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Sylling P.W.,Northwest and nter for Innovation | Wong E.S.,Northwest and nter for Innovation | Wong E.S.,University of Washington | Liu C.-F.,Northwest and nter for Innovation | And 13 more authors.
Medical Care

Background: The Veterans Health Administration (VHA) began implementing a patient-centered medical home (PCMH) model of care delivery in April 2010 through its Patient Aligned Care Team (PACT) initiative. PACT represents a substantial system reengineering of VHA primary care and its potential effect on primary care provider (PCP) turnover is an important but unexplored relationship. This study examined the association between a system-wide PCMH implementation and PCP turnover.Methods: This was a retrospective, longitudinal study of VHA-employed PCPs spanning 29 calendar quarters before PACT and eight quarters of PACT implementation. PCP employment periods were identified from administrative data and turnover was defined by an indicator on the last quarter of each uncensored period. An interrupted time series model was used to estimate the association between PACT and turnover, adjusting for secular trend and seasonality, provider and job characteristics, and local unemployment. We calculated average marginal effects (AME), which reflected the change in turnover probability associated with PACT implementation.Results: The quarterly rate of PCP turnover was 3.06% before PACT and 3.38% after initiation of PACT. In adjusted analysis, PACT was associated with a modest increase in turnover (AME = 4.0 additional PCPs per 1000 PCPs per quarter, P = 0.004). Models with interaction terms suggested that the PACT-related change in turnover was increasing in provider age and experience.Conclusions: PACT was associated with a modest increase in PCP turnover, concentrated among older and more experienced providers, during initial implementation. Our findings suggest that policymakers should evaluate potential workforce effects when implementing PCMH. Copyright © 2014 by Lippincott Williams & Wilkins. Source

Hernandez S.E.,University of Washington | Hernandez S.E.,Value Innovation | Taylor L.,Value Innovation | Grembowski D.,University of Washington | And 12 more authors.
Medical Care

Background: Implementation of Patient Aligned Care Teams (PACT), a patient-centered medical home model, has been inconsistent among the >900 primary care facilities in the Veterans Health Administration. Objective: Estimate if the degree of PACT implementation at a facility varied with the percentage of minority veteran patients at the facility. Research Design: Cross-sectional, facility-level analysis of PACT implementation measures in 2012. Subjects: Veterans Health Administration hospital-based and community-based primary care facilities. Measures: We used a previously validated PACT Implementation Progress Index (Pi2) and its 8 domains: access, continuity of care, care coordination, comprehensiveness, self-management support, and patient-centered care and communication, shared decisionmaking domains, and team functioning. Facilities were categorized as low (< 5.2%, n = 208), medium (5.2%-25.8%, n = 413), and high (> 25.8%, n = 206) percent minority based on the percent of their own veteran population. Results: Most minority veterans received care in high minority (69%) and medium minority facilities (29%). In adjusted analyses, medium and high minority facilities scored 0.773 (P = 0.009) and 0.930 (P = 0.008) points lower on the Pi2 score relative to low minority facilities. Relative to low minority facilities, both medium and high minority facilities were less likely of having high Pi2 scores (Z2) and more likely of having low Pi2 scores (r=2). Both medium and high minority facilities had the same 3 domain scores lower than low minority facilities (care coordination, comprehensiveness, and self-management). Conclusion: Overall PACT implementation varied with respect to the racial/ethnic composition of a facility, with medium and high minority facilities having a lower implementation scores. © 2013 Wolters Kluwer Health, Inc. All rights reserved. Source

Lipsky B.A.,General Internal Medicine Service | Lipsky B.A.,University of Washington | Byren I.,University of Oxford | Hoey C.T.,Pharmacy Service
Clinical Infectious Diseases

Prostatitis is characterized by voiding symptoms and genitourinary pain and is sometimes associated with sexual dysfunction. Up to 25% of men receive a diagnosis of prostatitis in their lifetime, but <10% have a proven bacterial infection. The causes and treatment of nonbacterial prostatitis are largely unknown, but bacterial prostatitis is caused by infection with uropathogens, especially gram-negative bacilli, although infection is sometimes due to gram-positive and atypical microorganisms. Acute bacterial prostatitis is easily diagnosed (by abrupt urogential and often systemic symptoms, along with bacteriuria) and treated (by systemic antibiotic therapy). Chronic bacterial prostatitis is characterized by prolonged or recurrent symptoms and relapsing bacteriuria; diagnosis traditionally requires comparing urinary specimens obtained before with specimens obtained after prostatic massage. Treating chronic bacterial prostatitis requires prolonged therapy with an antibiotic that penetrates the prostate (ie, one with high lipid solubility, a low degree of ionization, high dissociation constant, low protein binding, and small molecular size). We review recent pharmacological and clinical data on treating bacterial prostatitis. © 2010 by the Infectious Diseases Society ot America. All rights reserved. Source

Nelson K.M.,Value Innovation | Nelson K.M.,University of Washington | Helfrich C.,Value Innovation | Helfrich C.,University of Washington | And 22 more authors.
JAMA Internal Medicine

IMPORTANCE In 2010, the Veterans Health Administration (VHA) began implementing the patient-centered medical home (PCMH) model. The Patient Aligned Care Team (PACT) initiative aims to improve health outcomes through team-based care, improved access, and care management. To track progress and evaluate outcomes at all VHA primary care clinics, we developed and validated amethod to assess PCMH implementation. OBJECTIVES To create an index that measures the extent of PCMH implementation, describe variation in implementation, and examine the association between the implementation index and key outcomes. DESIGN, SETTING, AND PARTICIPANTS We conducted an observational study using data on more than 5.6 million veterans who received care at 913 VHA hospital-based and community-based primary care clinics and 5404 primary care staff from (1) VHA clinical and administrative databases, (2) a national patient survey administered to a weighted random sample of veterans who received outpatient care from June 1 to December 31, 2012, and (3) a survey of all VHA primary care staff in June 2012. Composite scores were constructed for 8 core domains of PACT: access, continuity, care coordination, comprehensiveness, self-management support, patient-centered care and communication, shared decision making, and team-based care. MAIN OUTCOMES AND MEASURES Patient satisfaction, rates of hospitalization and emergency department use, quality of care, and staff burnout. RESULTS Fifty-three items were included in the PACT Implementation Progress Index (Pi2). Compared with the 87 clinics in the lowest decile of the Pi2, the 77 sites in the top decile exhibited significantly higher patient satisfaction (9.33 vs 7.53; P < .001), higher performance on 41 of 48 measures of clinical quality, lower staff burnout (Maslach Burnout Inventory emotional exhaustion subscale, 2.29 vs 2.80; P = .02), lower hospitalization rates for ambulatory care-sensitive conditions (4.42 vs 3.68 quarterly admissions for veterans 65 years or older per 1000 patients; P < .001), and lower emergency department use (188 vs 245 visits per 1000 patients; P < .001). CONCLUSIONS AND RELEVANCE The extent of PCMH implementation, as measured by the Pi2, was highly associated with important outcomes for both patients and providers. This measure will be used to track the effectiveness of implementing PACT over time and to elucidate the correlates of desired health outcomes. © 2014 American Medical Association. Source

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