Clinician and Veteran Experiences After an Inhaler Formulary Switch in the Veterans Health Administration

Background A 2021 Veterans Health Administration (VHA) formulary change replaced budesonide-formoterol (BUD-FORM) metered-dose inhaler (MDI) with fluticasone-salmeterol (FLU-SAL) dry-powder inhaler (DPI) as the preferred controller agent for asthma and chronic obstructive pulmonary disease (COPD). This transition was associated with increased health care utilization among veterans, but the mechanisms underlying these outcomes remain poorly understood. Research Question How was the 2021 inhaler conversion implemented across VHA facilities, and how might clinician and veteran perspectives on the transition process inform future inhaler formulary changes? Study Design and Methods We conducted semistructured interviews with VHA pharmacists and pulmonologists purposively sampled from facilities with high (≥80%), medium (60-79%), and low (≤59%) conversion rates and with veterans affected by the conversion (those who remained on the FLU-SAL DPI and those who switched back to BUD-FORM MDI or to another inhaler). Interviews were conducted from January to April 2025, transcribed, and analyzed using qualitative content analysis, with iterative team consensus discussions to ensure the credibility, validity, and confirmability of findings. Results We interviewed 26 clinicians (13 pharmacists; 13 pulmonologists) and 12 veterans. Four themes emerged: (1) negative patient experiences with FLU-SAL DPI, including insufficient patient education, uncertainty about dose delivery, and challenges among veterans with limited dexterity or inspiratory force; (2) concerns about inhaler selection and conversion implementation, which were perceived as top-down and cost-driven, alongside veterans' frustration with limited notification and lack of choice in the switch; (3) facility-level variation in conversion goals, perceived autonomy, and decision-making roles; and (4) shared local constraints across facilities, including limited specialty expertise, staffing strain, and substantial workload related to patient complaints and non-formulary requests. Interpretation Clinicians and veterans described a high-complexity medication-and-device switch characterized by reactive rather than proactive education and substantial administrative burden, offering insight into potential mechanisms underlying previously observed adverse outcomes after this conversion.