Investigators from the Veterans Health Administration recently completed a multi-site trial of a Collaborative Cardiac Care Team (CCCT) intervention to improve management of chronic stable angina. The study found the CCCT intervention associated with overall improvement in guideline-concordant care (improved guideline concordance).
One concern with the CCCT intervention is that it could be perceived by primary care providers as encroaching on their professional prerogative, because the CCCT made unsolicited recommendations about patient care. However, past research on professional and organizational conflict suggests that individual professionals who feel a high degree of shared values and commitment to the mission of the organization (i.e., high organizational commitment) are more open to such practices. Likewise, past research suggests that provider caseload for a given clinical condition is positively associated with quality of care for that condition.
Both organizational commitment and ischemic heart disease (IHD) caseload were assessed as part of the CCCT trial. We wondered if these provider-level characteristics were independently associated with improved guideline concordance among participating patients, and whether these two characteristics may have moderated the effect of the CCCT intervention.
The objective of the present study was to determine the association of two provider-level characteristics, (1) providers' organizational commitment, and (2) IHD caseload, with improved guideline concordance for patients with chronic stable angina in the context of a randomized, controlled trial of a CCCT intervention.
1.Determine if providers' baseline organizational commitment is positively associated with improved guideline concordance for chronic stable angina patients in intervention and control arms.
2.Determine if providers' baseline IHD caseload is positively associated with improved guideline concordance for chronic stable angina patients in intervention and control arms.
3.Determine if providers' baseline organizational commitment and IHD caseload have stronger positive associations with improved guideline concordance among patients in the intervention arm relative to patients in the control arm.
We conducted a cross-sectional analysis of secondary data from the CCCT trial.
For all three study Aims, the unit of analysis was the patient (total n = 410; intervention arm = 197, and control arm = 213), and the dependent variable was change from baseline to follow-up in patient-level receipt of guideline concordant care for chronic stable angina; we refer to this as improved guideline concordance. Organizational commitment came from provider surveys; IHD caseload came from administrative data; and improved guideline concordance came from chart review data.
We used hierarchical modeling to examine providers' baseline organizational commitment (Aim 1) and IHD caseload (Aim 2) as predictors of improved guideline concordance for management of chronic stable angina. We then conducted stratified analyses for intervention and control arms to determine if organizational commitment and IHD caseload had stronger associations with improved guideline concordance in the intervention arm (Aim 3).
Neither providers' organizational commitment nor IHD caseload at baseline were significantly associated with improved guideline concordance. Results were no different in the analyses stratified by intervention and control arms, and did not change after adjusting for patient factors or study site. Higher guideline concordance at baseline was negatively associated with improved guideline concordance suggesting a ceiling effect.
Providers' organizational commitment and IHD caseload were not associated with improved guideline concordant care, either independently or as a moderator of the effect of the CCCT intervention. Our findings suggest these characteristics, in the context of chronic stable angina, are unlikely to be either unobserved confounders or effect modifiers of CCCT interventions, and should not be concerns in their own right for clinical managers.
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