Characteristics Associated with Spirometry Guideline Adherence in VA Patients Hospitalized with Chronic Obstructive Pulmonary Disease

Abstract

Background: The Global Initiative for Chronic Obstructive Lung Disease (GOLD) recommends at least annual spirometry for patients with chronic obstructive pulmonary disease (COPD). Since spirometry acquisition is variable in clinical practice, identifying characteristics associated with annual spirometry may inform strategies to improve care for patients with COPD.

Methods: We included veterans hospitalized for COPD at Veterans Health Administration (VHA) facilities from 10/2012 to 09/2015. Our primary outcome was spirometry within 1 year of COPD hospitalization. Patient demographics, health factors, and comorbidities as well as practice and geographic variables were identified using Corporate Data Warehouse; provider characteristics were obtained from the Survey of Healthcare Experiences of Patients. We used logistic regression with a random intercept to account for potential clustering within facilities.

Results: Spirometry was completed 1 year before or after hospitalization for 20,683/38,148 (54.2%) veterans across 114 facilities. Patients with spirometry were younger, (mean=67.2 years (standard deviation (SD)=9.3) vs. 69.4 (10.3)), more likely non-white (21.3% vs. 19.7%), and more likely to have comorbidities (p<0.0001 for asthma, depression, and post-traumatic stress disorder). Pulmonary clinic visit was most strongly associated with spirometry (odds ratio (OR)=3.14 [95% confidence interval 2.99-3.30]). There was no association for facility complexity. In a secondary analysis including provider-level data (3862 patients), results were largely unchanged. There was no association between primary care provider age, gender, or type (physician vs. advanced practice registered nurse vs. physician assistant) and spirometry.

Conclusion: In a cohort of high-risk COPD patients, just over half completed spirometry within 1 year of hospitalization. Pulmonary clinic visit was most strongly associated with 1-year spirometry, though provider variables were not. Spirometry completion for high-risk COPD patients remains suboptimal and strategies to improve post-hospitalization care for patients not seen in pulmonary clinic should be developed to ensure guideline concordant care.

Figure 1

Flow diagram of patient exclusions. VHA, Veterans Health Administration; COPD, chronic obstructive pulmonary disease; SHEP, Survey of Healthcare Experiences of Patients.

Figure 2

Distribution of spirometry completion over time in days relative to date of hospitalization (n=12,568 patients with spirometry completed). Yellow bars indicate spirometry acquisition within 90 days after hospital admission.

Figure 3

Practice and geographic factors associated with spirometry completion within 1 year of COPD hospitalization. NE, Northeast; CI, confidence interval. Analyses also adjusted for patient characteristics of demographics, smoking, substance use, diabetes, asthma, depression, and PTSD.

Figure 4

Provider-level characteristics associated with spirometry completion within 1 year of COPD hospitalization. APRN, advanced practice registered nurse; PA, physician assistant; CI, confidence interval. Analyses also adjusted for patient characteristics of demographics, smoking, substance use, diabetes, asthma, depression, and PTSD and practice and geographic characteristics of pulmonary clinic visit, rurality, complexity, and region.