PACTチームの構成が患者ケアに与える影響

タイトル: Impact of Primary Care Team Configuration on Access and Quality of Care

概要: ImportanceThe Joint Principles of the Patient Centered Medical Home (PCMH) call for a team-based approach to delivering primary care - however, they provide little guidance on what should be the optimal staffing configuration to best achieve care objectives. Given recent primary care physician reports of higher intentions to leave primary care because of workload concerns, configuring primary care correctly to deliver high-quality, accessible care equitably without losing clinicians along the way is paramount. ObjectiveThis paper aims to empirically examine the extent to which variations in team configurations within PACTs predict primary care access and quality. DesignProspective, observational database review of Veterans Health Administration (VHA) Corporate Data Warehouse measures describing staffing configuration and clinical performance (access, quality) of primary care teams. We extracted monthly data from February and December 2020. SettingVHA medical centers and community-based outpatient clinics nationwide. Participants22,392 primary-care personnel representing 7,750 PACTs from 1,050 VHA healthcare facilities nationwide. ExposureAdherence to a VHA-recommended primary care team configuration of one primary care provider, registered nurse, licensed vocational nurse, and administrative clerk, respectively. Using network analysis methods we calculated, for each team, an overall adherence score and two team network characteristics (degree, Blaus index) to capture role diversity and clinician assignment to multiple teams. We also calculated team size and number of full-time equivalents (FTE). Main Outcome and MeasuresAccess to care and quality of care, as measured by the following outcomes: 1) Average third next available appointment (2) ER/urgent care (UC) utilization rate (3) Inbound to total outbound primary care secure messages ratio); (4) Team 2-day post-discharge contact (5) Hemoglobin A1c control (an indicator of poor diabetes management) (6) Diabetic nephropathy screening and (7) Hypertension control). ResultsAdherence to the recommended configuration as measured by the adherence index, had different outcomes, both pre- and post-onset of the COVID pandemic. Pre-pandemic onset, overall adherence significantly predicted no outcomes. However, individual network characteristic analysis showed increased role diversity was associated with decreased ER/UC utilization and greater patient engagement through secure messaging. Larger teams exhibited improved 2-day post-hospital discharge contact, but worse access in terms of third next available appointments. Post-pandemic onset, teams with lower overall adherence showed higher ER/UC utilization. Higher multiple-team membership was associated with lower ER/UC utilization. Larger teams exhibited lower ER/UC utilization scores, but lower 2-day post-discharge contact and nephropathy screening scores. In nearly all cases, however, teams with larger numbers of FTEs were associated with better outcomes., Conclusions and RelevancePrimary care teams require a minimum amount of FTE capacity to deliver high quality and access to health care. Future work should examine the impact of staffing levels by specific job role to further optimize staffing configurations.