CLEVELAND—Veterans are three times more likely to develop chronic obstructive pulmonary disease than the general population, and COPD is the fifth most prevalent disease in the veteran population, affecting about 15% of VHA patients, according to previous research.

A new study published in the Journal of General Internal Medicine pointed out that more than half of the veterans diagnosed with mild-to-moderate COPD are prescribed inhaled corticosteroids, despite recommendations for use restricted to patients with frequent exacerbations.1

In an effort to find out why, VA Northeast Ohio Healthcare System-led researchers decided to document primary care providers’ experiences prescribing inhaled corticosteroids among patients with mild-to-moderate COPD as part of a quality improvement initiative. VA Puget Sound in Seattle and Edith Nourse Rogers Memorial VA Hospital in Bedford, MA, also participated in the study.

The study team used a sequential mixed-methods evaluation approach to understand factors influencing primary care providers’ inhaled corticosteroid prescribing for patients with mild-to-moderate COPD. The authors recruited healthcare providers from 13 primary care clinics affiliated with two urban VHA systems to participate in qualitative interviews and structured surveys. Interviews were transcribed and analyzed using content analysis.

Results indicated that many participants reported they were unaware of current evidence and recommendations for prescribing inhaled corticosteroids. Researchers explained that, “for example, 46% of providers reported they were unaware of risks of pneumonia.”

The providers also revealed that they often are unable to keep up with the current literature due to the broad scope of primary care practice, the authors wrote, adding, “We also found primary care providers may be reluctant to change inherited prescriptions, even if they thought inhaled corticosteroid therapy might not be appropriate.”

The researchers concluded, “Inhaled corticosteroid prescribing in this patient population is partly due to primary care providers’ lack of knowledge about the potential harms and availability of alternative therapies. Our findings suggest that efforts to expand access by increasing the number of prescribing providers a patient potentially sees could make it more difficult to de-implement harmful prescriptions. Our findings also corroborate prior findings that awareness of current evidence-based guidelines is likely an important part of medical overuse.”

1.Stryczek K, Lea C, Gillespie C, Sayre G, et. Al. De-implementing Inhaled Corticosteroids to Improve Care and Safety in COPD Treatment: Primary Care Providers’ Perspectives. J Gen Intern Med. 2019 Aug 8. doi: 10.1007/s11606-019-05193-2. [Epub ahead of print] PubMed PMID: 31396814.