Provider perceptions on steroid dosing in AECOPD: Laying the groundwork for steroid stewardship.

Abstract

Steroid overprescribing is well documented in acute exacerbations of COPD (AECOPD). Given the myriad of unwanted side effects of corticosteroids, facilities should implement steroid stewardship efforts. The objective of this project was to evaluate the prescribing habits of steroids in AECOPD for needs assessment and to tailor interventions in a single centre. A questionnaire was developed to evaluate practices and beliefs around steroid dosing in a simplified case of uncomplicated AECOPD. There were 31 total responders: 12 inpatient clinicians, 9 medical residents and 10 emergency department (ED) clinicians. All steroid dosing was converted to prednisone equivalents for reporting. Subgroup analysis was conducted between provider groups. Initial dosing ranged from 40 to 625mg/day with only four responders (13%) selecting 40mg/day. Dosing was not significantly different in newer providers ≤4 years' experience: mean 215mg versus >4 years' experience: mean 312mg (P=0.23). Less experienced providers selected shorter treatment durations: median 5 days (IQR 5,6) versus 8.5 days (IQR 6,10.5) (P=0.015). ED providers selected higher doses than non-ED providers: 447mg versus 208mg (P=0.003). Most responders (81%) selected IV agents over oral steroids. The majority (65%) stated dosing choices were based on prescribing habits/clinical experience, while 36% felt their selections were based on current evidence. Five (16%) of responders correctly identified consensus treatment guidelines and the majority (77%) reported being "very likely" or "somewhat likely" to prescribe lower doses. Baseline knowledge was a significant barrier to guideline utilisation. Education will need to focus on the evidence behind using lower doses, oral agents and disease severity.