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The American Journal of Managed Care March 2016
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Tara F. Bishop, MD, MPH; Stephen M. Shortell, PhD, MPH, MBA; Patricia P. Ramsay, MPH; Kennon R. Copeland, PhD; and Lawrence P. Casalino, MD, PhD
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Organizational Structure for Chronic Heart Failure and Chronic Obstructive Pulmonary Disease

Seppo T. Rinne, MD, PhD; Chuan-Fen Liu, PhD; Edwin S. Wong, PhD; Paul L. Hebert, PhD; Paul Heidenreich, MD; Lori A. Bastian, MD; and David H. Au, MD
In a nationwide cross-sectional comparison of organizational structure for chronic disease management, less attention was given to chronic obstructive pulmonary disease than chronic heart failure.

Objectives: In contrast to chronic heart failure (CHF), measures of quality of care for chronic obstructive pulmonary disease (COPD) are poor. Our objective was to examine differences in organizational structure available to support quality of care for patients with CHF and COPD.

Study Design: We performed 2 nationwide surveys exploring organizational structure for the management of CHF and COPD. We surveyed the chief of medicine and the chief of cardiology and pulmonary medicine at 120 Veterans Affairs facilities in the United States.

Methods: Analogous questions about organizational structure that enhanced adherence to guideline-based care were compared between CHF and COPD surveys.

Results: We found large and notable differences in the organizational structure for disease management, with systematically less attention given to COPD than CHF. These differences were evident in multiple processes of care. Key differences included fewer facilities: having COPD clinics than CHF clinics (12.7% vs 50.8%; P <.01), relating performance measures with COPD providers than CHF providers (17.1% vs 70%; P <.01), and having home monitoring programs for COPD than for CHF (50.5% vs 87.4%; P <.01).

Conclusions: Despite the growing burden of COPD, less organizational structure existed for COPD than CHF. Lack of organizational structure for COPD likely impedes an organization’s abilities to encourage high-quality care and avoid recently implemented hospital readmission penalties. Our results suggest the need to develop a systematic approach for healthcare systems to provide essential organizational structure based on the burden of disease in the population.

Am J Manag Care. 2016;22(3):e82-e87
Take-Away Points
Using 2 nationwide surveys to assess the organizational structure available for chronic disease management at Veterans Affairs facilities, we found systematically less attention given to management of chronic obstructive pulmonary disease (COPD) than to chronic heart failure (CHF). 
  • We identified key differences in the management of patients with COPD and CHF. 
  • Recognizing differences in organization structure for disease management may help health systems to prioritize quality improvement efforts for patients with COPD. 
  • Our study highlights how disparities in quality improvement can develop in the absence of a systematic approach based on the burden of disease.
Broad organizational efforts have led to implementation and dissemination of programs that drive quality and measurement of performance within healthcare organizations. These performance measures have guided a higher quality of care for patients with numerous chronic conditions, including chronic heart failure (CHF).1-3 Over the past 30 years, greater adoption of organizational structure for the management of CHF has been associated with a decline in CHF-related mortality.4 During this same period, mortality rates due to chronic obstructive pulmonary disease (COPD) have been steadily increasing, with COPD becoming the third most common cause of death.5,6

Between 2007 and 2011, the United States’ prevalence of CHF and COPD were 5.1 million and 12.7 million cases, accounting for $34.4 billion and $49.9 billion in annual healthcare spending, respectively.7 Within Veterans Affairs (VA), more patients have a diagnosis of COPD than CHF and there is higher total spending on COPD.8 However, organizational programs promoting guideline concordance for management of COPD, analogous to those for CHF, have not been systematically implemented.8,9 Recent studies in the United Kingdom have shown an unacceptable variation in the organization and delivery of care for patients with COPD.10 Contrasting how facilities structure their clinical practices and programs in managing CHF versus COPD could shed light on future directions to improve care for COPD at the organizational level. Applying the lessons learned from CHF could ensure a consistent and homogenous approach to conditions that typically do not receive as much attention as CHF.

We compared the organizational structures for CHF and COPD patients within VA facilities across the United States. We focused on differences in number and type of clinicians, specialty clinics, performance measures, and discharge practices. Identifying these differences in clinical practices and organizational structure could highlight methods for improving quality of care for COPD and pinpoint areas where clinical resources for COPD are insufficient.

We performed a nationwide, cross-sectional study of VA facilities to evaluate the clinical practices and organizational structure of COPD and CHF care. We surveyed chiefs of medicine, as well as cardiology and pulmonary medicine, of VA facilities with acute inpatient units. Respective CHF and COPD surveys asked about clinical support that enhanced adherence to guideline-based care. The CHF survey was developed by the CHF QUality Enhance Research Initiative (QUERI), a VA-based effort to improve the quality of evidence-based care. The COPD survey was developed by this study team to mirror questions in the CHF survey and target evidence-based practices identified from the National Quality Forum and the Agency for Health Research and Quality clearinghouse.11-15 Responses were compared between analogous questions from the 2 surveys.

The VA Puget Sound Health Care System Institutional Review Board approved the study.

Survey Development

The CHF QUERI developed the CHF survey to evaluate processes of care, clinical practices, and discharge practices at VA facilities (see eAppendix 1 [eAppendices available at]). The CHF survey included 19 questions and was expected to take 5 to 10 minutes to complete. Survey questions elicited information on the number of cardiologists, standardized heart failure programs, standardized computer order sets for CHF, and compliance with CHF guidelines. Questions relating to CHF practices and guidelines were developed based on existing recommendations for the treatment of heart failure.16 The CHF survey was conducted in 2008 by VA Patient Care Services at all 144 VA facilities, with a response rate of 100%.

We developed the COPD survey to parallel questions in the CHF survey, assessing organizational factors related to the management of COPD (see eAppendix 2). Analogous questions asked about the number of pulmonologists, standardized COPD programs, standardized computer order sets for COPD, compliance with COPD guidelines, and COPD discharge practices. Questions relating to COPD practice and guidelines were based on current recommendations for the treatment of COPD.11-14 The COPD survey was administered in 2011 to 122 VA facilities with acute inpatient units (120 of which were also sent the CHF survey); 111 facilities responded (91%). Although the 2 surveys were conducted in 2 different time periods, the VA organization structures remained stable without major policy changes for COPD during that time.


The final study sample included 120 VA facilities with acute inpatient units that were sent both CHF and COPD facility surveys. For facilities that had responses from both the chief of medicine and the chief of cardiology and pulmonary medicine, we used the responses from the chief of cardiology and pulmonary medicine in our study because they would have more detailed knowledge of clinical practices as the leader of the department.


We conducted a descriptive analysis to compare survey responses for analogous questions from the CHF and COPD surveys using a 2-sample t test of proportions. None of the survey questions had more than 2 missing responses, and missing responses were excluded from the analysis. All statistical analyses were performed using Stata version 14.1 (StataCorp, College Station, Texas).

There were notable differences in organizational structure for managing CHF and COPD reported by the facility leaders (Table 1). The majority of facilities had staffed pulmonologists and cardiologists (91% vs 93.3%; P = .51), and there was no significant difference between the proportion of pulmonologists specializing in COPD care and that of cardiologists specializing in CHF care (32.4% vs 39.2%; P = .28). However, there were significantly fewer facilities that reported having COPD clinics than having CHF clinics (12.7% vs 50.8%; P <.01).

For programs that were typically led by specialty services, there were no significant differences between management of COPD and CHF for most standardized practices and protocols in the outpatient setting. Facilities reported similar proportions of having protocols for outpatient management (27.0% vs 18.5%; P = .12), patient self-management (23.4% vs 25.2%; P = 0.75), and patient education programs (68.5% vs 67.5%; P = .87) for COPD and CHF, respectively. Compared with CHF outpatient disease management, COPD outpatient management included slightly fewer facilities that reported having a disease specific exercise program (29.7% vs 39.2%; P = .13) and less access to specialized pharmacists (45.9% vs 53.8%; P = .23).

A significantly lower proportion of facilities reported having COPD home monitoring programs than CHF home monitoring programs (50.5% vs 87.4%; P <.01). Among facilities that did have home monitoring programs, fewer telemedicine devices were used for monitoring data transmission for COPD than CHF (75% vs 88.5%; P = .03). Among facilities with home monitoring programs, COPD management also had significantly lower use of nurses for adjusting medications (10.7% vs. 31.7%; P <.01) and relied more heavily on physicians (46.4% vs 31.7%; P = .07) compared with CHF management.

There were no significant differences in reporting the use of standardized order sets for disease exacerbations (COPD: 29.7% vs CHF: 25%; P = .42), as well as inpatients routinely seen by a specialist (physicians, nurse practitioners, or nurses) during an inpatient stay (20.7% for COPD patients vs 25% for CHF patients; P = .44).

Although the majority of facilities reported routinely sharing disease-related performance measures with providers for CHF, less than one-fifth of hospitals reported sharing COPD-related performance measures (70% vs 17.1%; P <.01). Overall, facilities were more likely to share CHF-specific performance reminders than COPD-related performance reminders with providers. The majority of facilities reported sharing CHF-related performance reminders with providers, including 94.3% for angiotensin-converting enzyme (ACE) inhibitors, 78.4% for beta blockers, and 85.1% for ejection fraction (EF) (Table 2). Provider feedback for COPD management was much lower, and included 64% of hospitals providing feedback on appropriate use of oxygen therapy, 57.7% on smoking cessation counseling, 34.2% on spirometry assessment, and 16.2% on steroids for exacerbations.

Although a similar proportion of facilities reported assessing any quality measure prior to discharge for COPD and CHF patients (95.5% vs 95.8%; P = .90), there were notable differences in the specific quality measures that were assessed (Table 3). The majority of facilities reported assessing specific CHF measures, including EF assessment (83.3%), ACE inhibitors for (90%), beta blockers (80%), and spironolactone (51.7%). Assessing specific COPD measures occurred in 30% of facilities for prior confirmation of COPD by spirometry, 74.2% for assessment of smoking status, 70% for providing smoking cessation intervention, and 69.2% for oxygen for room air saturations of less than 88%.

In comparison to CHF, we found consistent and large systematic differences in the organizational structure available to support the high-quality management of COPD. These differences were evident across processes of care, including clinic structure, type of provider involved in patient care, home monitoring programs, provider feedback on performance measures, and quality measures assessed during hospitalization. A comparative lack of organizational structure for COPD likely contributes to documented concerns about quality of care for patients with COPD.9,17 The VA has hundreds of measures of quality, though there are no measures specifically adopted for COPD. Our findings identify a gap in disease-specific focus that may help prioritize quality improvement efforts at a system level for patients with COPD.

The lack of organizational structure that we observe may be due to a lack of research to identify appropriate process measures for COPD. COPD is ranked as the most underfunded condition relative to disease-specific mortality.18 National Institutes of Health (NIH) funding for COPD research has not grown in many years and is still only 6% of the funding available for heart disease.19 Nevertheless, over the past 30 years, mortality due to COPD has doubled, whereas death due to heart disease has decreased by more than half.5 This decline in the burden of cardiovascular disease followed substantial increases in research funding.19 To better allocate research spending, the Institute of Medicine in the United States has recommended that the NIH explicitly associate the amount of research funding with the burden of disease—an approach that is relevant to how health systems prioritize clinical quality efforts.20

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