Over recent decades major changes have been made in the structure of ambulatory care in the Veterans Health Administration (VA). Such changes continue, as exemplified by the major system-wide effort to implement Patient Aligned Care Teams (PACTs). PACTs are the future of primary care in the VA. They are a multifactorial intervention that bundles seven well-defined elements that are important to the care of patients. PACTs are also designed in accord with the chronic disease model, which is known to be beneficial. These characteristics are a great strength. Accordingly, PACTs are expected to improve both quality of care and patient outcomes, including survival. Pilot programs have shown this to be generally true, but mortality has not been studied. PACTs have multiple core elements, and variation in implementation will almost certainly occur. This will raise questions about degree of fidelity to the PACT model, how deviations correlate with patient outcomes, and which PACT elements are most important. Diabetes is a common condition that provides an opportunity to evaluate PACT effects. It is associated with substantial morbidity and mortality. Specific aspects of ambulatory care that can mitigate these outcomes have been codified in practice guidelines. All are targets of the chronic disease model that is integral to the design of the PACTs. Thus, the quality of care and survival of patients with diabetes can provide both a broad and sensitive way to assess the capacity of PACTs to improve care for these patients. The PACT elements are not new. Hence, it is possible to study them in the current system of care. The VA is in an unparalleled position to do this. It is the largest integrated health care system in the country, with hundreds of primary care clinics, millions of patients, and excellent computerized patient records. It has conducted surveys of both patients (The Survey of Health Experiences of Patients, or SHEP) and clinics (the Clinical Practice Organizational Survey, or CPOS) that make it possible to assess the core elements of the PACTs as they currently exist. We also have in hand a well-established risk adjustment method that can be used to determine the relationship between these core elements and the survival of patients with diabetes. Using these resources and methods previously developed, we will be able to rapidly provide information about the relationship of PACT elements to diabetes mortality and quality of care that would otherwise take longer to obtain. In this study, we will use existing data to examine the relation of the core elements of PACTs to the survival and quality of care of for patients with diabetes. Our findings will disclose the relative importance of each PACT element, the magnitude of their effect in aggregate, whether they act synergistically, and the degree to which their importance is magnified in patients with a high burden of illness.
This study will use existing data to examine the relation of the core elements of Patient Aligned Care Teams (PACTs) to the quality of care and survival of outpatients with diabetes. It will disclose the relative importance of each element, the magnitude of their effect in aggregate, and the degree to which their importance is magnified in patients with a high burden of illness. This, in turn, will: 1) Identify those elements of the PACTs that are important to the quality of care and survival of patients with diabetes;2) Determine which are most important for sicker patients;3) Help guide introduction of the PACTs, and;4) Inform policy decisions and allocation of resources.
