VA's patient-centered model may not aid glycemic or lipid control

Odds of glycemic control decreased following implementation of a patient-centered medical home system in a Veterans Affairs network, while there were no significant improvements in odds of lipid control, a study found.

The VA changed its primary care model to Patient-Aligned Care Teams (PACTs), its version of the patient-centered medical home, and in the process became the largest integrated health system to implement this care model. To assess the impact of this change on diabetes outcomes among patients receiving care among seven Midwestern VA facilities, researchers conducted a retrospective cohort analysis and multilevel logistic regression among 20,858 people who had a diagnosis of diabetes in both 2009 and 2012 and who received primary care between Oct. 1, 2008, and Sept. 30, 2009.

The researchers assessed glycemic and lipid control using the quality indicators of HbA1c less than 9% and LDL cholesterol level less than 100 mg/dL (2.6 mmol/L). Results were published online April 2 by the Journal of General Internal Medicine.

In 2009, 88.1% of the sample had HbA1c levels below 9%, versus 85.0% in 2012. Odds of glycemic control were lower in 2012 than in 2009 (odds ratio [OR], 0.72; P<0.001). This change varied by race (OR of the interaction between time and race, 1.18; P=0.028). While the disparity in glycemic control between white and black patients persisted after the patient-centered model was implemented, the magnitude of the disparity was smaller in 2012 compared to 2009 (ORs, 1.32 and 1.59, respectively; P<0.0001 for both comparisons).

Odds of lipid control did not significantly change between 2009 and 2012, and change did not vary by race and/or gender. The disparity in glycemic control between non-Hispanic white and black patients persisted, but the magnitude of this difference was smaller in 2012 than in 2009 (ORs, 1.32 and 1.59, respectively; P<0.0001 for both comparisons). The researchers noted that the odds of glycemic control were lower in 2012 than 2009, especially among non-Hispanic white patients. The three-way interaction between time, gender, and race did not predict glycemic control (OR, 0.95; P=0.91).

There was limited evidence of reduced racial disparities in glycemic control after implementing PACTs, the researchers noted.

“PACT offers the promise of narrowing patient outcome gaps, improving access to care, and fostering veteran-provider relationships. However, our analyses demonstrate limited evidence of PACT effectiveness for reducing disparities among diabetic veterans,” they wrote.