Geographic factors may result in guideline-discordant COPD care

Study included data of more than 30,000 people treated through VA

Marisa Wexler, MS avatar

by Marisa Wexler, MS |

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After hospitalization due to chronic obstructive pulmonary disease (COPD) exacerbation, patients who live in rural areas and/or have to drive long distances to get to lung specialty centers are more likely to be prescribed an inhaler therapy regimen that isn’t in line with medical guidelines.

That’s according to a study analyzing U.S. Veterans Health Administration (VA) data from more than 30,000 people.

“Our findings suggest that access to health care and challenges in care coordination are potentially contributing to suboptimal delivery of evidence-based COPD care in this high-risk patient population,” the researchers wrote.

The data also “highlight the need to develop effective methods of health care delivery to target COPD patients with these risk factors,” they added.

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The study, “Guideline-discordant inhaler regimens after COPD hospitalization: associations with rurality, drive time to care, and fragmented care – a United States cohort study,” was published in The Lancet Regional Health – Americas.

Inhaler-based treatments are commonly used in people with COPD to reduce the risk of hospitalizations and improve life quality. Prescribing recommended inhaler regimens to COPD patients is particularly important after hospitalization for disease exacerbations where symptoms suddenly worsen.

In these cases, guidelines suggest treatment with a combination of an inhaled long-acting muscarinic antagonist (LAMA) and an inhaled long-acting beta-agonist (LABA), or the LAMA-LABA combo with an inhaled corticosteroid.

“Nonetheless, prescription of guideline-discordant inhaler regimens to these patients is common,” the researchers wrote.

Potential factors leading to poor COPD outcomes

While “geographic factors—such as living in a rural area—and fragmented care are increasingly recognized as potential factors that contribute to poor health outcomes in COPD,” the researchers wrote, it remains unclear whether they influence the prescription of guideline-discordant inhaler regimens.

To address this knowledge gap, a team of researchers in the U.S. looked back at VA electronic health records of 33,785 adults with COPD who were hospitalized for an acute exacerbation between 2017 and 2020.

Their mean age was 70.5 years and most patients (96.2%) were men; 79.6% were white and 13.5% were Black/African American.

More than two-thirds of the patients lived in the Southern (42.5%) or Midwestern (25.6%) parts of the U.S., and more than a third (36.7%) lived in a rural area. Nearly two-thirds (64.2%) had to drive at least 30 minutes to get to the nearest VA pulmonary specialty care center.

More than one-quarter of patients (28.9%) had fragmented care, defined as primary care and prescriptions from the VA, but hospitalization outside the VA.

Results showed nearly half (48.6%) of the patients were on guideline-discordant inhaler regimens three months after the exacerbation. The most common regimen not in line with guidelines was LABA plus inhaled corticosteroids (23.3%), followed by short-acting inhalers (13.2%), and LAMA alone (9.6%).

Statistical tests showed that fragmented care was the strongest risk factor for guideline-discordant regimen prescription, being significantly associated with a 56% greater chance.

Also, patients living in rural areas were significantly more likely, by 18%, to be on guideline-discordant regimens relative to their urban counterparts.

Travel time associated with treatment

Living farther from specialty care centers also was significantly associated with a higher chance of being on regimens not part of the guidelines.

Patients who had to drive between 30 minutes to an hour were 9% more likely to be on guideline-discordant regimens than those who had to drive up to 30 minutes, and those who had to drive more than 90 minutes were 38% more likely.

“We found that living in a rural area and/or having a longer drive time to pulmonary specialty care were associated with prescription of guideline-discordant inhaler prescriptions,” the researchers wrote.

These results “show the separate associations between rurality and drive time to accessing care; while they are related, urban residents can also have long drive times, which may impact the quality of their care,” they added.

“Our findings show the need to focus on these two distinct, albeit related, geographic factors,” the team wrote.

Associations between either fragmented care or living in rural areas with non-guideline treatment were even more pronounced among Black/African American patients.

While the percentage of patients on guideline-discordant inhaler regimens dropped to 38.3% at six months after hospitalizations, all three factors remained significantly associated with greater odds of such treatment.

“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 scientists wrote.

The chances of being on treatment not part of the guidelines were also significantly higher, by 14%, in women relative to men, and significantly lower, by 19%, among Black patients compared with white patients.

The reasons for these differences aren’t totally clear, the researchers noted.

Also, given that people receiving care at the VA have unique demographic and socioeconomic considerations, it’s unclear whether the findings apply for the broader U.S. population.