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- Title
Overuse and Misuse of Inhaled Corticosteroids Among Veterans with COPD: a Cross-sectional Study Evaluating Targets for De-implementation.
- Authors
Griffith, Matthew F.; Feemster, Laura C.; Zeliadt, Steven B.; Donovan, Lucas M.; Spece, Laura J.; Udris, Edmunds M.; Au, David H.
- Abstract
<bold>Background: </bold>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).<bold>Objective: </bold>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.<bold>Participants: </bold>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.<bold>Main Measures: </bold>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.<bold>Conclusions: </bold>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 increase the likelihood of ICS use that could be targeted for system-level de-implementation interventions.
- Subjects
OBSTRUCTIVE lung diseases; CROSS-sectional method; CAUCASIAN race; VETERANS; CORTICOSTEROIDS; OBSTRUCTIVE lung disease diagnosis; RESEARCH; ADRENOCORTICAL hormones; DRUG overdose; RESEARCH methodology; MEDICAL cooperation; EVALUATION research; PSYCHOLOGY of veterans; COMPARATIVE studies; INHALATION administration
- Publication
JGIM: Journal of General Internal Medicine, 2020, Vol 35, Issue 3, p679
- ISSN
0884-8734
- Publication type
journal article
- DOI
10.1007/s11606-019-05461-1