Patients in Rural Areas Linked to Guideline-Discordant Inhaler Regimens for COPD

Patients who live in rural areas, receive fragmented care, and have a long commute to care have higher odds of being prescribed guideline-discordant inhaler regimens after chronic obstructive pulmonary disease (COPD) hospitalizations, according to a study published in The Lancet Regional Health – Americas.

Although guideline-concordant inhaler regimens are important for patients following COPD exacerbation hospitalizations, the researchers explained that evidence-based clinical practice guideline recommendations for COPD inhaled therapies are often not followed. Despite being at the highest risk for poor subsequent outcomes, patients with COPD recently hospitalized for an exacerbation are commonly prescribed guideline-discordant inhaler regimens.

The researchers noted that few studies evaluated whether factors such as living in a rural area, receiving fragmented care, and living far from care locations are associated with being prescribed guideline-concordant COPD inhaler regimens. Because of this, they conducted their study to evaluate differences in the prescription of guideline-discordant inhaler regimens in the subsequent 3 months after COPD exacerbation hospitalization based on these respective factors.

They defined guideline-concordant inhaler regimens as being a combination of a long-acting muscarinic antagonist and a long-acting beta-agonist (LAMA + LABA) or a combination of LAMA, LABA, and inhaled corticosteroids (ICS) (LAMA + LABA + ICS). On the other hand, the researchers defined guideline-discordant inhaler regimens as any other regimen (short-acting inhalers only, ICS monotherapy, ICS + LABA, LABA monotherapy, LAMA monotherapy, or LAMA + ICS).

The study population was created using data from the US Veterans Health Administration (VHA), “a network of national databases that incorporates data from multiple data sets throughout the VHA into 1 standard database structure to facilitate reporting and data analysis at the enterprise level.” The researchers included patients aged 40 and older hospitalized for acute COPD exacerbation between January 2016 and December 2019. They obtained each patient's rurality and drive time from geocoded addresses, and they defined fragmented care as hospitalization outside the VHA.

Male patient using an inhaler | Image Ljupco Smokovski - stock.adobe.com

The population consisted of 33,785 patients, of whom 32,465 (96.2%) were male; 26,893 (79.6%) White; and 4660 (13.5%) Black. Also, the mean (SD) age of patients was 70.5 (8.3) years. The researchers noted that more than 12,705 (36.7%) patients lived in a rural area; 21,692 (64.2%) had to drive more than 30 minutes to the closest VHA pulmonary specialty care; and 9769 (28.9%) had fragmented care.

The most prescribed inhaler regimen was the guideline-concordant combination LAMA + LABA + ICS (15,574; 46.1%), followed by the guideline-discordant regimen ICS + LABA (7884; 23.3%) and short-acting inhalers (4451; 13.2%). Consequently, the researchers noted that 16,398 (48.6%) patients received guideline-discordant inhaler regimens 3 months after hospitalization.

The researchers explained that 3 months after hospitalization, rural residents had higher odds of being prescribed guideline-discordant inhaler regimens compared with urban residents (adjusted odds ratio [aOR], 1.18; 95% CI, 1.12-1.23). They also associated higher odds with longer drive time to pulmonary specialty care (aOR, 1.38; 95% CI, 1.30-1.46) and fragmented care (aOR, 1.56; 95% CI, 1.48-1.63).

Six months after hospitalization, the number of patients with guideline-discordant inhaler regimens decreased to 12,188 (38%; 95% CI, 37.7%-38.8%), but living in a rural area, having a longer driving time to care, and fragmented care were still associated with higher odds of prescription.

Because of these findings, the researchers proposed various solutions to mitigate health care access issues. This included health systems identifying patients who live in rural areas, have longer drive times to care, or were recently hospitalized in a non-VHA facility and offering them additional support when setting up appointments.

“We need to test novel, targeted situations in health care delivery to improve guideline-concordant care for these high-risk populations,” the authors wrote.

The researchers also acknowledged their study’s limitations, one being that the inhaler data used relied on VHA pharmacy data, meaning they did not have data on inhalers prescribed by non-VHA providers. Because of this, they only included patients who actively used VHA inhaler prescriptions before and after hospitalization. Despite its limitations, the study’s findings demonstrate that challenges prevent the delivery of evidence-based care to high-risk patients with COPD.

“Our findings suggest the need for development of innovative programs to improve delivery of guideline-concordant COPD care, especially in high-risk COPD patients with geographic barriers to care and fragmented care,” the authors concluded.

Reference

Baldomero AK, Kunisaki KM, Wendt CH, et al. Guideline-discordant inhaler regimens after COPD hospitalization: associations with rurality, drive time to care, and fragmented care - a United States cohort study. Lancet Reg Health Am. 2023;26:100597. doi:10.1016/j.lana.2023.100597