Trends and Rural-Urban Differences in the Initial Prescription of Low-Value Inhaled Corticosteroids among US Veterans with COPD.

RATIONALE: Guidelines recommend inhaled corticosteroids (ICS) for patients with chronic obstructive pulmonary disease (COPD) and select indications, including asthma history, high exacerbation risk, or high serum eosinophils. ICS are commonly prescribed outside of these indications despite evidence of harm. We defined "low-value" ICS prescription as receipt of an ICS without evidence of a guideline-recommended indication. ICS prescription patterns are not well characterized and could inform health system interventions to reduce low-value practices.

OBJECTIVE: To evaluate the national trends in initial low-value ICS prescriptions in the Department of Veterans Affairs and determine whether rural-urban differences in low-value ICS prescribing exist.

METHODS: We performed a cross-sectional study between January 4, 2010 and December 31, 2018, identifying Veterans with COPD and who were new users of inhaler therapy. We defined low-value ICS as prescription in patients with (1) no asthma, (2) low risk of future exacerbation (GOLD groups A or B), and (3) serum eosinophils <300 cells/microliter. We performed multivariable logistic regression to evaluate trends in low-value ICS prescription over time, adjusting for potential confounders. We performed fixed effects logistic regression to assess rural-urban prescribing patterns.

RESULTS: We identified a total of 131,009 Veterans with COPD starting inhaler therapy, of which 57,472 (44%) were prescribed low-value ICS as initial therapy. From 2010 to 2018, the probability of receiving low-value ICS as initial therapy increased by 0.42 percentage points per year (95% CI 0.31 - 0.53). Compared to urban residence, rural residence was associated with a 2.5 percentage point (95% CI 1.9 - 3.1) higher probability of receiving low-value ICS as initial therapy.

CONCLUSIONS: The prescription of low-value ICS as initial therapy is common and increasing slightly over time for both rural and urban Veterans. Given the widespread and persistent nature of low-value ICS prescribing, health system leaders should consider system-wide approaches to address this low-value prescribing practice.