Lack of Awareness among VA Providers about Risk Associated with Prescribing Inhaled Corticosteroids to Veterans with COPD
More than 50% of patients with mild-to-moderate COPD in the U.S. are prescribed inhaled corticosteroids despite recommendations to restrict use to patients with frequent breathing exacerbations. These recommendations are based on evidence of harm (i.e., increased risk of severe pneumonia); the availability of safer medications; and the lack of evidence for benefit to patients with less severe disease. Investigators in this study explored VA primary care providers’ experiences prescribing inhaled corticosteroids among Veterans with mild-to-moderate COPD. Telephone interviews were conducted with 15 primary care providers (2 nurse practitioners and 13 physicians) from 13 primary care clinics affiliated with two urban VAMCs from May 2016 to October 2017. Surveys were completed by 46 primary care providers between July 2016 and January 2017.
li>Of the Veterans with COPD in this study cohort, 1,299 (15%) were prescribed an inhaled corticosteroid. However, 792 (61%) of these prescriptions were not clinically indicated.
- Providers reported being unaware of current evidence and recommendations for prescribing inhaled corticosteroids; e.g., 46% of providers reported they were unaware of the risk of pneumonia.
- Providers reported they are generally unable to keep up with the current literature due to the broad scope of primary care practice.
- Some providers expressed reluctance to change or stop prescribing if their patient was doing well.
- However, 52% of providers reported they would make an effort to reduce the use of inhaled corticosteroids, and 50% reported that they would make an effort to make greater use of alternative guideline-recommended medications.
- Efforts to expand access to care by increasing the number of prescribing providers a patient sees could make it more difficult to de-implement harmful prescriptions. Study results also corroborate prior findings that lack of awareness of current evidence-based guidelines is likely an important part of medical overuse.
- The observational, self-report, cross-sectional mixed-methods study approach limits the ability to draw causal inferences.
- Participation in the surveys and interviews was voluntary, thus findings may be affected by selection bias – and may represent atypical views and awareness.
This study was funded by VA HSR&D’s Quality Enhancement Research Initiative (QUERI). Ms. Stryczek is with the Cleveland VAMC; Mr. Lea, Dr. Sayre, Mr. Wanner, Dr. Feemster, Mr. Udris, Dr. Au and Dr. Helfrich are part of HSR&D’s Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, WA and Denver, CO. Drs. Gillespie, Rinne, and Wiener are with HSR&D’s Center of Innovation for Healthcare Organization and Implementation Research (CHOIR), Boston and Bedford, MA.
Stryczek K, Lea C, Gillespie C, Sayre G, Wanner S, Rinne S, Wiener RS, Feemster L, Udris E, Au DH, and Helfrich C. De-Implementing Inhaled Corticosteroids to Improve Care and Safety in COPD Treatment: Primary Care Providers’ Perspectives. Journal of General Internal Medicine. August 8, 2019; Epub ahead of print.