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