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The American Journal of Managed Care March 2016
Understanding Vaccination Rates and Attitudes Among Patients With Rheumatoid Arthritis
Diana S. Sandler, MD; Eric M. Ruderman, MD; Tiffany Brown, MPH; Ji Young Lee, MS; Amanda Mixon, PA; David T. Liss, PhD; and David W. Baker, MD, MPH
Remembering the Strength of Weak Ties
Brian W. Powers, AB; Ashish K. Jha, MD, MPH; and Sachin H. Jain, MD, MBA
Prevalence, Effectiveness, and Characteristics of Pharmacy-Based Medication Synchronization Programs
Alexis A. Krumme, MS; Danielle L. Isaman, BS; Samuel F. Stolpe, PharmD; J. Samantha Dougherty, PhD; and Niteesh K. Choudhry, MD, PhD
Impact of Cost Sharing on Specialty Drug Utilization and Outcomes: A Review of the Evidence and Future Directions
Jalpa A. Doshi, PhD; Pengxiang Li, PhD; Vrushabh P. Ladage, BS; Amy R. Pettit, PhD; and Erin A. Taylor, PhD, MSPH
Trends in Hospital Ownership of Physician Practices and the Effect on Processes to Improve Quality
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
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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.
Despite the relative lack of research funding for COPD, there is a body of literature that supports the implementation of organizational structure for COPD management. Systematic reviews of integrated disease management programs for COPD have demonstrated many parallels to CHF programs, with reduced hospital admissions, improved quality of life, and improved exercise capacity.21,22 Similarly, COPD and CHF studies on exercise programs have demonstrated better patient outcomes with participation in pulmonary and cardiac rehabilitation.23,24 Although there are still many deficiencies and controversies in COPD research, improving the organizational structure of disease management can lead to meaningful improvements in patient outcomes.25

In our study, we found significantly less organizational structure available, even among COPD interventions that have been well studied. There was less feedback for guideline-based performance measures and fewer quality measures assessed prior to hospital discharge for COPD than for CHF. Previous studies have demonstrated that awareness of COPD guidelines and adherence to guideline recommendations is low.26-28 Among 69,820 patients hospitalized in 360 different hospitals for acute COPD exacerbations, only 33% received appropriate guideline-based care.28 Similarly, only 46% of ambulatory patients received appropriate chronic COPD management.29 In contrast, previous studies have estimated that as many as 72% of ambulatory patients receive appropriate chronic CHF management.30 Developing and aligning quality and performance measures to widely accepted guidelines has driven the implementation of these practices into care for multiple clinical conditions, and would likely improve the quality of care for COPD.

Patients who receive healthcare at the VA tend to receive higher quality of care compared with patients who receive healthcare elsewhere.31 Much of this difference is seen in areas where the VA has adopted performance measures for disease management. The VA has instituted several performance measures for CHF and has developed the CHF QUERI to identify and apply best practices for CHF care.32 Despite more VA patients being affected by COPD than CHF, no similar programs exist to improve quality for COPD.9 The specific payment metrics that tend to focus on heart disease outcomes in the private sector do not affect the VA healthcare system, allowing for a broader approach to improving health quality.

We have shown that in a large, nationwide healthcare system, there is a relative deficiency of organizational structure available for the management of COPD patients. Nevertheless, new policies have recently been implemented that impact COPD care and have focused attention to the disease. CMS has expanded the Hospital Readmission Reduction Program to include COPD.33 Hospitals that have high risk–adjusted 30-day readmission rates are subject to a penalty with reduced reimbursement for Medicare patients. This penalty is being implemented without evidence demonstrating that readmissions are a function of the quality of COPD care, preventable, or lead to poor health outcomes.34 Despite the lack of a clear path to reduce readmissions, healthcare systems may attempt to develop and adopt organizational structure and practices for COPD management to offset the potential financial penalties.35 Adoption of carefully thought out processes that emphasize a culture of quality may improve outcomes, even with evidence to suggest that the individual processes may not be effective.36,37

Limitations and Strengths

We had a number of potential limitations that may affect the inferences we can draw from this study. We performed surveys that could be affected by response, recall, and social desirability bias, and we were unable to ascertain whether responses to the survey reflected true practice. In addition, the COPD survey was conducted several years after the CHF survey and we cannot account for any secular changes in practice during this period or between the time of the COPD survey and this publication. However, there was no systemwide intervention targeting COPD management in the VA during this period, and it is unlikely that organizational structure for COPD changed significantly. We believe that if a bias does exist, it likely reflects a greater discrepancy for organizational structure if both surveys had been taken in 2008. Although previous studies have found benefits from increased organizational structure, we were not able to assess whether individual practices were effective at improving outcomes. The time from initial surveys to publication may also limit the application of these results as increasing attention on COPD outcomes may have resulted in more organizational structures for COPD care. Lastly, the study setting was limited exclusively to VA facilities; therefore, our findings may not directly generalize to other healthcare systems.

This study also had important strengths. First, we engaged national VA clinical leaders to disseminate our surveys, which may have contributed to our high response rates and minimal missing data. Second, we surveyed all facilities, thereby minimizing any opportunity to introduce bias by the type of facility or the regional variations in care. Third, we addressed questions that were based on the National Quality Forum or other developed standards, enhancing the ability to utilize in real-world settings.

In our national comparative study on the organizational structure available for treatment of COPD and CHF, we found less organizational structure available for COPD than for CHF management, which highlights the value placed on health systems for developing these structures for COPD. We suspect that these deficiencies exist throughout various health systems, in part because of the paucity of research and quality improvement efforts that currently exist for COPD. Our study highlights how disparities in quality measurement can develop in the absence of a systematic approach to identify health conditions that warrant closer monitoring. With continuous emphasis placed on value of care, accountable care organizations and other integrated healthcare settings will need to develop processes to address conditions that lead to poor patient outcomes and significant financial risk.

Author Affiliations: VA Connecticut Health Care System, Department of Veterans Affairs (STR, LAB), West Haven, CT; Section of Pulmonary and Critical Care, Department of Internal Medicine, Yale University (STR), New Haven, CT; Health Services Research and Development, VA Puget Sound Health Care System, Department of Veterans Affairs (C-FL, ESW, PLH, DHA), Seattle, WA; Department of Health Services (C-FL, ESW, PLH) and Divisions of Pulmonary and Critical Care, Department of Medicine (DHA), University of Washington, Seattle, WA; Health Research and Policy, VA Palo Alto Health Care System, Department of Veterans Affairs (PH), Palo Alto, CA; Department of Medicine, University of Connecticut Health Center (LAB), Farmington, CT.

Source of Funding: Funding for this research was provided by a Veterans Affairs clinical research grant IIR-09-354. The views expressed here are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs.

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (STR, C-FL, LAB, ESW, DHA); acquisition of data (STR, C-FL, DHA, PH); analysis and interpretation of data (STR, C-FL, ESW, PLH); drafting of the manuscript (STR, C-FL, LAB, DHA, PLH, PH); critical revision of the manuscript for important intellectual content (STR, C-FL, LAB, DHA, PLH, PH); statistical analysis (STR, C-FL, ESW, PLH); provision of patients or study materials (STR); obtaining funding (C-FL, DHA, PH); administrative, technical, or logistic support (C-FL, PH, DHA); and supervision (C-FL, PH, DHA).

Address correspondence to: Dr David Au, MD, 1100 Olive Way, Ste 1400, Seattle, WA 98104-3801. E-mail:
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