BOSTON—At the VA and elsewhere, chronic obstructive pulmonary disease  often is managed by primary care physicians and sometimes pulmonologists, but it is not clear what factors spur consultations by pulmonary specialists.

In fact, according to a report in Respiratory and Critical Care Medicine, clinical guidelines don’t routinely include indications for referral.1

Boston University-led researchers said their primary objective was to understand trends in pulmonary consultations for veterans with incident COPD and to identify the patient, provider and site characteristics that drive consultations.

To do that, the study team conducted a retrospective cohort study of pulmonary consults for veterans with incident COPD during fiscal years 2010-2014. Researchers collected data on patient characteristics including age, sex, race (white, black or other), hospitalizations in the prior year and medical comorbidities for each patient with incident COPD.

For PCPs, the study compiled data on demographics, years of VA tenure, panel size, geographic location, presence of pulmonary specialists and academic affiliation. It then used multilevel logistic regression to examine patient, PCP and site-level characteristics associated with pulmonary visit within a year of COPD diagnosis.

Overall, 243,700 veterans with incident COPD were identified, of which 44,381 (18.2%) had pulmonary visits. The numbers of veterans with a new diagnosis of COPD increased yearly from 2010, with 42,175, through 2014, with 57,344. The number and rate of referrals for COPD also increased annually from 2010 to 2014,  17.4% to 19.4%.

Results indicated that patients were less likely to have pulmonary visits if they were 85 years of age, female, Black, Hispanic or had substance-use disorders. On the other hand, patients with one or more hospitalizations or cardiac comorbidities were more likely to have pulmonary visits.

The study found that PCPs were more likely to consult pulmonary if they had moderate-to-high panel sizes or more than 10 years of practice. In addition, primary care providers working at facilities with an on-site pulmonary specialist, or those in academic or urban settings were more likely to consult a specialist.

“Despite record low smoking rates in the U.S., our study cohort showed both the incidence of COPD and the rate of referral to a pulmonary specialist increased yearly,” the authors concluded. “Pulmonary visits were less common among veteran populations that commonly experience health disparities, including those in rural areas, females, Blacks, Hispanics and those with substance-use disorders.”

Researchers suggested that understanding the source of the variation “could lead to standardized guidelines on indications for COPD pulmonary consultation and interventions that address disparities and barriers to care for patients that would benefit from COPD referrals.”

  1. Nunez ER, Johnson SW, Qian S, Walkey AJ, Wiener RS, Rinne S. Patterns of Pulmonary Consultation for Veterans with Incident COPD. Am J Respir Crit Care Med 2020;201:A6258