Association Between Improvement in Institutional COPD Quality Assessment Grade and Risk of Acute Exacerbations in Primary and Secondary Care: A Nationwide Claims-Based Study

Abstract

Background: The Health Insurance Review and Assessment Service (HIRA) in South Korea assesses and grades primary and secondary healthcare institutions according to their management of chronic obstructive pulmonary disease (COPD). This study examined whether changes in institutional quality assessment grades were associated with variations in the concurrent risk of acute COPD exacerbations. Methods: Using national HIRA claims data, we identified 36,218 patients with COPD treated at 873 non-tertiary medical institutions between May 2016 and April 2018. Institutions were stratified into three groups based on their grade trajectories from the 3rd (May 2016–April 2017) to the 4th (May 2017–April 2018) assessment periods: the 158 improved-grade (n=5,118), 526 maintained-grade (n=25,286), and 189 declined-grade (n=5,814) institution groups. We compared the incidence and severity of exacerbations among these groups during the 4th assessment period. Incidence rate ratios (IRRs) for exacerbations were estimated using multivariable negative binomial regression models to adjust for potential confounders. Results: At baseline, improved-grade institutions exhibited significantly higher rates of pulmonary function testing (56.3% vs. 41.9%) and greater prescription of long-acting muscarinic antagonists (29.0% vs. 14.6%) compared with declined-grade institutions (p<0.001). During the 1-year outcome period (May 2017–April 2018), the incidence of moderate-to-severe COPD exacerbations was considerably higher in the declined-grade group (29.2%) than in the improved-grade group (26.1%) (p=0.008). In the negative binomial regression analyses using the maintained-grade group as the reference category, patients treated at improved-grade institutions had a significantly lower risk of exacerbations (adjusted IRR 0.864, 95% CI 0.795–0.939, p<0.001). Conclusion: This analysis of nationwide real-world claims data demonstrated that institutional improvement in COPD quality assessment grades was associated with a reduced concurrent risk of acute exacerbations in both primary and secondary care settings. These findings indicate that institutional indicators of guideline-aligned COPD care may correspond to clinically meaningful differences in patient-level outcomes.