Korean Quality Assessment Program Found to Be Effective at Improving COPD Care

A national quality assessment program has shown to be beneficial in improving management of and prognosis associated with chronic obstructive pulmonary disease (COPD), according to a recent study published in Respiratory Research.

“We believe that the continued application of this type of quality assessment program will help improve clinical outcomes and medical utilization for COPD patients,” wrote the investigators.

Since 2014, the Korean Health Insurance Review (HIRA) has conducted the national COPD Quality Assessment Program (CQAP) as a way to minimize the national socioeconomic burden of COPD and achieve an optimal treatment strategy to improve the quality of COPD health care in the Republic of Korea.

The CQAP evaluates how patients are treated in medical institutions and aims to improve quality of COPD management, clinical outcomes, and COPD prognosis. Although the results to the CQAP are made available to the public, the direct and indirect effects of the program on clinical practice have not been evaluated.

In the study, the investigators examined data from May 1, 2014, to April 30, 2017. The total numbers of patients with COPD recorded each year were 569,252 in 2014, 557,682 in 2015, and 539,708 in 2016. The mean age of the patients ranged from 67.5 to 68.2 years across the 3 years, and about 60% in each year were men.

Out of the roughly 560,000 patients with COPD, approximately 40% were evaluated at least once between 2014 and 2017. Additionally, 142,000 (25.5%) patients were assessed annually by the CQAP and 10% of patients were assessed during all 3 years.

Among the patients assessed by the CQAP, the rate of conducting pulmonary function tests (PFT) increased from 60.2% to 69.0%. Prescription rates for inhaled long-acting muscarinic antagonists (LAMAs) and long-acting beta-agonists (LABAs) also increased, from 45.1% to 51.8% and from 49.4% to 53.4%, respectively (P < .001).

The rates of PFT conduction, LAMA prescriptions, and LABA prescriptions were significantly lower among patients who were recorded but not assessed (all P < .001). However, conducting PFTs did increase at a smaller rate, from 24.8% to 27.8%.

Between 2014 to 2017, COPD-related hospital admission frequency slightly decreased (–3.6%) among assessed patients and increased among nonassessed patients (+22.0%; risk reduction rate [RRR], 21.2%; P < .001). The all-cause mortality rate was greatly increased in the nonassessed group (+65.2%) and slightly decreased in the assessed group (–0.3%; RRR, 40.7%; P < .001).

“The guidelines suggest that the use of inhaled bronchodilators has a positive effect on the management and prognosis of COPD patients, but they are not widely used in practice in Korea. This implies that both clinicians and patients need to change their perceptions about long-term management goals of COPD,” wrote the investigators.

The investigators speculated that the reason that higher rates of bronchodilators, admissions, and mortality were observed among assessed patients was because the assessed group may have been composed of patients with more severe COPD. Additionally, the natural course of COPD often results in higher mortality rates among patients with more severe cases.

“We speculate that this phenomenon is because the coverage of medical insurance increased with national income and the interest in the health of chronically ill patients increased,” wrote the investigators.

When the investigators conducted the matching analyses with the assessed and nonassessed patients from 2016 (n = 127,927 each) and 2014 (n = 137,402 each), they found that the rates of PFT conduction and inhaled LAMA prescriptions in both groups of matched assessed patients sharply decreased after increasing, suggesting that positive effects of the CQPA may be temporary.

The researchers identified several limitations, including that patients with COPD were defined using only diagnostic codes, the direct effects of CQAP could not be fully assessed, and the results cannot be applied to countries that do not have a national medical insurance system. Additionally, the CQAP may carry a possible but unmeasured negative impact.

“To reduce the socioeconomic burden of chronic illnesses, the physicians managing chronic illnesses should manage patients in the most efficient way possible (with regards to factors such as guidelines and action plans), and patients should show a high degree of adherence to the control and rescue medications,” noted the investigators.

Reference

Park HJ, Kim SR, Kim S, et al. Influence of government-driven quality assessment program on patients with chronic obstructive pulmonary disease. Respir Res. Published online March 21, 2021. doi:10.1186/s12931-021-01684-1