Provider anticipation and experience of patient reaction when deprescribing guideline discordant inhaled corticosteroids

Abstract

Introduction Despite evidence of possible patient harm and substantial costs, medication overuse is persistent. Patient reaction is one potential barrier to deprescribing, but little research has assessed this in specific instances of medication discontinuation. We sought to understand Veteran and provider experience when de-implementing guideline-discordant use of inhaled corticosteroids (ICS) in those with mild-to-moderate chronic obstructive pulmonary disease (COPD). Methods We conducted a mixed-methods analysis in a provider-randomized quality improvement project testing a proactive electronic-consultation from pulmonologists recommending ICS discontinuation when appropriate. PCPs at two Veterans Health Administration healthcare systems were included. We completed interviews with 16 unexposed providers and 6 intervention-exposed providers. We interviewed 9 patients within 3 months after their PCP proposed ICS discontinuation. We conducted inductive and deductive content analysis of qualitative data to explore an emergent theme of patient reaction. Forty-eight PCPs returned surveys (24 exposed and 24 unexposed, response rate: 35%).

A systematic review of blood eosinophils and continued treatment with inhaled corticosteroids in patients with COPD

“…Many barriers for withdrawing medication have been shown in previous RCTs [45,46]. A study from the US on attitudes towards withdrawal of ICS in patients with COPD showed that, even though physicians worried about resistance from the patients, most patients were willing to try ICS withdrawal [47]. The patients trusted and relied on their physician's expertise.…”

Sputum microbe community alterations induced by long-term inhaled corticosteroid use are associated with airway function in chronic obstructive pulmonary disease patients based on metagenomic next-generation sequencing (mNGS)

“…The most recent Global Initiative for Chronic Obstructive Lung Disease (GOLD) report (2023) recommends that ICS should only be administered in COPD patients who have a high risk of frequent exacerbations and on the basis of consideration of blood eosinophil indicators ( GOLD, 2023 ). However, evidence from real-world studies shows that the phenomenon of ICS overuse is pervasive, sometimes with triple therapy (its conjunction with LABA and LAMA) having been used as a common maintenance treatment for COPD patients ( Lucas et al, 2008 ; Parikh et al, 2020 ). To date, whether the long-term use of ICS triple therapy brings enough benefit to COPD patients, and the relevant mechanisms of its action, remain poorly understood.…”

DataSheet1.docx

“…The most recent Global Initiative for Chronic Obstructive Lung Disease (GOLD) report (2023) recommends that ICS should only be administered in COPD patients who have a high risk of frequent exacerbations and on the basis of consideration of blood eosinophil indicators (GOLD, 2023). However, evidence from real-world studies shows that the phenomenon of ICS overuse is pervasive, sometimes with triple therapy (its conjunction with LABA and LAMA) having been used as a common maintenance treatment for COPD patients (Lucas et al, 2008;Parikh et al, 2020). To date, whether the long-term use of ICS triple therapy brings enough benefit to COPD patients, and the relevant mechanisms of its action, remain poorly understood.…”