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

摘要 尽管国家对糖尿病护理提供质量的衡量标准显示出改善，但进展 太慢了。在整个美国，初级保健是改善糖尿病的关键杠杆 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、强调预防并加强合作的交付 多学科团队。以医疗改革为重点的立法倡议加快了通过 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 在糖尿病治疗中是最常见的初始关注点。PCMH的组织原则是好的 然而，业务定义各不相同，我们在理解哪些方面存在重大差距 变革领域推动实践改进，哪些服务或资源最有可能改善临床 结果，以及新服务可能成功或失败的情况 练习一下。更好地理解跨组织域的组件服务的影响是 对于在实践中广泛采用渐进式变化至关重要。这样的评估对于 告知采用新的初级保健模式，并确定新的初级保健服务是否 在多个环境和不同的糖尿病人群中提供一致的好处。 2008年，明尼苏达州立法机构通过了开创性的立法医疗改革，确立了 PCMH认证的标准化标准，包括一套全面的具体服务和资源。 从那时起，明尼苏达州581家符合条件的诊所中有384家(66%)支持为364万人提供护理 已获得PCMH认证。这个“自然实验”提供了一个独特的机会来利用这些数据 收集这项改革的结果和之前的政策协作，以深入评估初级教育的影响 护理实践重新设计糖尿病护理和结果。这项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，导致 糖尿病护理方面的最大改进。这项研究评估了跨多个组织领域的变化 以及它对糖尿病护理和卫生保健利用的影响，并根据实践和患者的差异进行调整 特点。我们的分析使用差异中的差异，贝叶斯框架中的倾向评分，以及 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。总体而言，该提案提供了一个独特的机会来发现 更好地为糖尿病患者提供护理，并有可能刺激国家变革 在初级保健环境中提供糖尿病护理。

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.