Initiating Low-Value Inhaled Corticosteroids in an Inception Cohort with Chronic Obstructive Pulmonary Disease.

Autor:	Spece LJ; Division of Pulmonary, Critical Care, and Sleep Medicine, and.; Health Services Research and Development, and., Donovan LM; Division of Pulmonary, Critical Care, and Sleep Medicine, and.; Health Services Research and Development, and., Griffith MF; Division of Pulmonary, Critical Care, and Sleep Medicine, and.; Health Services Research and Development, and., Keller T; Division of Pulmonary, Critical Care, and Sleep Medicine, and.; Health Services Research and Development, and., Feemster LC; Division of Pulmonary, Critical Care, and Sleep Medicine, and.; Health Services Research and Development, and., Smith NL; Cardiovascular Health Research Unit, University of Washington, Seattle, Washington.; Epidemiologic Research and Information Center, Department of Veterans Affairs Puget Sound Health Care System, Seattle, Washington; and.; Kaiser Permanente Washington Research Institute, Kaiser Permanente Washington, Seattle, Washington., Au DH; Division of Pulmonary, Critical Care, and Sleep Medicine, and.; Health Services Research and Development, and.
Jazyk:	angličtina
Zdroj:	Annals of the American Thoracic Society [Ann Am Thorac Soc] 2020 May; Vol. 17 (5), pp. 589-595.
DOI:	10.1513/AnnalsATS.201911-854OC
Abstrakt:	Rationale: Decreasing medication overuse represents an opportunity to avoid harm and costs in the era of value-based purchasing. Studies of inhaled corticosteroids (ICS) overuse in chronic obstructive pulmonary disease (COPD) have examined prevalent use. Understanding initiation of low-value ICS among complex patients with COPD may help shape deadoption efforts. Objectives: Examine ICS initiation among a cohort with low exacerbation risk COPD and test for associations with markers of patient and health system complexity. Methods: Between 2012 and 2016, we identified veterans with COPD from 21 centers. Our primary outcome was first prescription of ICS. We used the care assessment needs (CAN) score to assess patient-level complexity as the primary exposure. We used a time-to-event model with time-varying exposures over 1-year follow-up. We tested for effect modification using selected measures of health system complexity. Results: We identified 8,497 patients with COPD without an indication for ICS and did not have baseline use (inception cohort). Follow-up time was four quarters. Patient complexity by a continuous CAN score was associated with new dispensing of ICS (hazard ratio = 1.17 per 10-unit change; 95% confidence interval = 1.13-1.21). 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 first use of low-value ICS. Conclusions: Patient complexity may represent a symptom burden that clinicians are attempting to mitigate by initiating ICS. Lack of effect modification by health system complexity may reflect the paucity of structural support and low prioritization for COPD care.
Databáze:	MEDLINE
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