Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial VA Hospital, 200 Springs Rd, Bldg 70, Bedford, MA 01730. Email:
Am J Manag Care. 2020 Feb;26(2):63-68. doi: 10.37765/ajmc.2020.42394.
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.
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.
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.
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.
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.
改善慢性阻塞性肺疾病（COPD）的护理并降低医院再入院率是当前医疗体系的当务之急。然而，目前对于导致再入院率差异的组织因素知之甚少。其他慢性疾病的证据表明，护理协调是其中一个因素。
为了了解护理协调方面的站点间差异是否是导致再入院率差异的组织因素之一，我们调查了退伍军人事务部（VA）站点中 COPD 护理方面的提供者观点。
在这项混合方法的正偏离研究中，我们选择了 2016 年风险调整后 COPD 再入院率处于最低四分位数和最高四分位数的 3 个 VA 站点。在 2017 年 6 月至 10 月期间，我们对 VA 站点中 COPD 护理的初级和专科护理提供者进行了半结构化访谈，这些站点的再入院率较低（n = 14）和较高（n = 11）。
尽管所有站点的提供者都提到了正在进行的降低再入院率的举措，但只有低再入院率站点的提供者描述了以高关系协调为特征的实践环境（即高质量的工作关系和高质量的沟通）。他们还报告了在患者数量等方面合作方面的结构性障碍较少。
高再入院率和低再入院率站点之间最显著的差异与关系协调的质量和协调的结构性障碍的存在有关，而与特定的降低再入院率举措无关。实施旨在增强关系协调和消除协调结构性障碍的组织改革将改善 COPD 的护理质量，并可能改善其他慢性疾病的护理质量。
