De-implementing Inhaled Corticosteroids to Improve Care and Safety in COPD Treatment: Primary Care Providers' Perspectives.

Abstract

Chronic obstructive pulmonary disease (COPD) is among the most common medical diagnoses among Veterans. More than 50% of Veterans diagnosed with mild-to-moderate COPD are prescribed inhaled corticosteroids despite recommendations for use restricted to patients with frequent exacerbations. We explored primary care providers' experiences prescribing inhaled corticosteroids among patients with mild-to-moderate COPD as part of a quality improvement initiative. We used a sequential mixed-methods evaluation approach to understand factors influencing primary care providers' inhaled corticosteroid prescribing for patients with mild-to-moderate COPD. Participants were recruited to participate in qualitative interviews and structured surveys. We used a purposive sample of primary care providers from 13 primary care clinics affiliated with two urban Veteran Health Administration healthcare systems. Interviews were transcribed and analyzed using content analysis. Qualitative findings informed a subsequent survey. Surveys were administered through REDCap and analyzed descriptively. Key qualitative and quantitative findings were compared. Participants reported they were unaware of current evidence and recommendations for prescribing inhaled corticosteroids; for example, 46% of providers reported they were unaware of risks of pneumonia. Providers reported they are generally unable to keep up with the current literature due to the broad scope of primary care practice. We also found primary care providers may be reluctant to change inherited prescriptions, even if they thought inhaled corticosteroid therapy might not be appropriate. 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.