Protected Time for Self-Care for Veterans Health Administration (VA) Employees.

OBJECTIVES: Employee Whole Health (EWH) empowers VA employees to take charge of their well-being by integrating self-care into their workday, but employees lack time to participate. METHODS: Employees at three VA medical centers participated in a 12-month feasibility cohort study to protect 60 minutes of time per week for self-care. Questionnaire data was collected at three time points; qualitative data at two time points. Pilot offerings included education and complementary and integrative health modalities for well-being. RESULTS: Employees enrolled spring 2021 (n = 312). Complete-case regression analyses indicated significant improvements in wellness culture, resiliency, self-efficacy, perceived stress, and flourishing at twelve months. Multiple imputation analyses confirmed improvements except for self-efficacy. Qualitative findings supported quantitative findings. CONCLUSIONS: Providing protected time for self-care was feasible and supported improvements in well-being. However, high workload was identified as an ongoing barrier to participation.

The Impact of Involvement in Whole Health System for Veterans or Participating in It for Oneself on Job Attitudes in VA Employees.

OBJECTIVE: The aim of the study is to examine how involvement in the Whole Health System of care, clinically and personally (through employee-focused activities), would affect employee satisfaction, engagement, burnout, and turnover intent in the Veterans Health Administration. METHODS: Multivariate logistic regression analysis of cross-sectional survey from Veterans Health Administration employees was used to determine the influence of Whole Health System involvement and Employee Whole Health participation on job attitudes. RESULTS: Whole Health System involvement was associated higher job satisfaction, higher levels of engagement, lower burnout, and lower turnover intent. A similar pattern of results was identified when looking specifically at Employee Whole Health participation and associated job attitudes. CONCLUSIONS: Employees who are either directly involved in delivering Whole Health services to veterans or who have participated in Whole Health programming for their own benefit may experience a meaningful positive impact on their well-being and how they experience the workplace.

What We Have Learned About the Implementation of Whole Health in the Veterans Administration.

As we have advanced the concept of Whole Health (WH) in the Veterans Administration over the past 10 years, we have had the unique advantage of working in a health care system in which a wide range of WH services-ranging from acupuncture to coaching to yoga and Tai Chi to nutrition classes to peer-facilitated empowerment and skill-building groups-are fully covered by the system as part of standard medical benefits. This has given us the opportunity to evaluate both the process and the outcomes of offering this type of Whole Person care on a system-wide scale. This article will review some of the lessons learned from that ongoing evaluation process in the areas of integration of complementary/integrative health approaches as well as health coaching and peer-led groups, WH education, employee well-being, cost impacts, and whole-system transformation. This is not a systematic review, as we will touch on numerous questions and lessons learned rather than dive deeply into the literature seeking the answer to one narrower question. Hopefully the narrative review approach taken here will stimulate further discussion in the field regarding what we are learning and what we can continue to learn from this large scale innovation.

Veterans Health Administration's Whole Health System of Care: Supporting the Health, Well-Being, and Resiliency of Employees.

The Veterans Health Administration (VHA) is implementing a Whole Health System (WHS) of care that empowers and equips Veterans to take charge of their health and well-being and live their lives to the fullest, and increasingly leaders recognize the need and value in implementing a similar approach to support the health and well-being of employees. The purpose of this paper is to do the following: 1) provide an overview of the WHS of care in VHA and applicability in addressing employee resiliency; 2) provide a brief history of employee well-being efforts in VHA to date; 3) share new priorities from VHA leadership as they relate to Employee Whole Health strategy and implementation; and 4) provide a summary of the impacts of WHS of care delivery on employees. The WHS of care utilizes all therapeutic, evidence-based approaches to support self-care goals and personal health planning. Extending these approaches to employees builds upon 10 years of foundational work supporting employee health and well-being in VHA. In 2017, one facility in each of the 18 Veterans Integrated Service Networks (VISNs) in VHA was selected to participate in piloting the WHS of care with subsequent evaluation by VA's Center for Evaluating Patient-Centered Care (EPCC). Early outcomes, from an employee perspective, suggest involvement in the delivery of the WHS of care and personal use of the whole health approach have a meaningful impact on the well-being of employees and how they experience the workplace. During the COVID-19 pandemic, VHA has continued to support employees through virtual resources to support well-being and resiliency. VHA's shift to this patient-centered model is supporting not only Veteran care but also employee health and well-being at a time when increased support is needed.

The Health Status of Veteran Employees Compared to Civilian Employees in Veterans Health Administration.

INTRODUCTION: Veterans Health Administration (VHA) is undergoing changes in the practice of health care focusing on approaches that prioritize veteran well-being. Given transformation efforts, opportunities exist to enhance the health and well-being of patients and employees alike - a significant proportion of whom are veterans. To date, differences in health status between veteran and civilian employees within VHA have not been examined. MATERIALS AND METHODS: Data from an annual organizational census survey with health promotion module conducted in 2015 were analyzed to estimate the prevalence of health risk behaviors, mental health, and chronic health conditions by veteran status within genders (n = 86,257). To further examine associations by gender between veteran status and health measures controlling for covariates, multivariate logistic regression analyses were utilized. RESULTS: Prevalence estimates generally indicated veterans have worse health status and health risk behaviors than their civilian counterparts. Results from multivariate logistic regression analyses indicated many significant associations between veteran status and health by gender controlling for other important demographic variables and a total comorbidity score. Compared to civilian employees within respective genders, both male and female veteran employees have increased odds of being a current smoker. Both male and female veteran employees have decreased odds of physical inactivity compared to civilian employees. For mental health and chronic health conditions, there are several conditions that veteran employees have increased odds for when compared to civilian employees of like gender; these include low back problems, arthritis, anxiety, depression, and sleep disorders. CONCLUSIONS: Veteran employees in VHA have worse health status than their civilian counterparts on a number of measures of health risk behaviors, mental health, and chronic health conditions. Given current organizational priorities aimed at cultural transformation, the present time is an optimal one to work collaboratively to enhance the health and well-being services that are available for patients and employees alike. All employees, particularly our unique population of veteran employees, will benefit from such an approach.

Employee Perceptions of Safety, Health, and Well-Being: Focus Group Findings From One Veterans Affairs Medical Center.

OBJECTIVE: Focus groups were conducted at one veterans affairs (VA) medical center to understand (1) how the work environment and conditions of work influence employee safety, health, and well-being; (2) what programs, policies, and practices promote and protect employee safety and health in VA; and (3) how employee safety, health, and well-being impact the organizational mission. METHODS: Nine focus groups were conducted with leadership, supervisor, and frontline employees. Focus groups were audio recorded, transcribed, and content analysis was performed. RESULTS: Fifty-five employees participated in the focus groups. Six common themes emerged-stressful working conditions, health hazards, organizational factors, current program knowledge, participation barriers, and program suggestions. CONCLUSIONS: Employees identified organizational and structural elements of work that impact safety, health, and well-being. Application of the Total Worker Health™ hierarchy of controls provided a novel framework for discussion of focus group findings.

Examining burnout profiles in relation to health and well-being in the Veterans Health Administration employee population.

The goals of this paper were twofold: (a) To provide a population overview of burnout profiles by occupation in a large, health care sector employee population and (b) to investigate how burnout profiles relate to self-reported health behaviours, chronic conditions, and absenteeism. Burnout profiles were considered by 5 main occupational groups (physicians, nurses, other clinical, administrative, and wage grade [trade, craft, and labor workers]) in survey respondents (n = 86,257 employees). Logistic regression analyses were conducted to examine how burnout profiles were associated with health controlling for gender, age, race, ethnicity, and occupational group. Employees in the "Frustrated/Burning Up" and "Withdrawing/Burned Out" profiles, respectively, had significantly increased odds of anxiety (OR = 2.17; 99% CI [2.04, 2.31]; OR = 2.21; 99% CI [2.05, 2.38]), depression (OR = 2.06; 99% CI [1.93, 2.20]; OR = 2.20; 99% CI [2.04, 2.38]), sleep disorders (OR = 1.98; 99% CI [1.85, 2.12]; OR = 1.97; 99% CI [1.81, 2.13]), low back disease (OR = 1.60; 99% CI [1.50, 1.71]; OR = 1.58; 99% CI [1.47, 1.70]), physical inactivity (OR = 1.49; 99% CI [1.38, 1.60]; OR = 1.68; 99% CI [1.54, 1.83]), and 5 or more days away from work (OR = 1.74; 99% CI [1.65, 1.85]; OR = 2.15; 99% CI [2.01, 2.30]). Burnout is related to the health of employees. Burnout profiles offer a way to assess patterns of burnout by occupational group and may help customize future interventions.

Decreasing Physical Inactivity in the Veterans Health Administration Employee Population.

OBJECTIVE: The aim of this study was to describe a comprehensive approach to decrease physical inactivity in the Veterans Health Administration (VHA) employee population. METHODS: The approach included (1) initiatives to decrease physical inactivity in the workplace; (2) two operational surveys to assess system-wide service provision; and (3) two national employee surveys. RESULTS: From 2010 to 2012, 86 employee fitness centers were completed in VA medical centers. A grants program (2010 to 2015) funded smaller projects designed to decrease physical inactivity in the workplace. Projects involved the provision of equipment to decrease sedentary behaviors, including stability balls, treadmill and sit-to-stand desks, stairwell projects, and funding for on-site fitness classes, bicycle racks, and outdoor par courses and walking paths among others. CONCLUSIONS: A comprehensive approach to decrease physical inactivity in VHA employees was successful. Overall, self-reported, age-adjusted physical inactivity in VHA employees decreased from 25.3% in 2010 to 16.1% in 2015.

Integrated Employee Occupational Health and Organizational-Level Registered Nurse Outcomes.

OBJECTIVE: The study examined organizational culture, structural supports, and employee health program integration influence on registered nurse (RN) outcomes. METHODS: An organizational health survey, employee health clinical operations survey, employee attitudes survey, and administration data were collected. Multivariate regression models examined outcomes of sick leave, leave without pay, voluntary turnover, intention to leave, and organizational culture using 122 medical centers. RESULTS: Lower staffing ratios were associated with greater sick leave, higher turnover, and intention to leave. Safety climate was favorably associated with each of the five outcomes. Both onsite employee occupational health services and a robust health promotion program were associated with more positive organizational culture perceptions. CONCLUSIONS: Findings highlight the positive influence of integrating employee health and health promotion services on organizational health outcomes. Attention to promoting employee health may benefit organizations in multiple, synergistic ways.

Validation and Dimensionality of the Integration of Health Protection and Health Promotion Score: Evidence From the PULSE Small Business and VA Medical Center Surveys.

OBJECTIVE: To conduct validation and dimensionality analyses for an existing measure of the integration of worksite health protection and health promotion approaches. METHODS: A survey of small to medium size employers located in the United States was conducted between October 2013 and March 2014 (N = 115). A survey of Department of Veterans Affairs (VA) administrative parents was also conducted from June to July 2014 (N = 140). Exploratory factor analysis (EFA) was used to determine the dimensionality of the Integration Score in each sample. RESULTS: Using EFA, both samples indicated the presence of one unified factor. The VA survey indicated that customization improves the relevance of the Integration Score for different types of organizations. CONCLUSIONS: The Integration Score is a valid index for assessing the integration of worksite health protection and health promotion approaches and is customizable based on industry. CLINICAL SIGNIFICANCE: The Integration Score may be used as a single metric for assessing the integration of worksite health protection and health promotion approaches in differing work contexts.

From Policy to Practice: Tobacco Use Cessation for Employees in the Veterans Health Administration.

OBJECTIVE: To describe a comprehensive approach to increase tobacco use cessation in the Veterans Health Administration (VHA) employee population. METHODS: The approach included: 1) national policy; 2) a pilot tobacco use cessation program; and 3) two operational surveys to assess system-wide tobacco use cessation service provision. RESULTS: The proportion of VHA facilities offering a comprehensive tobacco use cessation program increased from 51% in 2010 to 72% in 2014, with 83% of facilities providing nicotine replacement therapy to employees. The WIN by Quitting Tobacco program was successful; employees who participated in the pilot program quit tobacco at high rates (64% at 1 month post quit date). CONCLUSIONS: From policy to practice, the comprehensive approach to tobacco use cessation in VHA was successful and may serve as a model for future workplace health promotion and occupational safety and health initiatives.

Management support, worksite culture, and local resources for healthier employees: the Veterans Affairs experience.

OBJECTIVE: To determine whether a "worksite culture of health" exists within the Veterans Health Administration and implications on integrating employee health promotion programs. METHODS: Three national surveys were used-an organizational health survey, a health behaviors survey, and a worksite environment survey. Cross-sectional associations between measures of organizational health and employee health behaviors and between measures of organizational health and worksite environment were assessed. RESULTS: There were significant associations between a number of organizational health measures and a combined measure of health behaviors. Likewise, presence of employee-wellness committees and/or coaches was significantly associated with higher appraisal on organizational health measures. CONCLUSION: Results suggest that a worksite culture of health exists in some but not all facilities within Veterans Health Administration; this has implications for integrating employee health promotion programs systemwide. A phased-in approach is likely warranted.

Sitting on stability balls: biomechanics evaluation in a workplace setting.

Use of a stability ball alone and stability ball chair were evaluated in the Veterans Health Administration as possible alternatives to incorporate with regular office chair use. The evaluation of stability ball use was conducted under the auspices of a work site health promotion program as a cross-over trial with participants rotating through use of the stability ball, stability ball chair, and regular office chair on a monthly basis for a total duration of 3 months. Rotations on regular office chairs served as the control. Three medical facilities participated. A total of 193 employees completed a baseline questionnaire; 159 completed at least one post-rotation questionnaire. Self-reported measures included perceived posture when sitting, perceptions of overall balance, energy levels, job performance, safety, and pain. Use was associated with improvements in perceived posture (p < 0.0001) and energy levels (p = 0.007) for stability ball users compared with the office chair control, and improvements in perceived posture (p < 0.0001) and overall balance (p = 0.05) for stability ball chair users compared with the control. Use of stability balls at work decreases the likelihood of reporting pain from regular office chair use from approximately 45% to 21%. Alternatively, a high number of participants reported pain with use of the stability ball alone and stability ball chair, 42% and 45%, respectively. The perceived risks and benefits of stability ball use should be weighed when incorporating use.

Innovative approaches for understanding seasonal influenza vaccine declination in healthcare personnel support development of new campaign strategies.

OBJECTIVE: The main objectives of our study were to explore reasons for seasonal influenza vaccine acceptance and declination in employees of a large integrated healthcare system and to identify underlying constructs that influence acceptance versus declination. Secondary objectives were to determine whether vaccine acceptance varied by hospital location and to identify facility-level measures that explained variability. DESIGN: A national health promotion survey of employees was conducted that included items on vaccination in the 2009-2010 influenza season. The survey was administered with two other institutional surveys in a stratified fashion: approximately 40% of participating employees were randomly assigned to complete the health promotion survey. SETTING: National single-payer healthcare system with 152 hospitals. PARTICIPANTS: Employees of the healthcare system in 2010 who responded to the survey. METHODS: Factor analysis was used to identify underlying constructs that influenced vaccine acceptance versus declination. Mean factor scores were examined in relation to demographic characteristics and occupation. Multilevel logistic regression models were used to determine whether vaccine acceptance varied by location and to identify facility-level measures that explained variability. RESULTS: Four factors were identified related to vaccine declination and were labeled as (1) "don't care," (2) "don't want," (3) "don't believe," and (4) "don't know." Significant differences in mean factor scores existed by demographic characteristics and occupation. Vaccine acceptance varied by location, and vaccination rates in the previous year were an important facility-level predictor. CONCLUSIONS: Results should guide interventions that tailor messages on the basis of particular reasons for declination. Occupation-specific and culturally appropriate messaging should be considered. Continued efforts will be taken to better understand how workplace context influences vaccine acceptance.

Disparities in health behaviors and chronic conditions in health care providers in the Veterans Health Administration.

OBJECTIVE: To determine baseline prevalence of health behaviors and chronic health conditions in Veterans Health Administration (VHA) employees and highlight disparities by occupation group. METHODS: There were 29,834 responses to the survey. Age-standardized prevalence estimates for VHA employees were compared to national estimates from BRFSS surveys. The VHA estimates were analyzed for physicians and dentists; physician assistants and nurse practitioners; registered nurses; licensed practical nurses and nursing assistants; other clinical; nonclinical; and wage grade staff. Multilevel regression explored the effect of worksite. RESULTS: The VHA employees have higher rates of unhealthy behaviors and chronic health conditions than US adults, except for smoking. Results illustrated significant disparities between occupation groups by demographics and variability by worksite. CONCLUSIONS: Veterans Health Administration's population appears less healthy than the US general population. Disparities between occupation groups support the establishment of targeted health promotion programs, with attention paid to differences in local culture.

2009 influenza pandemic impact on sick leave use in the Veterans Health Administration: framework for a health care provider-based national syndromic surveillance system.

OBJECTIVE: To determine relations between sick leave use and the 2009 novel influenza A (H1N1) influenza pandemic among clinical and nonclinical staff in the Veterans Health Administration (VHA). METHODS: Aggregate sick leave use for all VHA employees was monitored in near-real time during the 2009 H1N1 influenza pandemic and compared with historical data from 2004 to 2008. The ratio of sick leave use between clinical and nonclinical staff was examined. An autoregressive integrated moving average model was used to assess whether the pandemic had a significant effect on sick leave use. RESULTS: The H1N1 influenza pandemic was associated with a significant effect on sick leave use in the VHA during the second wave of the pandemic. During this wave, the ratio of clinical to nonclinical sick leave use changed; clinical staff began taking more leave than nonclinical staff for 3 successive 2-week pay periods, with ratio measures of 1.004, 1.018, and 1.011, respectively. Using an autoregressive integrated moving average model with a pulse variable representing the pandemic, there was a significant effect on sick leave use. The average hours of sick leave used per full-time equivalent staff member per month increased by 0.3904 hours (P = .003) for clinical staff and 0.3898 hours (P = .01) for nonclinical staff over previous months during the first month of the second pandemic wave. CONCLUSIONS: Work loss associated with a pandemic is an important indicator of disease activity and may be a more sensitive indicator of emerging strains than deaths. Monitoring sick leave use in near real time in a large national health care system may be an important early indicator of pandemic severity with practical implications that should be considered in addition to more traditional measures of influenza epidemic and pandemic severity.

The magnitude of acute serum creatinine increase after cardiac surgery and the risk of chronic kidney disease, progression of kidney disease, and death.

BACKGROUND: Long-term outcomes after acute kidney injury remain poorly defined. We determined the association between the magnitude of creatinine increase after cardiac surgery and the risk of incident chronic kidney disease (CKD), CKD progression, and death. METHODS: We identified 29,388 individuals who underwent cardiac surgery at Veterans Affairs hospitals between November 1999 and September 2005. The magnitude of creatinine increase was defined by the percent change from baseline to peak creatinine levels after cardiac surgery and categorized as none (≤0%) or as class I, (1%-24%), II (25%-49%), III (50%-99%), or IV (≥100%). Cox proportional hazard models were used to examine the association between the magnitude of creatinine increase and outcomes. RESULTS: The relative hazards for outcomes increased monotonically with greater increases in creatinine levels compared with no change in creatinine levels. The relative hazards for adverse outcomes were significantly higher immediately after the creatinine increase and attenuated over time. Three months after surgery, creatinine increase classes I, II, III, and IV were associated with a greater risk of incident CKD (hazard ratios [HRs] 2.1, 4.0, 5.8, and 6.6, respectively; all P<.01), progression of CKD stage (HRs 2.5, 3.8, 4.4, and 8.0; all P<.01), and long-term mortality (HRs 1.4, 1.9, 2.8, and 5.0; all P<.01). At 5 years, the associations were lower in magnitude: incident CKD (HRs 1.4, 1.9, 2.3, and 2.3; all P<.01), CKD progression (HRs 1.5, 1.7, 1.7, and 2.4; all P<.01), and mortality (HRs 1.0, 1.2, 1.4, and 1.8; all P<.01, except class I). CONCLUSION: The magnitude of creatinine increase after cardiac surgery is associated in a graded manner with an increased risk of incident CKD, CKD progression, and mortality.

Mental health diagnosis and occupational functioning in National Guard/Reserve veterans returning from Iraq.

Occupational functioning represents both an important outcome for military service members returning from Operation Iraqi Freedom (OIF) and Operation Enduring Freedom and a predictor for long-term mental health functioning. We investigated the role of mental health diagnoses, determined by structured clinical interviews, on occupational functioning in a group of 262 National Guard/Reserve service members within 1 year of returning from a 16-month OIF combat deployment. We assessed occupational functioning at the time of diagnostic interviews and 1 year later. We hypothesized that service members with diagnoses of posttraumatic stress disorder (PTSD), depression, and/or alcohol abuse or dependence would exhibit lower rates of employment at both time points and lower rates of reported work and/or school role functioning. Service members with a diagnosis of PTSD (5%, n = 13), subthreshold PTSD (6%, n = 15), a major depressive disorder (11%, n = 29), or alcohol abuse or dependence (11%, n = 28) did not differ on employment status from service members without a diagnosis at either time point. However, those with a diagnosis of PTSD, depression, and/or alcohol abuse or dependence reported lower levels of work role functioning. In addition, service members with a diagnosis of PTSD reported greater rates of deterioration in work role functioning over time.

Using the Medicare Current Beneficiary Survey to conduct research on Medicare-eligible veterans.

The Medicare Current Beneficiary Survey (MCBS) is a longitudinal, multipurpose panel survey of a nationally representative sample of Medicare beneficiaries sponsored by the Centers for Medicare and Medicaid Services (CMS). The MCBS serves as a comprehensive data source on self-reported health and socioeconomic status, health insurance, healthcare utilization and costs, and patient satisfaction. CMS uses Medicare claims data to validate self-reported Medicare Fee-For-Service (FFS) utilization. Because the Veterans Health Administration (VHA) does not bill for services, CMS imputes VHA costs. This article addresses the quality of the MCBS dataset for conducting research on Medicare-eligible veterans by addressing the sample's representativeness, quality of self-reported data, and accuracy of imputed VHA cost estimates. We compared demographic data from the 1992 and 2001 National Survey of Veterans (NSV) with the MCBS 1992 and 2001 Cost and Use files. We compared self-reported VHA utilization and CMS's imputed costs with VHA administrative datasets. The VHA's Pharmacy Benefits Management (PBM) database is available from fiscal year (FY) 1999 onward, and the VHA Health Economics Resource Center's (HERC) Average Cost datasets are available from FY1998 onward. While the samples were comparable in terms of age, sex, and race, the MCBS respondents were in better health, less likely to be married, and more likely to be widowed than NSV respondents. MCBS underreporting rates were higher for VHA than Medicare outpatient events. Underreporting and differences between CMS's and HERC's costing methodologies contributed to lower MCBS versus VHA administrative person- and event-level costs. Alternatively, average annual VHA prescription costs per capita were higher in the MCBS than in the PBM data. Differences in socioeconomic characteristics of the NSV and MCBS samples may be attributable to differences in sampling methodologies. Higher underreporting rates for VHA versus Medicare FFS outpatient events are likely due to systemic differences between the VHA and private healthcare sectors. While VHA formulary discounts may not be reflected in MCBS's VHA prescriptions costs, lower PBM prescriptions costs are also due to deficient indirect cost data. Since reliable VHA utilization and cost data existed in either FY1998 or FY1999 onward, study goals include estimating the relative share and/or cost of care provided by Medicare and the VHA. Researchers with access to VHA datasets should consider merging them into the MCBS and replacing self-reported utilization and CMS's imputed costs with VHA administrative data. This replacement would significantly improve the accuracy, quality, and usefulness of the MCBS dataset for policy research.

Disease management program for chronic obstructive pulmonary disease: a randomized controlled trial.

RATIONALE: The effect of disease management for chronic obstructive pulmonary disease (COPD) is not well established. OBJECTIVES: To determine whether a simplified disease management program reduces hospital admissions and emergency department (ED) visits due to COPD. METHODS: We performed a randomized, adjudicator-blinded, controlled, 1-year trial at five Veterans Affairs medical centers of 743 patients with severe COPD and one or more of the following during the previous year: hospital admission or ED visit for COPD, chronic home oxygen use, or course of systemic corticosteroids for COPD. Control group patients received usual care. Intervention group patients received a single 1- to 1.5-hour education session, an action plan for self-treatment of exacerbations, and monthly follow-up calls from a case manager. MEASUREMENTS AND MAIN RESULTS: We determined the combined number of COPD-related hospitalizations and ED visits per patient. Secondary outcomes included hospitalizations and ED visits for all causes, respiratory medication use, mortality, and change in Saint George's Respiratory Questionnaire. After 1 year, the mean cumulative frequency of COPD-related hospitalizations and ED visits was 0.82 per patient in usual care and 0.48 per patient in disease management (difference, 0.34; 95% confidence interval, 0.15-0.52; P < 0.001). Disease management reduced hospitalizations for cardiac or pulmonary conditions other than COPD by 49%, hospitalizations for all causes by 28%, and ED visits for all causes by 27% (P < 0.05 for all). CONCLUSIONS: A relatively simple disease management program reduced hospitalizations and ED visits for COPD. Clinical trial registered with www.clinicaltrials.gov (NCT00126776).