1049 — De-Implementing Inhaled Steroids to Improve Care and Safety in COPD (DISCuS COPD)

Lead/Presenter: Laura Feemster, 
All Authors: Feemster LC (VA HSR&D Center of Innovation for Veteran Centered and Value-Driven Care and University of Washington School of Medicine, Seattle, WA), Majerczyk B (VA HSR&D Center of Innovation for Veteran Centered and Value-Driven Care, Seattle, WA); Rinne ST (Center for Healthcare Organization and Implementation Research and Boston University School of Medicine; Boston, MA), Wiener RS (Center for Healthcare Organization and Implementation Research and Boston University School of Medicine; Boston, MA), Lea C (VA HSR&D Center of Innovation for Veteran Centered and Value-Driven Care, Seattle, WA); Reece S (Center for Healthcare Organization and Implementation Research, Boston, MA); Coggeshall S (VA HSR&D Center of Innovation for Veteran Centered and Value-Driven Care, Seattle, WA); Rise P (VA HSR&D Center of Innovation for Veteran Centered and Value-Driven Care, Seattle, WA); Au DH (VA HSR&D Center of Innovation for Veteran Centered and Value-Driven Care and University of Washington School of Medicine, Seattle, WA)

Objectives:
Chronic obstructive pulmonary disease (COPD) affects up to one in four Veterans. Inhaled corticosteroids (ICS) increase pneumonia risk among patients with COPD and are only indicated for patients receiving long-acting bronchodilators who still experience severe/frequent exacerbations. Despite this narrow recommended use, ICS remain among the most commonly prescribed COPD medications. We sought to examine the effectiveness of pulmonary specialists in a population management approach to de-implementation. The intervention included proactive pulmonary electronic consults (e-consults) with facilitation that nudged primary care providers (PCPs) to discontinue inappropriate ICS among Veterans with COPD.

Methods:
We performed a randomized program evaluation with the PCP as the unit of analysis. The program was implemented at the VA Puget Sound Health Care System and the VA Bedford Healthcare System. We stratified by site, PCP type, and median number of eligible patients and randomized PCPs to either the intervention or usual care (UC). Eligible patients included those with COPD receiving potentially inappropriate ICS and an upcoming clinic appointment with a participating PCP (index date). The de-implementation intervention included patient-tailored recommendations for evidence-based care formulated by pulmonary specialists and delivered in the form of an e-consult that included the rationale for ICS discontinuation with accompanying orders for the PCP to modify, sign, or discontinue (“nudges”). Our primary outcome was discontinuation of ICS prescription at 6 months. Our secondary outcomes included rates of COPD exacerbations and pneumonia as well as all-cause mortality at 6 months. We performed logistic regression with mixed-random effects to account for clustering and adjusted for smoking status to assess our primary outcome (odds of discontinuation) and our secondary outcomes of exacerbation and pneumonia at 6 months.

Results:
We randomized 181 PCPs. Of 550 patients enrolled, 269 were cared for by intervention PCPs and 281 by PCPs in the UC group. The majority of patient participants were elderly (mean age of 69.9 years (SD 8.9)) white (86%) males (98%). At 6 months, patients cared for by intervention providers were significantly more likely to have discontinued ICS [65% vs. 34%; adjusted OR 3.66 (95% CI, 2.50-5.38)]. We found a non-significant reduction in pneumonia [1.9% vs. 2.9%; adjusted OR 0.63 (95% CI, 0.20-1.96)] and no difference in exacerbations [10% vs 12%; adjusted OR 0.80 (95% CI, 0.44-1.47)] or mortality (3.7% vs 3.2%, p = 0.7).

Implications:
Our specialty care driven proactive population management de-implementation intervention delivered through an e-consult with facilitation for uptake of recommendations reduced the use of ICS without evidence of patient harm.

Impacts:
Our intervention systematically overcame referral and other access barriers while utilizing existing clinical and data infrastructure to improve care delivery and outcomes. We improved COPD care with minimal burden to PCPs, patients or the health system (e.g. no new clinic structure or visits needed), demonstrating the substantial potential of such an approach to improve care quality.