Abstract Introduction/Rationale Clinical guidelines for chronic obstructive pulmonary disease (COPD) identify exacerbation history as a central determinant in pharmacotherapy decisions. Hospitalization for a severe exacerbation is a guideline-based indication for intensifying maintenance inhaler therapy, and hospital discharge is a key opportunity for doing so. We sought to characterize maintenance inhaler prescribing patterns following COPD-related hospitalizations. Methods This retrospective cohort study used Veterans Health Administration (VA) electronic health record and pharmacy data to identify all Veterans hospitalized for a COPD exacerbation in 2022 and 2023 and discharged home. The primary outcome was intensification of outpatient inhaler regimens on discharge with the addition of new inhalers—a long-acting muscarinic antagonist (LAMA), a long-acting beta-agonist (LABA), an inhaled corticosteroid (ICS) or any combination of the three. Discharge medications were defined as those filled within 7 days of discharge. Patients already on maximal inhaler therapy with all three classes (LAMA/LABA/ICS) on admission were excluded. Multivariate logistic regression identified differences in inhaler regimen intensification on discharge, controlling for patient sociodemographic, clinical, and hospitalization covariates and hospital-level clustering. Results The cohort included 14,128 COPD hospitalizations (65.2% 70 years and older, 94.3% male, 68.2% non-Hispanic White, 21,1% Black) across 125 VA medical centers. On admission, 27.7% were using LAMAs, 37.3% LABAs and 24.9% ICSs. On discharge, 33.4% of Veterans were prescribed an intensified inhaler regimen: 19.1% were newly prescribed a LAMA, 20.6% a LABA, 22.1% an ICS. 3,279 Veterans (23.2%) not previously on LAMA/LABA/ICS were discharged on maximal triple therapy. Admission inhaler use was most predictive of regimen intensification. Intensification was more likely for Veterans not on any long-acting inhalers (adjusted OR 3.27, 95% CI 2.90 to 3.70) or on a non-Global Initiative for COPD (GOLD) recommended regimen (aOR 2.63, 95% CI 2.12 to 3.27) compared to those on a GOLD-recommended regimen. Regimen intensification was also more likely for patients who received inpatient pulmonary consultation (aOR 1.68, 95% CI 1.49-1.90). Figure 1 shows additional associations between key covariates and likelihood of inhaler intensification. Across VA medical centers, there was substantial variation in inhaler intensification rates (median 33.0%, IQR 14.9%-51.1%). Conclusion Substantial variation in inhaler regimen intensification rates following hospitalization for COPD exacerbations was observed in the national VA health system. Admission inhaler regimen and involvement of pulmonary specialists during the hospitalization were most predictive of inhaler intensification, highlighting opportunities for quality improvement initiatives to standardize evidence-based prescribing practices at hospital discharge. This abstract is funded by: VA Dr. Eugene Marsh Center for Healthcare Evaluation, Research, and Promotion (CHERP) Pilot Program Award, NIH
Ren et al. (Fri,) studied this question.
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