Research ArticleOriginal Research

System Transformation in Patient-Centered Medical Home (PCMH): Variable Impact on Chronically Ill Patients' Utilization

Caroline S. Carlin, Thomas J. Flottemesch, Leif I. Solberg and Ann M. Werner
The Journal of the American Board of Family Medicine July 2016, 29 (4) 482-495; DOI: https://doi.org/10.3122/jabfm.2016.04.150360

Article Figures & Data

Figures

  • Figure 1.
    Figure 1.

    Marginal effect of increasing maturity in overall Physician Practice Connections–Research Survey (relative to early stage transformation) by patient comorbidity status. **P < .05; ***P < .01. DM, diabetes mellitus; CVD, cardiovascular disease; IP, inpatient; ED, emergency department.

  • Figure 2.
    Figure 2.

    Marginal effect of increasing maturity in health care organization (relative to early stage transformation) by patient comorbidity status. **P < .05; ***P < .01. DM, diabetes mellitus; CVD, cardiovascular disease; HCO, health care organization; ED, emergency department; IP, inpatient.

  • Figure 3.
    Figure 3.

    Marginal effect of increasing maturity in delivery system redesign (relative to early stage transformation) by patient comorbidity status. **P < .05; ***P < .01. DM, diabetes mellitus; DSR, delivery system redesign; CVD, cardiovascular disease; IP, inpatient; ED, emergency department.

  • Figure 4.
    Figure 4.

    Marginal effect of increasing maturity in clinical information systems (relative to early stage transformation) by patient comorbidity status. **P < .05; ***P < .01. DM, diabetes mellitus; CIS, clinical information systems; CVD, cardiovascular disease; IP, inpatient; ED, emergency department.

  • Figure 5.
    Figure 5.

    Marginal effect of increasing maturity in decision support (relative to early stage transformation) by patient comorbidity status. **P < .05; ***P < .01. DM, diabetes mellitus; DS, decision support; CVD, cardiovascular disease; IP, inpatient; ED, emergency department.

  • Figure 6.
    Figure 6.

    Marginal effect of increasing maturity in self-management support (relative to early stage transformation) by patient comorbidity status. **P < .05; ***P < .01. DM, diabetes mellitus; SMS, self-management support; CVD, cardiovascular disease; IP, inpatient; ED, emergency department.

Tables

  • Table 1.

    Elements of Physician Practice Connections–Readiness Survey, by Domain

    Chronic Care Model DomainElements of the Physician Practice Connections–Readiness Survey
    Health care organizationIndividual provider feedback
    Performance measurement
    Formal quality improvement activities
    Delivery system redesignAdvanced access visits
    Primary care teams
    Scheduling system for physician continuity
    Non-MD educator*
    Nurse manager*
    Previsit planning*
    After-visit follow-up*
    Missed appointments follow-up*
    Clinical information systemsDisease registry*
    Problem lists
    Medication lists
    Process flow sheets*
    Checklists of tests or interventions*
    Patient assessment questionnaire*
    Clinical test tracking
    Referral tracking
    Decision SupportClinical guidelines*
    Clinical guidelines preventive services
    Clinician reminders for chronic illness care*
    Clinician reminders for preventive services
    Clinician reminders for risk assessments
    Clinician reminders for counseling
    Abnormal radiology and lab test alerts
    Abnormal test protocols
    Self-management supportPatient reminders for chronic illness care*
    Patient reminders for preventive services
    Self-management programs for risk factors
    Individualized patient education about chronic illness*
    Self-management programs for chronic illness*
    Self-management plans/materials for chronic illness*
    Electronic information/communication with patients
    Systematic risk factor screening

    • ↵* Asked separately for diabetes, cardiovascular disease, depression, and asthma.

  • Table 2.

    Summary Statistics of Variables by Study Population

    Diabetes MellitusCardiovascular Disease
    Observations, n9,0322,280
    Overall Utilization in TCRRVs, mean (SD)18,956 (34,703)27,796 (55,104)
    Prescriptions, mean (SD)50.9 (44.7)46.2 (41.9)
    Outpatient Visits, mean (SD)45.6 (69.0)45.0 (56.6)
    ≥1 Inpatient admission1,348 (14.9)604 (26.5)
    ≥1 Emergency department visits1,983 (22.0)615 (27.0)
    Age (years)
        <40751 (8.3)23 (1.0)
        40–491,533 (17.0)183 (8.0)
        50–541,432 (15.9)289 (12.7)
        55–591683 (18.6)414 (18.2)
        60–641,868 (20.7)600 (26.3)
        ≥651,765 (19.5)771 (33.8)
    Female sex4,537 (50.2)726 (31.8)
    Comorbidities
        06,144 (68.0)304 (52.1)
        12,129 (23.6)1,319 (34.3)
        ≥2759 (8.4)657 (13.6)
    Type of coverage
        Commercial5,450 (60.3)1,278 (56.0)
        Medicare1,226 (13.6)585 (25.7)
        Medicaid
            Mothers and children2,211 (24.5)394 (17.3)
            Special needs145 (1.6)23 (1.0)

    • Data are n (%) unless otherwise indicated.

    • SD, standard deviation; TCRRV, total cost relative resource value.

  • Table 3.

    Distribution of Patients by Transformation Status of Their Primary Care Clinic

    Transfer Stage, by Clinic TypeDiabetes MellitusCardiovascular Disease
    PPC-RS
        Early1200 (13.3)343 (15.0)
        Intermediate5245 (58.1)1305 (57.3)
        Late2587 (28.6)632 (27.7)
    Health care organization
        Early455 (5.1)102 (4.5)
        Intermediate2351 (26.0)584 (25.6)
        Late6226 (68.9)1594 (69.9)
    Delivery system redesign
        Early2632 (29.2)756 (33.1)
        Intermediate5123 (56.7)1274 (55.9)
        Late1277 (14.1)250 (11.0)
    Clinical information system
        Early1470 (16.3)418 (18.3)
        Intermediate4605 (51.0)1168 (51.2)
        Late2957 (32.7)694 (30.5)
    Decision support
        Early688 (7.6)241 (10.6)
        Intermediate3528 (39.1)787 (34.5)
        Late4816 (53.3)1252 (54.9)
    Self-management system
        Early1696 (18.8)448 (19.7)
        Intermediate4248 (47.0)1088 (47.7)
        Late3088 (34.2)744 (32.6)

    • Data are n (%).

    • PPC-RS, Physician Practice Connections–Readiness Survey.

  • Table A1.

    Marginal Effect of Increasing Maturity in Overall Physician Practice Connections–Readiness Survey (Relative to Early Stage Transformation) by Patient Comorbidity Status

    Marginal Effect of Maturity on Utilization Measures (P Value)
    Intermediate-Stage TransformationLate-Stage Transformation
    Diabetes Mellitus
        Total utilization*
            Average across comorbidity statuses0.040 (.407)0.079 (.151)
            0 Comorbidities0.066 (.272)0.095 (.115)
            1 Comorbidity−0.011 (.876)0.030 (.679)
            ≥2 Comorbidities−0.026 (.752)0.083 (.613)
        Number of prescriptions*
            Average across comorbidity statuses0.028 (.374)0.039 (.444)
            0 Comorbidities0.051 (.230)0.061 (.225)
            1 Comorbidity−0.028 (.511)−0.009 (.904)
            ≥2 Comorbidities0.003 (.959)−0.009 (.922)
        Number of outpatient visits*
            Average across comorbidity statuses−0.078 (.231)−0.151 (.020)
            0 Comorbidities−0.047 (.560)−0.147 (.075)
            1 Comorbidity−0.130 (.030)−0.172 (.004)
            ≥2 Comorbidities−0.184 (.005)−0.124 (.172)
        ≥1 Inpatient admission†
            Average across comorbidity statuses0.007 (.600)0.002 (.854)
            0 Comorbidities0.000 (.992)−0.005 (.620)
            1 Comorbidity0.011 (.718)0.007 (.821)
            ≥2 Comorbidities0.061 (.248)0.066 (.297)
        ≥1 Emergency department visit†
            Average across comorbidity statuses0.012 (.498)0.024 (.239)
            0 Comorbidities0.014 (.362)0.014 (.401)
            1 Comorbidity0.036 (.431)0.064 (.179)
            ≥2 Comorbidities−0.074 (.126)−0.009 (.855)
    Cardiovascular disease
        Total utilization*
            Average across comorbidity statuses−0.035 (.607)−0.072 (.505)
            0 Comorbidities−0.076 (.349)−0.175 (.107)
            1 Comorbidity0.055 (.510)0.159 (.294)
            ≥2 Comorbidities−0.111 (.424)−0.256 (.147)
        Number of prescriptions*
            Average across comorbidity statuses−0.046 (.287)−0.047 (.543)
            0 Comorbidities−0.083 (.234)−0.099 (.309)
            1 Comorbidity0.040 (.388)0.047 (.579)
            ≥2 Comorbidities−0.125 (.141)−0.089 (.401)
        Number of outpatient visits*
            Average across comorbidity statuses−0.167 (.002)−0.201 (.010)
            0 Comorbidities−0.198 (.004)−0.340 (.000)
            1 Comorbidity−0.055 (.530)0.029 (.835)
            ≥2 Comorbidities−0.342 (.004)−0.261 (.024)
        ≥1 Inpatient admission†
            Average across comorbidity statuses0.029 (.362)−0.001 (.985)
            0 Comorbidities0.014 (.532)−0.021 (.377)
            1 Comorbidity0.064 (.177)0.073 (.199)
            ≥2 Comorbidities−0.001 (.992)−0.105 (.258)
    Cardiovascular disease
        ≥1 Emergency department visit†
            Average across comorbidity statuses0.009 (.802)−0.012 (.752)
            0 Comorbidities−0.038 (.287)−0.104 (.008)
            1 Comorbidity0.062 (.143)0.100 (.057)
            ≥2 Comorbidities0.061 (.578)0.066 (.520)

    • ↵* Approximate percentage change (0.10 = 10%) in outcome variable when clinic moves from early stage to intermediate- or late-stage transformation.

    • ↵† Estimated percentage-point change (0.10 = 10 percentage points) in the probability of outcome when a clinic moves from early stage to intermediate- or late-stage transformation.

  • Table A2.

    Marginal Effect of Increasing Maturity by Patient-Centered Medical Home Domain (Relative to Early Stage Transformation)

    Marginal Effect of Maturity on Utilization Measures (P Value)
    Intermediate-Stage DomainLate-Stage Domain
    Diabetes mellitus
        Total utilization*
            Overall impact of all domains (PPC-RS)0.040 (.407)0.079 (.151)
            Health care organization0.140 (.063)0.152 (.025)
            Delivery system redesign0.026 (.435)0.102 (.066)
            Clinical information system0.070 (.134)−0.005 (.940)
            Decision support−0.180 (.001)−0.218 (.000)
            Self-management system0.103 (.007)0.149 (.011)
        Number of prescriptions*
            Overall impact of all domains (PPC-RS)0.028 (.374)0.039 (.444)
            Health care organization−0.001 (.991)−0.001 (.985)
            Delivery system redesign0.037 (.330)0.160 (.015)
            Clinical information system0.059 (.225)0.010 (.879)
            Decision support0.012 (.816)−0.101 (.089)
            Self-management system−0.009 (.849)0.054 (.412)
        Number of outpatient visits*
            Overall impact of all domains (PPC-RS)−0.078 (.231)−0.151 (.020)
            Health care organization0.160 (.108)0.150 (.097)
            Delivery system redesign0.063 (.132)0.092 (.153)
            Clinical information system−0.083 (.101)−0.303 (.000)
            Decision support−0.137 (.160)−0.102 (.293)
            Self-management system0.085 (.047)0.093 (.168)
        ≥1 Inpatient admission†
            Overall impact of all domains (PPC-RS)0.007 (.600)0.002 (.854)
            Health care organization0.021 (.253)0.037 (.035)
            Delivery system redesign−0.003 (.749)0.005 (.674)
            Clinical information system0.019 (.117)0.004 (.758)
            Decision support−0.033 (.078)−0.038 (.045)
            Self-management system0.015 (.223)0.017 (.283)
        ≥1 Emergency department visit†
            Overall impact of all domains (PPC-RS)0.012 (.498)0.024 (.239)
            Health care organization0.025 (.099)0.027 (.068)
            Delivery system redesign0.016 (.192)−0.020 (.264)
            Clinical information system0.014 (.296)0.012 (.458)
            Decision support0.003 (.882)0.020 (.386)
            Self-management system−0.014 (.317)0.009 (.653)
    Cardiovascular disease
        Total utilization*
            Overall impact of all domains (PPC-RS)−0.035 (.607)−0.072 (.505)
            Health care organization0.041 (.696)0.003 (.976)
            Delivery system redesign0.001 (.988)−0.066 (.638)
            Clinical information system0.097 (.330)0.065 (.601)
            Decision support0.013 (.923)−0.003 (.982)
            Self-management system−0.038 (.697)−0.021 (.866)
        Number of prescriptions*
            Overall impact of all domains (PPC-RS)−0.046 (.287)−0.047 (.543)
            Health care organization−0.040 (.607)−0.014 (.855)
            Delivery system redesign−0.083 (.057)−0.149 (.072)
    Cardiovascular disease
        Number of prescriptions*
            Clinical information system0.215 (.004)0.151 (.104)
            Decision support−0.165 (.096)−0.256 (.012)
            Self-management system0.036 (.605)0.184 (.052)
        Number of outpatient visits*
            Overall impact of all domains (PPC-RS)−0.167 (.002)−0.201 (.010)
            Health care organization0.198 (.031)0.057 (.486)
            Delivery system redesign0.009 (.895)−0.141 (.209)
            Clinical information system0.006 (.964)−0.020 (.866)
            Decision support−0.133 (.343)−0.066 (.664)
            Self-management system0.027 (.757)0.036 (.770)
        ≥1 Inpatient admission†
            Overall impact of all domains (PPC-RS)0.029 (.362)−0.001 (.985)
            Health care organization−0.026 (.662)−0.033 (.554)
            Delivery system redesign0.003 (.890)−0.011 (.821)
            Clinical information system−0.013 (.713)−0.001 (.986)
            Decision support0.081 (.067)0.069 (.121)
            Self-management system−0.027 (.476)−0.042 (.353)
        ≥1 Emergency department visit†
            Overall impact of all domains (PPC-RS)0.009 (.802)−0.012 (.752)
            Health care organization−0.008 (.928)−0.013 (.873)
            Delivery system redesign−0.041 (.068)−0.017 (.641)
            Clinical information system−0.040 (.332)−0.032 (.479)
            Decision support0.109 (.033)0.105 (.032)
            Self-management system−0.027 (.497)−0.041 (.428)

    • ↵* Approximate percentage change (0.10 = 10%) in outcome variable when clinic moves from early stage to intermediate- or late-stage transformation.

    • ↵† Estimated percentage-point change (0.10 = 10 percentage points) in the probability of outcome when a clinic moves from early stage to intermediate- or late-stage transformation.

    • PPC-RS, Physician Practice Connections–Readiness Survey.

  • Table A3.

    Marginal Effect of Increasing Maturity by Patient-Centered Medical Home Domain (Relative to Early Stage Transformation) by Patient Comorbidity Status

    Marginal Effect of Maturity on Utilization Measures (P Value)
    Intermediate-Stage DomainLate-Stage Domain
    Diabetes mellitus
        Total utilization*
            Health care organization
                Average across comorbidity statuses0.140 (.063)0.152 (.025)
                0 Comorbidities0.115 (.113)0.121 (.055)
                1 Comorbidity0.179 (.094)0.197 (.040)
                ≥ 2 Comorbidities0.279 (.054)0.336 (.028)
            Delivery system redesign
                Average across comorbidity statuses0.026 (.435)0.102 (.066)
                0 Comorbidities0.043 (.124)0.091 (.054)
                1 Comorbidity−0.007 (.906)0.097 (.222)
                ≥ 2 Comorbidities−0.016 (.907)0.234 (.301)
            Clinical information system
                Average across comorbidity statuses0.070 (.134)−0.005 (.940)
                0 Comorbidities0.062 (.171)0.011 (.830)
                1 Comorbidity0.050 (.533)−0.038 (.670)
                ≥ 2 Comorbidities0.247 (.284)−0.024 (.924)
            Decision support
                Average across comorbidity statuses−0.180 (.001)−0.218 (.000)
                0 Comorbidities−0.194 (.001)−0.248 (.000)
                1 Comorbidity−0.182 (.082)−0.204 (.098)
                ≥ 2 Comorbidities−0.063 (.797)−0.015 (.947)
            Self-management system
                Average across comorbidity statuses0.103 (.007)0.149 (.011)
                0 Comorbidities0.129 (.001)0.166 (.003)
                1 Comorbidity0.117 (.116)0.160 (.101)
                ≥ 2 Comorbidities−0.207 (.095)−0.036 (.877)
        Number of prescriptions*
            Health care organization
                Average across comorbidity statuses−0.001 (.991)−0.001 (.985)
                0 Comorbidities−0.011 (.839)−0.004 (.943)
                1 Comorbidity0.007 (.951)0.011 (.916)
                ≥ 2 Comorbidities−0.023 (.855)−0.033 (.795)
            Delivery system redesign
                Average across comorbidity statuses0.037 (.330)0.160 (.015)
                0 Comorbidities0.036 (.368)0.107 (.102)
                1 Comorbidity0.041 (.508)0.263 (.008)
                ≥ 2 Comorbidities0.101 (.179)0.383 (.001)
            Clinical information system
                Average across comorbidity statuses0.059 (.225)0.010 (.879)
                0 Comorbidities0.048 (.375)0.008 (.898)
                1 Comorbidity0.083 (.303)0.049 (.615)
                ≥ 2 Comorbidities0.035 (.737)−0.077 (.534)
            Decision support
                Average across comorbidity statuses0.012 (.816)−0.101 (.089)
                0 Comorbidities0.087 (.133)−0.060 (.328)
                1 Comorbidity−0.135 (.113)−0.184 (.055)
                ≥ 2 Comorbidities−0.194 (.026)−0.205 (.077)
    Diabetes mellitus
        Number of prescriptions*
            Self-management system
                Average across comorbidity statuses−0.009 (.849)0.054 (.412)
                0 Comorbidities−0.018 (.706)0.090 (.192)
                1 Comorbidity−0.015 (.817)−0.044 (.668)
                ≥ 2 Comorbidities0.042 (.618)−0.033 (.805)
        Number of outpatient visits*
            Health care organization
                Average across comorbidity statuses0.160 (.108)0.150 (.097)
                0 Comorbidities0.121 (.282)0.125 (.228)
                1 Comorbidity0.175 (.098)0.130 (.149)
                ≥ 2 Comorbidities0.457 (.000)0.452 (.000)
            Delivery system redesign
                Average across comorbidity statuses0.063 (.132)0.092 (.153)
                0 Comorbidities0.059 (.154)0.080 (.251)
                1 Comorbidity0.080 (.101)0.081 (.364)
                ≥ 2 Comorbidities0.064 (.482)0.325 (.019)
            Clinical information system
                Average across comorbidity statuses−0.083 (.101)−0.303 (.000)
                0 Comorbidities−0.064 (.211)−0.316 (.000)
                1 Comorbidity−0.140 (.145)−0.266 (.003)
                ≥ 2 Comorbidities−0.024 (.842)−0.258 (.063)
            Decision support
                Average across comorbidity statuses−0.137 (.160)−0.102 (.293)
                0 Comorbidities−0.162 (.174)−0.144 (.229)
                1 Comorbidity−0.100 (.374)−0.039 (.733)
                ≥ 2 Comorbidities−0.084 (.478)0.045 (.706)
            Self-management system
                Average across comorbidity statuses0.085 (.047)0.093 (.168)
                0 Comorbidities0.120 (.019)0.128 (.088)
                1 Comorbidity0.059 (.315)0.048 (.629)
                ≥ 2 Comorbidities−0.156 (.034)−0.144 (.306)
        ≥1 Inpatient admission†
            Health care organization
                Average across comorbidity statuses0.021 (.253)0.037 (.035)
                0 Comorbidities0.029 (.006)0.034 (.000)
                1 Comorbidity0.035 (.460)0.041 (.337)
                ≥ 2 Comorbidities−0.077 (.434)0.043 (.676)
            Delivery system redesign
                Average across comorbidity statuses−0.003 (.749)0.005 (.674)
                0 Comorbidities0.002 (.765)0.009 (.469)
                1 Comorbidity−0.025 (.326)−0.030 (.408)
                ≥ 2 Comorbidities−0.005 (.951)0.066 (.525)
            Clinical information system
                Average across comorbidity statuses0.019 (.117)0.004 (.758)
                0 Comorbidities−0.001 (.963)−0.006 (.643)
                1 Comorbidity0.073 (.013)0.027 (.291)
                ≥ 2 Comorbidities0.068 (.501)0.006 (.959)
    Diabetes mellitus
        ≥1 Inpatient admission†
            Decision support
                Average across comorbidity statuses−0.033 (.078)−0.038 (.045)
                0 Comorbidities−0.035 (.041)−0.024 (.175)
                1 Comorbidity−0.042 (.468)−0.103 (.080)
                ≥ 2 Comorbidities0.010 (.926)0.017 (.869)
            Self-management system
                Average across comorbidity statuses0.015 (.223)0.017 (.283)
                0 Comorbidities0.024 (.020)0.004 (.736)
                1 Comorbidity0.013 (.546)0.104 (.015)
                ≥ 2 Comorbidities−0.055 (.433)−0.062 (.595)
        ≥1 Emergency department visit†
            Health care organization
                Average across comorbidity statuses0.025 (.099)0.027 (.068)
                0 Comorbidities0.016 (.160)0.019 (.061)
                1 Comorbidity−0.002 (.959)−0.005 (.885)
                ≥ 2 Comorbidities0.228 (.006)0.210 (.009)
            Delivery system redesign
                Average across comorbidity statuses0.016 (.192)−0.020 (.264)
                0 Comorbidities0.025 (.033)−0.005 (.793)
                1 Comorbidity−0.009 (.755)−0.078 (.038)
                ≥ 2 Comorbidities−0.016 (.706)0.004 (.939)
            Clinical information system
                Average across comorbidity statuses0.014 (.296)0.012 (.458)
                0 Comorbidities0.040 (.005)0.015 (.283)
                1 Comorbidity−0.029 (.517)0.040 (.346)
                ≥ 2 Comorbidities−0.079 (.280)−0.079 (.283)
            Decision support
                Average across comorbidity statuses0.003 (.882)0.020 (.386)
                0 Comorbidities−0.047 (.005)−0.028 (.150)
                1 Comorbidity0.098 (.059)0.124 (.028)
                ≥ 2 Comorbidities0.114 (.210)0.094 (.301)
            Self-management system
                Average across comorbidity statuses−0.014 (.317)0.009 (.653)
                0 Comorbidities−0.007 (.628)0.013 (.563)
                1 Comorbidity−0.007 (.822)−0.002 (.971)
                ≥ 2 Comorbidities−0.093 (.065)−0.007 (.926)
    Cardiovascular disease
        Total utilization*
            Health care organization
                Average across comorbidity statuses0.041 (.696)0.003 (.976)
                0 Comorbidities0.056 (.733)0.021 (.896)
                1 Comorbidity−0.029 (.778)−0.042 (.663)
                ≥ 2 Comorbidities0.231 (.413)0.136 (.605)
            Delivery system redesign
                Average across comorbidity statuses0.001 (.988)−0.066 (.638)
                0 Comorbidities0.062 (.495)−0.036 (.800)
                1 Comorbidity−0.098 (.262)−0.321 (.157)
                ≥ 2 Comorbidities0.055 (.741)0.425 (.076)
    Cardiovascular disease
        Total utilization*
            Clinical information system
                Average across comorbidity statuses0.097 (.330)0.065 (.601)
                No comorbidities0.105 (.351)0.040 (.760)
                One comorbidity0.224 (.146)0.339 (.055)
                Two or more comorbidities−0.191 (.450)−0.354 (.082)
            Decision support
                Average across comorbidity statuses0.013 (.923)−0.003 (.982)
                0 Comorbidities−0.038 (.825)−0.048 (.753)
                1 Comorbidity−0.079 (.680)−0.142 (.467)
                ≥ 2 Comorbidities0.197 (.516)0.256 (.453)
            Self-management system
                Average across comorbidity statuses−0.038 (.697)−0.021 (.866)
                0 Comorbidities−0.093 (.482)−0.112 (.474)
                1 Comorbidity0.142 (.279)0.256 (.176)
                ≥ 2 Comorbidities−0.221 (.335)−0.355 (.298)
        Number of prescriptions*
            Health care organization
                Average across comorbidity statuses−0.040 (.607)−0.014 (.855)
                0 Comorbidities0.007 (.932)0.004 (.956)
                1 Comorbidity−0.058 (.535)−0.015 (.861)
                ≥ 2 Comorbidities−0.216 (.025)−0.154 (.110)
            Delivery system redesign
                Average across comorbidity statuses−0.083 (.057)−0.149 (.072)
                0 Comorbidities−0.180 (.001)−0.267 (.008)
                1 Comorbidity−0.021 (.734)−0.123 (.285)
                ≥ 2 Comorbidities0.186 (.039)0.273 (0036)
            Clinical information system
                Average across comorbidity statuses0.215 (.004)0.151 (.104)
                0 Comorbidities0.311 (.002)0.152 (.201)
                1 Comorbidity0.131 (.155)0.201 (.064)
                ≥ 2 Comorbidities−0.148 (.449)−0.004 (.981)
            Decision support
                Average across comorbidity statuses−0.165 (.096)−0.256 (.012)
                0 Comorbidities−0.196 (.127)−0.366 (.005)
                1 Comorbidity−0.154 (.192)−0.060 (.623)
                ≥ 2 Comorbidities−0.033 (.884)−0.146 (.524)
            Self-management system
                Average across comorbidity statuses0.036 (.605)0.184 (.052)
                0 Comorbidities0.068 (.413)0.372 (.002)
                1 Comorbidity0.087 (.271)−0.002 (.987)
                ≥ 2 Comorbidities−0.155 (.213)−0.261 (.217)
        Number of outpatient visits*
            Health care organization
                Average across comorbidity statuses0.198 (.031)0.057 (.486)
                0 Comorbidities0.290 (.017)0.093 (.457)
                1 Comorbidity0.068 (.611)−0.024 (.819)
                ≥ 2 Comorbidities0.378 (.165)0.348 (.184)
    Cardiovascular disease
        Number of outpatient visits*
            Delivery system redesign
                Average across comorbidity statuses0.009 (.895)−0.141 (.209)
                0 Comorbidities0.006 (.947)−0.137 (.280)
                1 Comorbidity−0.024 (.801)−0.286 (.171)
                ≥ 2 Comorbidities0.167 (.147)0.242 (.106)
            Clinical information system
                Average across comorbidity statuses0.006 (.964)−0.020 (.866)
                0 Comorbidities0.010 (.945)−0.055 (.710)
                1 Comorbidity0.080 (.609)0.107 (.514)
                ≥ 2 Comorbidities−0.205 (.393)−0.118 (.464)
            Decision support
                Average across comorbidity statuses−0.133 (.343)−0.066 (.664)
                0 Comorbidities−0.092 (.560)−0.022 (.902)
                1 Comorbidity−0.236 (.194)−0.198 (.298)
                ≥ 2 Comorbidities−0.191 (.485)−0.082 (.783)
            Self-management system
                Average across comorbidity statuses0.027 (.757)0.036 (.770)
                0 Comorbidities0.000 (.999)−0.044 (.760)
                1 Comorbidity0.155 (.156)0.276 (.098)
                ≥ 2 Comorbidities−0.145 (.376)−0.319 (.249)
        ≥1 Inpatient admission†
            Health care organization
                Average across comorbidity statuses−0.026 (.662)−0.033 (.554)
                0 Comorbidities0.001 (.987)0.003 (.964)
                1 Comorbidity−0.087 (.044)−0.095 (.016)
                ≥ 2 Comorbidities0.109 (.558)0.102 (.580)
            Delivery system redesign
                Average across comorbidity statuses0.003 (.890)−0.011 (.821)
                0 Comorbidities0.045 (.127)0.045 (.127)
                1 Comorbidity−0.057 (.083)−0.057 (.083)
                ≥ 2 Comorbidities0.018 (.804)0.018 (.804)
            Clinical information system
                Average across comorbidity statuses−0.013 (.713)−0.001 (.986)
                0 Comorbidities−0.006 (.893)0.004 (.932)
                1 Comorbidity0.044 (.388)0.112 (.025)
                ≥ 2 Comorbidities−0.089 (.359)−0.185 (.042)
            Decision support
                Average across comorbidity statuses0.081 (.067)0.069 (.121)
                0 Comorbidities0.006 (.919)0.014 (.785)
                1 Comorbidity0.124 (.050)0.041 (.529)
                ≥ 2 Comorbidities0.144 (.355)0.219 (.191)
            Self-management system
                Average across comorbidity statuses−0.027 (.476)−0.042 (.353)
                0 Comorbidities−0.036 (.458)−0.078 (.143)
                1 Comorbidity0.011 (.824)0.074 (.306)
                ≥ 2 Comorbidities−0.123 (.141)−0.225 (.092)
    Cardiovascular disease
        ≥1 Emergency department visit†
            Health care organization
                Average across comorbidity statuses−0.008 (.928)−0.013 (.873)
                0 Comorbidities−0.026 (.681)0.020 (.744)
                1 Comorbidity0.011 (.855)−0.024 (.682)
                ≥ 2 Comorbidities0.104 (.727)0.033 (.911)
            Delivery system redesign
                Average across comorbidity statuses−0.041 (.068)−0.017 (.641)
                0 Comorbidities−0.037 (.232)−0.072 (.105)
                1 Comorbidity−0.039 (.215)0.021 (.746)
                ≥ 2 Comorbidities−0.042 (.685)0.110 (.390)
            Clinical information system
                Average across comorbidity statuses−0.040 (.332)−0.032 (.479)
                0 Comorbidities0.027 (.522)0.038 (.424)
                1 Comorbidity−0.083 (.234)−0.040 (.536)
                ≥ 2 Comorbidities−0.031 (.840)−0.185 (.209)
            Decision support
                Average across comorbidity statuses0.109 (.033)0.105 (.032)
                0 Comorbidities−0.002 (.968)0.015 (.763)
                1 Comorbidity0.182 (.002)0.145 (.016)
                ≥ 2 Comorbidities0.145 (.480)0.149 (.497)
            Self-management system
                Average across comorbidity statuses−0.027 (.497)−0.041 (.428)
                0 Comorbidities−0.078 (.114)−0.130 (.014)
                1 Comorbidity0.027 (.543)0.060 (.431)
                ≥ 2 Comorbidities−0.008 (.949)0.083 (.690)

    • ↵* Approximate percentage change (0.10 = 10%) in outcome variable when a clinic moves from early stage to intermediate- or late-stage transformation.

    • ↵† Estimated percentage-point change (0.10 = 10 percentage points) in probability of outcome when a clinic moves from early stage to intermediate- or late-stage transformation.

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