Identifying Primary Care Practice Components Leading to Optimal Diabetes Care in Patient-Centered Medical Homes

确定初级保健实践的组成部分，从而在以患者为中心的医疗之家中实现最佳的糖尿病护理

• 批准号: 9316597
• 负责人: CAROLINE S CARLIN
• 金额: $ 51.86万
• 依托单位: UNIVERSITY OF MINNESOTA
• 依托单位国家: 美国
• 财政年份: 2016
• 资助国家: 美国
• 起止时间: 2016-07-16 至 2021-05-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/9316597
• 关键词: Adopted; Adoption; Bayesian Modeling; Caring; Case Mixes; Certification; Characteristics; Clinic; Clinical; Clinical Services; Collaborations; Communities; Community Practice; Community of Practice; Data; Deltastab; Diabetes Mellitus; Eligibility Determination; Evaluation; Goals; Health Care Reform; Healthcare Systems; Home environment; Individual; Interview; Link; Measures; Medical Records; Medical center; Methods; Minnesota; Modeling; Natural experiment; Nature; Neighborhoods; Organizational Change; Outcome; Patients; Pattern; Performance; Physicians; Policies; Population; Population Heterogeneity; Prevention; Primary Health Care; Research Design; Resources; Sampling; Services; Site Visit; Source; Standardization; Surveys; System; Time; United States; Variant; base; care delivery; care systems; flexibility; health care service utilization; improved; insight; multidisciplinary; organizational structure; patient oriented; population based; primary care setting; socioeconomics; success

Abstract Although national measures of the quality of diabetes care delivery demonstrate improvement, progress has been slow. Throughout the United States, primary care presents a critical leverage point for improving diabetes outcomes, but improving support for diabetes care in primary care practices requires a new model of care delivery that increases coordination, emphasizes prevention, and enhances collaboration between multidisciplinary teams. Legislative initiatives focusing on health care reform have accelerated adoption of the Patient Centered Medical Home (PCMH) as the preferred model for primary care redesign, with improvement in diabetes care being the most common initial focus. The organizing principles of the PCMH are well established, however operational definitions vary and important gaps exist in our understanding about which domains of change drive practice improvement, which services or resources are most likely to improve clinical outcomes, and the circumstances under which new services might succeed or fail when introduced by a practice. A better understanding of the impact of component services across organizational domains is essential for widespread adoption of incremental change in practice. Such an evaluation is critical for informing the adoption of new models of primary care and for determining whether new PCMH services provide consistent benefits across multiple settings and across diverse diabetes populations. In 2008 the Minnesota legislature adopted pioneering legislative health care reform that established standardized criteria for PCMH certification including a comprehensive set of specific services and resources. Since that time, 384 (66%) of the 581 eligible practices in Minnesota supporting care for 3.64 million people have become PCMH certified. This `natural experiment' provides a unique opportunity to leverage the data collected as a result of this reform and prior policy collaboratives to intensively evaluate the impact of primary care practice redesign on diabetes care and outcomes. The overall goal of this proposal is to identify the specific services and resources associated with primary care PCMH practice redesign that result in the greatest improvement in diabetes care. The study evaluates change across multiple organizational domains and its impact on diabetes care and health care utilization, adjusting for differences in practice and patient characteristics. Our analyses use difference-in-differences, propensity scoring in a Bayesian framework, and instrumental variable methods to draw causal conclusions under increasingly flexible assumptions about the non-random nature of PCMH certification. Overall, the proposal provides a unique opportunity to discover better ways of providing care for individuals with diabetes, and has the potential to stimulate national change in the delivery of diabetes care in primary care settings.

摘要 虽然国家糖尿病护理服务质量的措施表明有所改善，但进展 慢了。在整个美国，初级保健是改善糖尿病的关键杠杆点 结果，但在初级保健实践中改善对糖尿病护理的支持需要一种新的护理模式 加强协调，强调预防，并加强 多学科团队。以医疗保健改革为重点的立法举措加快了《医疗保健法》的通过， 以患者为中心的医疗之家（PCMH）作为初级保健重新设计的首选模式，并有所改进 糖尿病护理是最常见的初始焦点。PCMH的组织原则很好 然而，业务定义各不相同，我们对这些问题的理解存在重大差距， 变更领域推动实践改进，哪些服务或资源最有可能改善临床 结果，以及在何种情况下，新的服务可能成功或失败时，介绍了一个 实践要更好地理解组件服务在组织域中的影响， 这对于在实践中广泛采用渐进式变革至关重要。这样的评价对以下方面至关重要： 告知采用新的初级保健模式，并确定新的PCMH服务是否 在多种环境和不同的糖尿病人群中提供一致的益处。 2008年，明尼苏达州立法机构通过了开创性的立法医疗保健改革， PCMH认证的标准化标准，包括一套全面的特定服务和资源。 从那时起，明尼苏达州581个合格的做法中有384个（66%）支持364万人的护理 已获得PCMH认证。这种“自然实验”提供了利用数据的独特机会 由于这一改革和先前的政策合作而收集的数据， 对糖尿病护理和结果的护理实践重新设计。本提案的总体目标是确定 与初级保健PCMH实践相关的特定服务和资源重新设计， 糖尿病护理的最大改善。该研究评估了多个组织领域的变化 及其对糖尿病护理和卫生保健利用的影响，调整实践和患者的差异， 特色我们的分析使用差异中的差异，贝叶斯框架中的倾向评分， 工具变量方法，在越来越灵活的假设下得出因果结论， PCMH认证的非随机性。总的来说，该提案提供了一个独特的机会， 为糖尿病患者提供更好的护理方式，并有可能刺激国家改变， 在初级保健环境中提供糖尿病护理。