As part of an ongoing quality improvement initiative aiming to discontinue inappropriate prescribing of inhaled corticosteroids among patients with mild-to-moderate chronic obstructive pulmonary disease (COPD), Stryczek and colleagues used a sequential mixed methods approach to explore primary care provider perspectives on inhaled corticosteroid prescribing patterns in patients with low-to-moderate COPD.1 They found that primary care providers’ broad scope of practice made it challenging to keep current with evidence and recommendations. Other key factors in primary care providers’ decision-making included a reluctance to discontinue inherited prescriptions and a deference to the expertise of pulmonologists.
This study identifies multiple barriers to reducing inappropriate prescribing of inhaled corticosteroids. Reductions in prescribing will require confronting some of the larger contextual pressures that strain primary care providers and contribute to these barriers. While education about guidelines may address gaps in knowledge about current evidence and recommendations, this alone is unlikely to be sufficient to effect behavior change.2 A narrowly defined intervention targeting this aspect alone would not address the underlying issue identified by this study—the broad scope of practice in primary care, and would likely not be transferable to other primary care priorities.1 Worse, it could, especially when coupled with the high rates of burnout in primary care,3 lead to change fatigue rather than success.
The two other barriers identified, a reluctance to discontinue inherited prescriptions and a deference to expertise of pulmonologists, are both coordination of care issues. Solutions could help embattled providers deal with the broader challenges of being at the nexus of two potentially incompatible priorities: access to care and continuity of care. Pressures to improve access can cause unintended consequences for continuity.4,5 As the authors suggest: “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”.1 Strengthening coordination of care capabilities would directly address the coordination barriers leading to inappropriate inhaled corticosteroid prescription, but it could also address coordination of care challenges across the broad scope of practice in primary care, thereby amplifying its value to providers.
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Miake-Lye, I.M. Capsule Commentary on Stryczek et. al., De-implementing Inhaled Corticosteroids to Improve Care and Safety in COPD Treatment: Primary Care Providers’ Perspectives. J GEN INTERN MED 35, 398 (2020). https://doi.org/10.1007/s11606-019-05395-8