying this variation are not fully understood. This study used administrative data from 908 VHA outpatient facilities to examine the association of racial and ethnic minority patient concentration and other facility characteristics with facility ratings of patient-centered care. The primary finding was that patient-centered ratings were lower for facilities with medium or high concentrations of Hispanic patients (medium: estimate [Est] = -0.40, standard error [SE] = 0.20, P = 0.046; high: Est = -0.99, SE = 0.23, P < 0.001). In addition, patient-centered ratings decreased as patient panel sizes increased, especially among facilities with higher concentrations of black patients. This study indicates that efforts to improve patient-centered care may be needed at VHA facilities that serve Hispanic and VHA facilities with large panel sizes of high concentrations of black patients.

Organization Complexity and Primary Care Providers' Perceptions of Quality Improvement Culture Within the Veterans Health Administration.

This study examined how aspects of quality improvement (QI) culture changed during the introduction of the Veterans Health Administration (VHA) patient-centered medical home initiative and how they were influenced by existing organizational factors, including VHA facility complexity and practice location. A voluntary survey, measuring primary care providers' (PCPs') perspectives on QI culture at their primary care clinics, was administered in 2010 and 2012. Participants were 320 PCPs from hospital- and community-based primary care practices in Pennsylvania, West Virginia, Delaware, New Jersey, New York, and Ohio. PCPs in community-based outpatient clinics reported an improvement in established processes for QI, and communication and cooperation from 2010 to 2012. However, their peers in hospital-based clinics did not report any significant improvements in QI culture. In both years, compared with high-complexity facilities, medium- and low-complexity facilities had better scores on the scales assessing established processes for QI, and communication and cooperation.

Impact of the patient-centered medical home on veterans' experience of care.

OBJECTIVES: A core tenet of the patient-centered medical home is improving patient experiences of care, but evidence is limited on the impact of medical home adoption on patient experiences of care. STUDY DESIGN: We conducted a repeated cross-sectional, patient-level analysis in 1 region of the Veterans Health Administration (VHA), which includes 56 primary care sites. METHODS: Our primary outcomes include 5 domains of patient care experience from the Survey of Healthcare Experiences of Patients (SHEP). We used a linear probability model to test whether changes in medical home implementation are associated with changes in patient experience of care. RESULTS: During the study period, 30,849 SHEP respondents received care. We observed significant increase in medical home implementation: a 10-fold increase in percentage of primary care providers who were part of a medical home, a 7-fold increase in 8 out of 9 structural measures of the medical home, and an increase in overall quality of medical home implementation. Yet, we found no association between medical home adoption and 5 domains of patient experience of care. For example, patients assigned to a medical home provider had a 0.51 percentage point (95% CI, -1.8 to 2.8) higher response in how well they communicate with their provider compared with patients not assigned to a medical provider and with patients in the pre-medical home period. CONCLUSIONS: Despite wide implementation of the medical home, we did not see an improvement in patient experiences of care in the VHA. As we focus on primary care transformation, we need to find ways to incorporate the patient's voice and input into these transitions.

The effect of organizational climate on patient-centered medical home implementation.

Organizational climate is a key determinant of successful adoption of innovations; however, its relation to medical home implementation is unknown. This study examined the association between primary care providers' (PCPs') perception of organization climate and medical home implementation in the Veterans Health Administration. Multivariate regression was used to test the hypothesis that organizational climate predicts medical home implementation. This analysis of 191 PCPs found that higher scores in 2 domains of organizational climate (communication and cooperation, and orientation to quality improvement) were associated with a statistically significantly higher percentage (from 7 to 10 percentage points) of PCPs implementing structural changes to support the medical home model. In addition, some aspects of a better organizational climate were associated with improved organizational processes of care, including a higher percentage of patients contacted within 2 days of hospital discharge (by 2 to 3 percentage points) and appointments made within 3 days of a patient request (by 2 percentage points).

The Effect of Primary Care Provider Turnover on Patient Experience of Care and Ambulatory Quality of Care.

IMPORTANCE: Primary care provider (PCP) turnover is common and can disrupt patient continuity of care. Little is known about the effect of PCP turnover on patient care experience and quality of care. OBJECTIVE: To measure the effect of PCP turnover on patient experiences of care and ambulatory care quality. DESIGN, SETTING, AND PARTICIPANTS: Observational, retrospective cohort study of a nationwide sample of primary care patients in the Veterans Health Administration (VHA). We included all patients enrolled in primary care at the VHA between 2010 and 2012 included in 1 of 2 national data sets used to measure our outcome variables: 326,374 patients in the Survey of Healthcare Experiences of Patients (SHEP; used to measure patient experience of care) associated with 8441 PCPs and 184,501 patients in the External Peer Review Program (EPRP; used to measure ambulatory care quality) associated with 6973 PCPs. EXPOSURES: Whether a patient experienced PCP turnover, defined as a patient whose provider (physician, nurse practitioner, or physician assistant) had left the VHA (ie, had no patient encounters for 12 months). MAIN OUTCOMES AND MEASURES: Five patient care experience measures (from SHEP) and 11 measures of quality of ambulatory care (from EPRP). RESULTS: Nine percent of patients experienced a PCP turnover in our study sample. Primary care provider turnover was associated with a worse rating in each domain of patient care experience. Turnover was associated with a reduced likelihood of having a positive rating of their personal physician of 68.2% vs 74.6% (adjusted percentage point difference, -5.3; 95% CI, -6.0 to -4.7) and a reduced likelihood of getting care quickly of 36.5% vs 38.5% (adjusted percentage point difference, -1.1; 95% CI, -2.1 to -0.1). In contrast, PCP turnover was not associated with lower quality of ambulatory care except for a lower likelihood of controlling blood pressure of 78.7% vs 80.4% (adjusted percentage point difference, -1.44; 95% CI, -2.2 to -0.7). In 9 measures of ambulatory care quality, the difference between patients who experienced no PCP turnover and those who had a PCP turnover was less than 1 percentage point. These effects were moderated by the patients' continuity with their PCP prior to turnover, with a larger detrimental effect of PCP turnover among those with higher continuity prior to the turnover. CONCLUSIONS AND RELEVANCE: Primary care provider turnover was associated with worse patient experiences of care but did not have a major effect on ambulatory care quality.

The medical home transformation in the Veterans Health Administration: an evaluation of early changes in primary care delivery.

OBJECTIVE: To evaluate the effect of medical home implementation on primary care delivery in the Veterans Health Administration (VHA). DATA SOURCES/STUDY SETTING/STUDY DESIGN: We link interview-based qualitative data on medical home implementation to quantitative outcomes from VHA clinical encounter data. We use a longitudinal analysis with provider fixed effects (taking advantage of variation in timing of implementation and allowing each provider to serve as a control for him or herself) to test whether patient-aligned care team (PACT) implementation was associated with changes in organizational processes and patient outcomes. PRINCIPAL FINDINGS: Among 683 PCPs, caring for 321,295 patients, the uptake of eight of nine PACT structural changes significantly increased from July 2010 to June 2012 as did the percentage of primary care appointments occurring by telephone and hospital discharges contacted within 2 days of discharge. We found that PACT implementation was associated with significant improvements in 2-day post-hospital discharge contact, but not primary care visits occurring by telephone or within 3 days of the requested date. We found no association between medical home implementation and rates of emergency department use by patients. CONCLUSIONS: Medical home implementation at the VHA resulted in large changes in the structure of care but few changes in patient-level outcomes. These results highlight both the complexity of studying the effect of the medical home as well as implementing this model to change primary care delivery.

Do cognitive perceptions influence CPAP use?

OBJECTIVE: Nonadherence to CPAP increases health and functional risks of obstructive sleep apnea. The study purpose was to examine if disease and treatment cognitive perceptions influence short-term CPAP use. METHODS: A prospective longitudinal study included 66, middle-aged (56.7 ± 10.7 yr) subjects (34 [51.5%] Caucasians; 30 [45.4%] African Americans) with severe OSA (AHI 43.5 events/hr ± 24.6). Following full-night diagnostic/CPAP polysomnograms, home CPAP use was objectively measured at 1 week and 1 month. The Self Efficacy Measure for Sleep Apnea (SEMSA) questionnaire, measuring risk perception, outcome expectancies, and self-efficacy, was collected at baseline, post-CPAP education, and after 1 week CPAP treatment. Regression models were used. RESULTS: CPAP use at one week was 3.99 ± 2.48 h/night and 3.06 ± 2.43 h/night at one month. No baseline SEMSA domains influenced CPAP use. Post-education self-efficacy influenced one week CPAP use (1.52 ± 0.53, p=0.007). Self-efficacy measured post-education and after one week CPAP use also influenced one month CPAP (1.40 ± 0.52, p=0.009; 1.20 ± 0.50, p=0.02, respectively). CONCLUSION: Cognitive perceptions influence CPAP use, but only within the context of knowledge of CPAP treatment and treatment use. PRACTICE IMPLICATIONS: Patient education is important to OSA patients' formulation of accurate and realistic disease and treatment perceptions which influence CPAP adherence.