Unnecessary inhaled corticosteroids in COPD: understanding patient and health system complexity as contributors

OBJECTIVE

To determine if patient complexity is associated with unnecessary use of inhaled corticosteroids (ICS) among patients with chronic obstructive pulmonary disease (COPD) at low risk of exacerbations and if health system complexity modifies this association.

METHODS

We identified Veterans with COPD without a guideline-recommended indication for ICS from electronic health records between January 2012 and September 2016. Our primary outcome was incident prescription of ICS. We used the Care Assessment Needs (CAN) score to describe complexity at the patient-level as the primary exposure. We used a time-to-event model with time-varying exposures over one year of follow-up time. We tested for effect modification using health system data from the Strategic Analytics for Improvement and Learning (SAIL) report. Results: We identified 8,497 patients with COPD who did not have an indication for ICS. The mean follow-up time was 4 quarters. Patient complexity by CAN was associated with unnecessary ICS (HR 1.017 per CAN unit; 95% CI 1.013 – 1.021). This association demonstrated a dose-response when examining quartiles of CAN score. Markers of health system complexity did not modify the association between patient complexity and unnecessary ICS.

CONCLUSIONS

As patient complexity increased, patients were more likely to have unnecessary ICS therapy initiated. Complexity as reflected in CAN scores may represent a marker for patients who have persistent and bothersome symptom despite appropriate therapies. Lack of effect-modification by health system complexity likely reflects the paucity of structural support and low prioritization for COPD care. Future efforts are needed to understand provider-level barriers to care quality in COPD as are efforts to prioritize complex patients with COPD.