1. Based on this randomized clinical trial, there was no significant difference between the intensive outpatient patient-centered medical home care program (ImPACT) and the usual Veteran’s Affairs primary care program (PACT) in decreasing acute care usage costs or monthly health care expenditures.
2. Despite this, many ImPACT participants stated they would recommend the program to others.
Evidence Rating Level: 2 (Good)
Study Rundown: There have been many attempts to optimize inpatient and outpatient care to reduce acute care readmissions. This randomized controlled trial aimed to evaluate if an intensive outpatient program for high-need patients changed utilization patterns and reduced costs after implementing an integrated setting with a patient-centered medical home (ImPACT programs) as compared to usual Veteran’s Affairs primary care (PACT program).
After accounting for program costs, both the adjusted monthly health care expenditures and acute and extended care utilization rates decreased similarly for ImPACT and PACT patients. However, when polled, the ImPACT patients reported that they would recommend the program to others. While the study did use a randomized controlled design, using a single site does limit the generalizability of the results.
In-Depth [randomized controlled trial]: This was a single-center, randomized clinical trial that was conducted in a Stanford California VA center from October 2011 to June 2012. Inclusion criteria included veterans who received care from one of 14 primary care clinicians and had a total VA health care cost in the top 5% for the facility, or if the veteran’s risk for one-year hospitalization in November 2012 was in top 5% as per the VA Care Assessment Need risk-prediction algorithm. Exclusion criteria included veterans who died before randomization, those with in-home based primary care, those in palliative care, those in mental health intensive case management and those with a length of stay >50% of the eligibility phase. The primary outcome of interest was difference-in-difference analyses examining changes in health care costs and acute and extended care utilization over a 16-month baseline and 17-month follow-up period. The secondary outcomes of interest were estimations of the interventions effect on ImPACT participants. The data was analyzed using t tests for continuous variables and χ2 test for dichotomous and categorical variables with intention-to-treat analysis.
A total of 583 people that met inclusion criteria were randomized, 150 to ImPACT and 433 to receive PACT care. The adjusted person-level monthly health care expenditures and acute and extended care utilization rates were similar in both the ImPACT and PACT care patients (difference-in-difference [SE] -$101 [$623]). In a follow-up survey with 56% (n = 54) response rate, 96% reported that they would recommend the program to others and there were modest increases in satisfaction with VA care (mean [SD] increased from 2.90 [0.72] to 3.16 [0.60]; p = 0.04) and communication (mean [SD] increased from 2.99 [0.74] to 3.18 [0.60]; p = 0.03).
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