Overuse and Misuse of Inhaled Corticosteroids Among Veterans with COPD: a Cross-sectional Study Evaluating Targets for D
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Seattle-Denver Center of Innovation for Veteran-Centered & Value-Driven Care, VA Eastern Colorado Health Care System, Aurora, CO, USA; Seattle-Denver Center of Innovation for Veteran-Centered & Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, USA; 3Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, WA, USA.
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BACKGROUND: Inhaled corticosteroid (ICS) use among patients with COPD increases the risk of pneumonia and other complications. Current recommendations limit ICS use to patients with frequent or severe COPD exacerbations. However, use of ICS among patients with COPD is common and may be occurring both among those with mild disease (overuse) and those misdiagnosed with COPD (misuse). OBJECTIVE: To identify patients without identifiable indication for ICS and assess patient and provider characteristics associated with potentially inappropriate to targeted in de-implementation efforts DESIGN: We performed a cross-sectional study of patients with COPD in the Veterans Affairs (VA) system with recent spirometry. PARTICIPANTS: After setting an index date, we identified individuals with a clinical diagnosis of COPD who had spirometry completed in the prior 5 years. We excluded individuals with an appropriate indication for ICS based on the 2017 GOLD statement, including asthma and a recent history of frequent or severe exacerbations. MAIN MEASURES: ICS use without identifiable indication KEY RESULTS: We identified 26,536 patients with COPD without an identifiable indication for ICS. Nearly ¼ of patients (n = 6330) filled ≥2 prescriptions for ICS in the year prior to the index date. We found that older age (adjusted prevalence ratio [APR] 1.06 per decade, 95% confidence interval [CI] 1.04–1.08), white race (APR 1.11, 95% CI 1.05–1.19), and more primary care visits (APR 1.05 per visit, 95% CI 1.03–1.07) were associated with increased likelihood of potentially inappropriate use. Primary care clinic complexity and provider training were not associated with ICS use. Among patients misdiagnosed with COPD, we found that 14% used ICS. CONCLUSIONS: Potentially inappropriate ICS use is common among patients with and without airflow obstruction who are diagnosed with COPD. We identified patient comorbidities and patterns of healthcare utilization that
Prior Presentation Portions of this work were presented at the American Thoracic Society meeting in Dallas, TX, USA in May 2019. Received March 26, 2019 Revised August 20, 2019 Accepted September 12, 2019
increase the likelihood of ICS use that could be targeted for system-level de-implementation interventions. KEY WORDS: overuse; misuse; de-implementation; de-prescribing; COPD care quality. J Gen Intern Med DOI: 10.1007/s11606-019-05461-1 © Society of General Internal Medicine (This is a U.S. government work and not under copyright protection in the U.S.; foreign copyright protection may apply) 2019
INTRODUCTION
Long-acting inhaled medications reduce the severity of symptoms and exacerbation risk among patients with C
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