High Patient Complexity in COPD Associated With Low-Value ICS Prescription

female patient in hospital bed being shown chest x ray
Higher patient complexity is associated with incident prescription of low-value inhaled corticosteroids in COPD.

Higher patient complexity is associated with incident prescription of low-value inhaled corticosteroids (ICS) in chronic obstructive pulmonary disease (COPD), according to study results published in Annals of the American Thoracic Society.

In this cohort study, researchers identified veterans with COPD who had received a pulmonary function test from 21 centers between 2012 and 2016 (N=8497). The Care Assessment Needs (CAN) score was used to assess patient-level complexity as the primary exposure, to estimate the probabilities of hospitalization and death, and then to rank the findings into scores between 0 and 100. Scores between 95 and 100 represented the 5% of patients with the highest probability of hospitalization or death. The main outcome measure was the first prescription of a low-value ICS.

During the follow-up period (mean follow-up, 4 quarters), researchers identified 22.2% of patients with a first ICS prescription (n=1889). Of these patients, only 2.5% (n=48) were on dual long-acting muscarinic antagonists (LAMA) and long-acting beta-agonists (LABA) before ICS was initiated as a third-line therapy. A higher CAN score was significantly associated with the first ICS prescription in the model, which tested CAN as a continuous measure, adjusting for age (hazard ratio, 1.17 per 10 CAN units; 95% CI, 1.13-1.21). In the year after index, 212 patients were hospitalized for COPD and another 344 had ≥2 outpatient exacerbations and became eligible for ICS.

This study was limited by the information that may not have been captured in the Veterans Affairs dataset, such as hospitalization for COPD at a non-Veterans Affairs facility. Patient-reported symptoms were also not available in the dataset. The generalizability of these results is limited because the study was conducted within a Veterans Affairs population.

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“Healthcare continues to move toward value-based purchasing that will increasingly transfer the risk of healthcare services to healthcare systems,” the researchers concluded. “Preferred provider status for large contracts will also include demonstration of provision of high quality, cost effective approaches to population health management. Targeting overuse of ICS 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.”


Spece LJ, Donovan LM, Griffith MF, et al. Initiating low-value inhaled corticosteroids in an inception cohort with COPD [published online January 3, 2020]. Ann Am Thorac Soc. doi:10.1513/AnnalsATS.201911-854OC