Patient complexity linked to low-value corticosteroid use in COPD

Among patients with COPD at low risk for exacerbations, prescription of inhaled corticosteroids was associated with patient complexity, study results published in the Annals of the American Thoracic Society suggest.

Recently, evidence has fueled concerns that inhaled corticosteroids may be overused in COPD and, therefore, of “low value,” according to the researchers.

“De-adopting inhaled corticosteroids has great potential for harm reduction in patients and cost savings to health systems,” they wrote. “Given this interest to reduce harm and costs, a few studies of inhaled corticosteroid overuse have been performed using cohorts of prevalence users. While these studies have shown important barriers to de-adoption, the findings are subject to prevalent user bias and do not describe why low-value medications are initiated.”

To gain more insight into this issue, the researchers used the Care Assessment Needs (CAN) score — a measure that includes patient characteristics such as demographics, vital signs, health factors, utilizations and medications — to evaluate the complexity of 8,497 veterans with COPD at low risk for exacerbations who had no indication for inhaled corticosteroids. The score was calculated quarterly during a 1-year follow-up period, with higher scores representing a higher probability for hospitalization or death.

During follow-up, 22.2% of the patients were prescribed an inhaled corticosteroid for the first time. When using CAN score as a continuous measure, patient complexity was linked to first prescription for inhaled corticosteroids after adjustment for age (HR = 1.17 per 10-U change; 95% CI, 1.13-1.21). When analyzing CAN score according to quartiles, results also revealed a dose-response relationship between CAN score and first prescription for inhaled corticosteroids.

Additionally, during 1-year follow-up, a number of patients became eligible for inhaled corticosteroids, including 212 who were hospitalized for COPD and 344 who had at least two outpatient exacerbations. After accounting for these exacerbations and the competing risk for death, the association between CAN score and first inhaled corticosteroid prescription remained (HR = 1.03; 95% CI, 1.016-1.025).

The researchers also used Strategic Analytics for Improvement and Learning Value Model (SAIL) data to assess system-level complexity at each health care site. They found that, although the initiation of low-value inhaled corticosteroids varied significantly across sites, the relationship between CAN score and first use of low-value inhaled corticosteroids was not affected by site volume or complexity.

“Health care continues to move toward value-based purchasing that will increasingly transfer the risk of health care services to health care systems. Preferred provider status for large contracts will also include demonstration of provision of high quality, cost effective approaches to population health management,” they wrote. “Targeting overuse of inhaled corticosteroids represents an opportunity to improve care value by mitigating risk of harm to patients, avoiding potential costs from treating iatrogenic harms and increasing savings from reduced medication acquisition.” – by Melissa Foster

Disclosure: Healio Pulmonology could not confirm relevant financial disclosures at the time of publication.