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The American Journal of Managed Care February 2020
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Care Coordination for Veterans With COPD: A Positive Deviance Study
Ekaterina Anderson, PhD; Renda Soylemez Wiener, MD, MPH; Kirsten Resnick, MS; A. Rani Elwy, PhD; and Seppo T. Rinne, MD, PhD
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Care Coordination for Veterans With COPD: A Positive Deviance Study

Ekaterina Anderson, PhD; Renda Soylemez Wiener, MD, MPH; Kirsten Resnick, MS; A. Rani Elwy, PhD; and Seppo T. Rinne, MD, PhD
Improving relational coordination and reducing structural barriers to collaboration may enhance quality of care for chronic obstructive pulmonary disease (COPD) and other chronic conditions.

Objectives: Improving chronic obstructive pulmonary disease (COPD) care and reducing hospital readmissions is an urgent healthcare system priority. However, little is known about the organizational factors that underlie intersite variation in readmission rates. Evidence from other chronic diseases points to care coordination as one such factor.

Study Design: To understand whether intersite differences in care coordination may be one of the organizational factors contributing to the variation in readmission rates, we examined provider perspectives on COPD care at Veterans Affairs (VA) sites.

Methods: In this mixed-methods positive deviance study, we selected 3 VA sites in the lowest quartile and 3 in the highest quartile for 2016 risk-adjusted COPD readmission rates. During June to October 2017, we conducted semistructured interviews with primary and specialty care providers involved in COPD care at VA sites with low (n = 14) and high (n = 11) readmission rates.

Results: Although providers at all sites referenced ongoing readmission reduction initiatives, only providers at low-readmission sites described practice environments characterized by high relational coordination (ie, high-quality work relationships and high-quality communication). They also reported fewer significant structural barriers to collaboration in areas like patient volume.

Conclusions: The most notable differences between high- and low-readmission sites were related to the quality of relational coordination and the presence of structural barriers to coordination, rather than specific readmission reduction initiatives. Implementing organizational reforms aimed at enhancing relational coordination and removing structural barriers would enhance care for COPD and may improve quality of care for other chronic conditions.

Am J Manag Care. 2020;26(2):63-68.
Takeaway Points

We discovered that although Veterans Affairs sites with both high and low readmission rates for chronic obstructive pulmonary disease (COPD) had readmission reduction initiatives in place, it was providers at sites with low readmission rates for COPD who described practice environments characterized by a greater degree of relational coordination and reported fewer structural barriers than their counterparts at sites with high readmission rates. Because the features of practice environments that enable relational coordination are not unique to COPD, improving relational coordination may also improve quality of care for other chronic diseases.
  • Stakeholders may consider launching initiatives to foster relationships and support high-quality communication between clinicians involved in COPD care.
  • These initiatives may also be extended to non-COPD contexts, as improved relational coordination is likely to improve care for other chronic conditions.
  • Efforts to improve relational coordination ought to also target structural barriers to collaboration, such as excessive workload and understaffing.
Chronic obstructive pulmonary disease (COPD) affects 12.7 million individuals in the United States, including nearly 1.25 million US veterans (25% of the veteran population).1-4 In 2010 alone, COPD was responsible for approximately 10.3 million physician appointments, 1.5 million emergency department visits, and 700,000 hospitalizations.5 In 2014, CMS began imposing financial penalties on hospitals with high risk-adjusted COPD readmission rates.6-9 Although Veterans Affairs (VA) does not penalize hospitals based on readmission rates, it tracks readmissions3 and incorporates these metrics into its yearly hospital star ratings,10 thus providing an excellent opportunity to examine differences in COPD care among hospitals according to readmission rates.

Hospital readmission rates for COPD vary widely,11 yet few interventions have reliably reduced COPD readmissions.12 COPD readmissions are associated with other hospital quality indicators,9 suggesting that common organizational or institutional factors may drive high-quality care.13 Care coordination is one organizational factor that could explain these associations. The few COPD interventions that have effectively improved readmissions relied on high-quality care coordination,14-16 and care coordination has improved care quality for other conditions.17-20 Relational coordination theory conceptualizes differences in organizational approaches to coordination as contingent on 2 mutually reinforcing factors: relationships (with high quality defined by shared knowledge, shared goals, and mutual respect) and communication (with high quality defined as frequent, timely, accurate, and problem-solving).21-23 Exploring differences in relationships and communication at sites with high versus low COPD readmissions could identify opportunities to improve coordination and ultimately enhance the quality of COPD care and chronic care more broadly.

The primary purpose of this paper is to explore organizational factors, including relational coordination, at VA sites with high versus low COPD readmissions. Our findings could help identify specific, modifiable organizational characteristics associated with lower COPD readmissions. These results could also guide initiatives that support care coordination for other chronic diseases to improve the overall quality of care. This work has been expanded from the abstracts presented at the American Thoracic Society International Conference in May 201824 and the VA HSR&D/QUERI National Conference in October 2019.25


We conducted a mixed-methods study of healthcare provider perspectives on care coordination for veterans with COPD. We used the positive deviance approach (ie, the study of the underlying causes of exceptionally high organizational performance)26,27 and an explanatory sequential design, wherein quantitative data inform qualitative data collection and analysis.28 We reviewed VA Hospital Compare website data on 2016 risk-adjusted COPD readmission rates for VA medical centers (VAMCs), which are typically composed of inpatient and outpatient clinical settings located on the same campus, nationwide.29 Relying on purposive sampling and taking care to ensure diversity in geography and size, we selected 3 VAMCs in the lowest and highest readmission quartiles, respectively (Table 1).

We recruited providers at the selected sites between June and October 2017 through emails and phone calls, using snowball sampling for further recruitment. We interviewed inpatient and outpatient providers caring for veterans with COPD in their regular clinical practice (n = 25, including 13 internal medicine providers, 10 pulmonologists, and 2 mental health care providers) (Table 1) over the phone. Mental health care providers were included to capture diverse professional perspectives. The interviews explored provider definitions of and experiences with COPD care coordination, as well as local organizational practices related to COPD care (eAppendix [available at]). Thematic saturation was reached (ie, no new concepts emerged with new interviews)30 after 25 interviews (14 low-readmission sites and 11 high-readmission sites). The professionally transcribed and verified interviews were analyzed with the qualitative software package NVivo version 11 (QSR International; Melbourne, Australia).

Using principles of conventional content analysis, 2 investigators (K.R. and S.T.R.) independently read all of the transcripts line by line and inductively constructed initial codes.31 They then compared their notes, reviewing the code structure for logic and comprehensiveness. Throughout the coding process, they met regularly and discussed select sections of the transcripts to agree on code definition and application, revise the codebook, and discuss emergent themes with the larger research team. The team then produced summaries of organizational practices of all sites, drawing on positive deviance methodology26 to determine practices that distinguished high-performing sites. To ensure objectivity and minimize confirmation bias, the investigators acknowledged negative attributes of high-performing sites and positive attributes of low-performing ones. The team then reanalyzed the dominant themes using relational coordination theory, a theoretical framework that, unlike traditional approaches to organizational coordination and performance that focus on formal coordination mechanisms (scheduling, routines, standardization) or individual metrics (individual performance, skills, or motivation), foregrounds relational dynamics.23,32 The study was approved by the Edith Nourse Rogers Memorial Veterans Hospital Institutional Review Board.


Low- and high-readmission sites alike had initiatives to improve COPD care and reduce readmissions (Table 2). However, the nature and scope of these initiatives varied among sites. Further, whereas respondents from low-readmission sites reported collaborative working relationships (characterized by shared knowledge, shared goals, and mutual respect), stronger communication, and fewer significant structural barriers to collaboration, their counterparts at high-readmission sites described challenges in these domains, suggesting noteworthy intersite differences in practice environments.

COPD Care Improvement Initiatives and Programs

Participants from low- and high-readmission sites alike described the following types of initiatives and programs: (1) inpatient and out­patient education programs, including smoking cessation counseling; (2) postdischarge follow-ups, sometimes by designated coordinators or case managers; (3) pulmonary rehabilitation programs; and (4) postdischarge outpatient clinics. However, the programs at sites with low readmissions can be characterized as more extensive and more deliberately designed. For example, COPD coordinators not only were tasked with appointment scheduling and occasional follow-ups like their high-readmission counterparts, but also took and triaged patient calls. Similarly, at another low-readmission site, all patients at risk for readmission were referred to a multidisciplinary postdischarge clinic, whereas at high-readmission sites no such systematic approach was used.

More fundamentally, although sites with high readmissions had some innovative initiatives in place (eg, standardized COPD order set, early palliative care consults, interdisciplinary huddles), provider accounts from these facilities do not convey a sense of deliberate, coordinated attempts to address readmissions. As one interviewee observed, “Our readmission rates with COPD are up for some reason, and I don’t think anybody really knows why they’re up.” By contrast, providers at low-readmission sites reported that their sites formed working groups tasked with summarizing best practices and reviewing readmissions case by case to “try to understand why that happened.”

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