Care Found Lacking for Many With Obstructive Lung Disease

LOS ANGELES, Nov. 14 -- Patients with asthma and chronic obstructive pulmonary disease (COPD) get only half the care that they should, according to a national sample.

Although there are a variety of guidelines for the care of patients with obstructive lung disease, the extent to which they receive it has been largely unknown, said Richard Mularski, M.D., of the Veterans Affairs Healthcare System here, and researchers at Rand Health and UCLA School of Public Health.

The national sample found a grim story, with varying levels of routine and exacerbation care, as well standards of delivery (history taking, laboratory and radiologic studies, geographic location), and patient education, the investigators reported in the November issue of Chest.

The researchers extracted medical records for two prior years from 429 consenting participants in a random telephone survey in 12 communities. Using the modified Delphi expert panel methodology, they measured the quality of care provided with 45 explicit, process-based quality indicators for asthma and COPD.

Overall, participants received only 55.2% of recommended care for obstructive lung disease, the researchers reported. Their findings came from 2,394 care events identified among 260 asthma participants and 1,664 events among 169 COPD participants.

Asthma patients received 53.5% of recommended care, with routine care better (66.9%) than exacerbation care (47.8%). COPD patients received 58.0% of recommended care, but received better exacerbation care (60.4%) than routine care (46.1%), the researchers found.

The considerable variation in mode of care included substantial deficits in documenting recommended aspects of medical history (41.4%) and use of diagnostic studies (40.1%).

Also, there was modest variation between racial groups, geographical areas, insurance types, and other characteristics, the researchers reported.

Although the guidelines emphasize the importance of education and involving patients in the management of obstructive lung diseases, there were shortfalls in this area as well, the researchers reported. Particularly poor scores were found for the use of spacers with metered dose inhalers (11% for asthma and 32% for COPD), they reported.

Among other findings:

• Participants in the lowest income bracket, even after controlling for insurance status and other demographic characteristics, received lower quality care.
• Quality scores for the 12 communities ranged from 46% to 63% overall, with the better locations for asthma and COPD being similar.
• Small variation was also seen between different insurance types, with Medicaid patients achieving statistically better care than HMO enrollees.
• In a sample of patients with at least some access to care, after adjusting for other covariates, African Americans received better overall care than all other race categories (67%). Other rates were whites (52%), while Hispanics had the poorest care (48%) and particularly poor care for COPD (37%). The racial variation in this study may be different from prior studies in that the researchers controlled for a wider range of sociodemographic, health status, and utilization covariates.

However, Dr. Mularski and his colleagues took care to emphasize that "all these variations are dwarfed by the overall deficits documented in the quality of care."

It is difficult to know the extent of excess morbidity and mortality that the deficits in specified care documented here might engender, the researchers said. As an example, they noted that only 32% of COPD patients with baseline hypoxia received home oxygen for routine management.

From estimates of the number of U.S. hypoxic patients and the mortality reductions demonstrated by the Nocturnal Oxygen Therapy Trial, oxygen therapy for COPD patients could prevent 27,000 to 54,000 annual deaths.

Similarly, the investigators said, only 56% of hospitalized asthmatic patients received systemic steroids, which could lead to excess mortality estimates that approach 2,000 a year.

Among the study's limitations, the researchers mentioned the use of medical record review for quality assessment, so that some of the quality shortfall may have been due to under-documentation. Chart abstraction underestimates rates by at most 10% as compared with direct observation. Nevertheless, the researchers said it is hard to explain the considerable shortfalls identified purely on the basis of poor documentation.

Second, they said, the response rate of only 37% of all those who were eligible introduces the potential for bias. The low prevalence of obstructive lung disease in the sample (3.9% for asthma and 2.5% for COPD) may reflect a younger population relative to national demographics, as well as the reliance on provider diagnosis for inclusion.

In summary, the researchers wrote that the reasons for lack of adherence to recommended care processes may relate to the complexity and diversity of the health care system. This study did not directly suggest strategies to improve care, they said, but whatever strategies are used -- and there are many, from the use information technology to linking quality performance to reimbursement -- national efforts combined with local innovation aimed at system change will be required.

"The data from this study should be a resounding call for quality improvement efforts and further understanding of the deficits in processes of care for obstructive lung disease," the team concluded.