RESUMO
OBJECTIVES: In 2009 and 2010, 17 primary care sites within 1 healthcare system became patient-centered medical homes (PCMHs), but the sites trained different personnel (pharmacists vs nurses) to improve diabetes care using self-management support (SMS). We report the challenges and successes of our efforts to: 1) assemble a new multipayer (Medicare, Medicaid, commercial) claims dataset linked to a clinical registry and 2) use the new dataset to perform comparative effectiveness research on implementation of the 2 SMS models. STUDY DESIGN: Longitudinal cohort study. METHODS: We lost permission to use private-payer data. Therefore, we used claims from Medicare fee-for-service and Medicare/Medicaid dual-eligible patients merged with chronic disease registry data. We studied 2008 to 2010, which included 1 year pre- and 1 year post the 2009 implementation time period. Outcomes were outpatient and emergency department visits, hospitalizations, care process (use of statin), and 3 intermediate outcomes (glycemic control, blood pressure [BP], and low-density lipoprotein cholesterol [LDL-C]). RESULTS: In our sample of 2826 patients, quality of care improved and utilization decreased over the 2.5 years. Both approaches improved lipid control (LDL-C decreased by an average of 4 mg/dL for pharmacy-SMS and 5.6 mg/dL for nurse-SMS) and diastolic BP (-1.5 mm Hg for pharmacy-SMS and -1.3 mm Hg for nurse-SMS), whereas only the pharmacy-led approach decreased primary care visits (by 0.8 visits). The groups differed slightly on 2 measures (glycated hemoglobin, systolic BP) with respect to the trajectory of improvement over time, but performance was similar by 2.5 years. CONCLUSIONS: Diabetes care improved during PCMH implementation systemwide, supporting both nurse-led and pharmacist-led SMS models.
