Jean Yoon, PhD, MHS; Evelyn Chang, MD, MSHS; Lisa V. Rubenstein, MD, MSPH; Angel Park, MPH, MS; Donna M. Zulman, MD, MS; Susan Stockdale, PhD; Michael K. Ong, MD, PhD; David Atkins, MD; Gordon Schectman, MD; Steven M. Asch, MD, MPH
Acknowledgment: The authors thank the following participating investigators, who served as scientific advisors and provided and cared for study patients: Brook Watts, Jessica Eng, Neha Pathak, Parag Dalsania, and Jeff Jackson. They also thank the following contributors, who served as scientific or technical advisors, provided data analysis, or provided ethics consultation: Kathryn Corrigan, Carrie Patton, Belinda Velazquez, Elvira Jimenez, Mingming Wang, Ava Wong, Karen Chu, Andrew Lanto, Jennifer Yang Scott, Barbara Simon, Alissa Simon, and Melissa Bottrell.
Financial Support: By the VHA Office of Primary Care Services.
Disclosures: Authors have disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M17-3039.
Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that her spouse has stock options/holdings with Targeted Diagnostics and Therapeutics. Darren B. Taichman, MD, PhD, Executive Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Deborah Cotton, MD, MPH, Deputy Editor, reports that she has no financial relationships or interest to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Catharine B. Stack, PhD, MS, Deputy Editor for Statistics, reports that she has stock holdings in Pfizer and Johnson & Johnson.
Reproducible Research Statement:Study protocol: See Supplement. Statistical code: Available from Dr. Yoon (e-mail, email@example.com). Data set: The data in this trial were analyzed for the purposes of a quality improvement initiative designed to help the VA Office of Primary Care Services design national programs to manage high-risk patients. Therefore, the project team cannot release any data from the project without prior approval from the VA Office of Primary Care Services. Any requests for data must be directed to them.
Corresponding Author: Jean Yoon, PhD, MHS, Health Economics Resource Center, VA Palo Alto Health Care System, 795 Willow Road (152 MPD), Menlo Park, CA 94025; e-mail, firstname.lastname@example.org.
Current Author Addresses: Drs. Yoon, Zulman, and Asch and Ms. Park: VA Palo Alto Health Care System, Center for Innovation to Implementation, 795 Willow Road (152 MPD), Menlo Park, CA 94025.
Dr. Chang: 11301 Wilshire Boulevard, Department of General Internal Medicine (111G), Los Angeles, CA 90073.
Dr. Rubenstein: 801 North Foothill Road, Medford, OR 97504.
Dr. Stockdale: VA HSR&D Center for the Study of Innovation, Implementation and Policy, 16111 Plummer Avenue, Building 25, Room A103, North Hills, CA 91343.
Dr. Ong: VA Greater Los Angeles Healthcare System, 11301 Wilshire Boulevard, Building 500, Room 3213A, Los Angeles, CA 90073.
Dr. Atkins: Health Services Research and Development, Department of Veterans Affairs (10P9H), 810 Vermont Avenue Northwest, Washington, DC 20420.
Dr. Schectman: Veterans Health Administration, Primary Care Program Office (10NC3), 1575 I Street Northwest, Washington, DC 20420.
Author Contributions: Conception and design: J. Yoon, E. Chang, L.V. Rubenstein, D.M. Zulman, M.K. Ong, D. Atkins, G. Schectman, S.M. Asch.
Analysis and interpretation of the data: J. Yoon, E. Chang, L.V. Rubenstein, A. Park, D.M. Zulman.
Drafting of the article: J. Yoon, E. Chang, L.V. Rubenstein, S. Stockdale, S.M. Asch.
Critical revision for important intellectual content: J. Yoon, E. Chang, L.V. Rubenstein, D.M. Zulman, M.K. Ong, S.M. Asch.
Final approval of the article: J. Yoon, E. Chang, L.V. Rubenstein, A. Park, D.M. Zulman, S. Stockdale, M.K. Ong, D. Atkins, G. Schectman, S.M. Asch.
Statistical expertise: J. Yoon.
Obtaining of funding: L.V. Rubenstein, G. Schectman.
Administrative, technical, or logistic support: L.V. Rubenstein, D. Atkins.
Collection and assembly of data: J. Yoon, L.V. Rubenstein, A. Park.
Primary care models that offer comprehensive, accessible care to all patients may provide insufficient resources to meet the needs of patients with complex conditions who have the greatest risk for hospitalization.
To assess whether augmenting usual primary care with team-based intensive management lowers utilization and costs for high-risk patients.
Randomized quality improvement trial. (ClinicalTrials.gov: NCT03100526)
5 U.S. Department of Veterans Affairs (VA) medical centers.
Primary care patients at high risk for hospitalization who had a recent acute care episode.
Locally tailored intensive management programs providing care coordination, goals assessment, health coaching, medication reconciliation, and home visits through an interdisciplinary team, including a physician or nurse practitioner, a nurse, and psychosocial experts.
Utilization and costs (including intensive management program expenses) 12 months before and after randomization.
2210 patients were randomly assigned, 1105 to intensive management and 1105 to usual care. Patients had a mean age of 63 years and an average of 7 chronic conditions; 90% were men. Of the patients assigned to intensive management, 487 (44%) received intensive outpatient care (that is, ≥3 encounters in person or by telephone) and 204 (18%) received limited intervention. From the pre- to postrandomization periods, mean inpatient costs decreased more for the intensive management than the usual care group (−$2164 [95% CI, −$7916 to $3587]). Outpatient costs increased more for the intensive management than the usual care group ($2636 [CI, $524 to $4748]), driven by greater use of primary care, home care, telephone care, and telehealth. Mean total costs were similar in the 2 groups before and after randomization.
Sites took up to several months to contact eligible patients, limiting the time between treatment and outcome assessment. Only VA costs were assessed.
High-risk patients with access to an intensive management program received more outpatient care with no increase in total costs.
Veterans Health Administration Primary Care Services.
Yoon J, Chang E, Rubenstein LV, Park A, Zulman DM, Stockdale S, et al. Impact of Primary Care Intensive Management on High-Risk Veterans' Costs and Utilization: A Randomized Quality Improvement Trial. Ann Intern Med. 2018;168:846–854. doi: 10.7326/M17-3039
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Published: Ann Intern Med. 2018;168(12):846-854.
Published at www.annals.org on 5 June 2018
Ethics, Healthcare Delivery and Policy, High Value Care, Hospital Medicine.
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Print ISSN: 0003-4819 | Online ISSN: 1539-3704
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