Journal of General Internal Medicine

, Volume 35, Issue 1, pp 51–56 | Cite as

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

  • Krysttel Stryczek
  • Colby Lea
  • Chris Gillespie
  • George Sayre
  • Scott Wanner
  • Seppo T. Rinne
  • Renda Soylemez Wiener
  • Laura Feemster
  • Edmunds Udris
  • David H. Au
  • Christian D. HelfrichEmail author
Original Research



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.

Main Measures

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.

Key Results

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.


de-implementation quality improvement mixed methods de-prescribing COPD 



We are thankful to our project manager, Barbara Majerczyk, MPH, for her contributions that made this work possible. This work was supported by the United States Department of Veterans Affairs VA Quality Enhancement Research Initiative (QUERI) QUE 15-271 as part of VHA Health Care Operations in accordance with VHA Handbooks 1605.1 and 1605.2. We have previously presented a portion of these data as posters or oral presentations at the AcademyHealth Annual Conference on the Science of Dissemination & Implementation annual meetings (Washington, D.C., 2016, 2017, and 2018), the AcademyHealth Annual Research Meeting (New Orleans, LA, 2017), the Health Services Research & Development/Quality Enhancement Research Initiative National Conference (Washington, D.C., 2017), and 4th Biennial Society for Implementation Research Collaboration (Seattle, WA, 2017).

Compliance with Ethical Standards

Conflict of Interest

Dr. Feemster receives funding from NIH K23 HL111116. Dr. Au receives remuneration from Novartis Inc. for participation on a data safety monitoring board. He serves as a Deputy Editor for the Annals of the American Thoracic Society and is a member of the Exam Committee for the American Board of Internal Medicine Pulmonary Board, for which he receives remuneration. The remaining authors declare that they have no conflict of interest.


The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States Government.

Supplementary material

11606_2019_5193_MOESM1_ESM.docx (24 kb)
ESM 1 (DOCX 24 kb)


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Copyright information

© Society for General Internal Medicine (This is a U.S. government work and not under copyright protection in the U.S.; foreign copyright protection may apply) 2019

Authors and Affiliations

  • Krysttel Stryczek
    • 1
    • 2
  • Colby Lea
    • 2
  • Chris Gillespie
    • 3
  • George Sayre
    • 2
    • 4
  • Scott Wanner
    • 5
  • Seppo T. Rinne
    • 3
    • 6
  • Renda Soylemez Wiener
    • 3
    • 6
  • Laura Feemster
    • 2
    • 7
  • Edmunds Udris
    • 2
  • David H. Au
    • 2
    • 7
  • Christian D. Helfrich
    • 2
    • 4
    Email author
  1. 1.VA Northeast Ohio Healthcare SystemClevelandUSA
  2. 2.Seattle-Denver Center of Innovation for Veteran-Centered & Value-Driven Care VA Puget Sound Health Care SystemSeattleUSA
  3. 3.Center for Healthcare Organization & Implementation ResearchEdith Nourse Rogers Memorial VA HospitalBedfordUSA
  4. 4.Department of Health ServicesUniversity of Washington School of Public HealthSeattleUSA
  5. 5.Seattle UniversitySeattleUSA
  6. 6.The Pulmonary CenterBoston University School of MedicineBostonUSA
  7. 7.Division of Pulmonary, Critical Care, and Sleep MedicineUniversity of WashingtonSeattleUSA

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