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Chronic obstructive pulmonary disease (COPD) is a group of progressive lung diseases that cause breathing-related problems, and is one of the most common medical diagnoses among Veterans, affecting as many as one in four. Inhaled corticosteroids (ICS) are commonly prescribed to Veterans with COPD. For patients with severe fixed-airflow obstruction and/or frequent exacerbations, ICS help reduce breathing exacerbations.
However, patients with mild to moderate COPD and no frequent exacerbations derive little benefit from inhaled corticosteroids. QUERI research suggests that as many as 48% of Veterans with a diagnosis of COPD do not have airflow obstruction by spirometry – a test to measure air flow in and out of the lungs, and a key test for determining if patients would benefit from an ICS. Yet approximately 40% of these patients had received inappropriate inhaled medications that were continued even after testing confirmed that a COPD diagnosis was unsupported. Moreover, ICS are not without risk and are associated with increased rates of pneumonia, fractures, cataracts, and poor diabetes control. QUERI investigators estimate that for every 62 patients with mild-to-moderate COPD for whom ICS is discontinued, at least one case of pneumonia can be prevented, and the risk reduction is potentially much higher. Also, for patients with mild to moderate COPD and no frequent exacerbations there are safer medications, such as long-acting muscarinic agonists and long-acting beta agonists.
To reduce inappropriate ICS use, the Improving Safety and Quality through Evidence-Based De-Implementation of Ineffective Diagnostics and Therapeutics QUERI program is testing an intervention at two VA medical centers: VA Puget Sound Health Care System and the Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA and their 10 affiliated community-based outpatient clinics. QUERI investigators, along with pulmonary and primary care leaders are conducting the project at both locations. The proactive E-consult intervention utilizes VA's electronic medical record (EHR), which provides the ability for specialists to review patient-specific information before a patient visit so they can provide tailored advice to primary care providers (PCPs).
QUERI investigators identify VA patients who have a limited clinical indication for an ICS, and who also have a concurrent upcoming primary care appointment. At weekly team meetings, intervention staff and pulmonologists review these Veterans' medical records and provide PCPs with guideline-based expert recommendations. Investigators also provide patient-tailored notes and guideline-based orders in the EHR, so the PCPs are able to review the notes and orders when the patients visit. If the PCPs agree with the orders, they only have to sign off on them. Of course PCPs can disagree and not sign them, and then they have the option of including a note to explain why.
This E-consult process represents an approach to improving specialty care access, as well as population health management by having relevant specialty care clinicians monitor and take action to improve care. Interviews and surveys of providers, both MD and nurse practitioners – before and after receipt of the intervention – will reveal potential clinical impacts, as well as the effects of workplace climate and morale regarding the intervention. Given the prevalence of clinically diagnosed COPD, the significant overuse of ICS, and the adverse risks from ICS use, this QUERI intervention has the potential to substantially improve the delivery of evidence-based care and specialty care access, thereby improving patient-centered outcomes, including safety and quality, for a large number of Veterans. This intervention also has the potential to reduce the burden on VA primary care providers.
Operational partners for this Improving Safety and Quality QUERI program project include VA's Pulmonary National Program Director, Office of Specialty Care Services and Pharmacy Benefits Management (PBM).
For more information about Safety and Quality QUERI, please contact David Au, MD at David.Au@va.gov .