How do you prescribe ICS to COPD patients?

21 Dec 2023 How do you prescribe ICS to COPD patients?

The Therapeutics Initiative produced and distributed individual prescribing Portraits on prescribing of inhaled corticosteroids (ICS) for patients with chronic obstructive pulmonary disease (COPD) (2017-2021) to approximately 5000 clinicians in BC. Eligible clinicians (primary care physicians and nurse practitioners) were randomized to receive the Portrait in two groups, an early group of clinicians received Portrait in December 2022 and a delayed group received Portrait in December 2023. This Portrait was accompanied by the Therapeutics Letter: Minimizing inhaled corticosteroids for COPD.¹

Abbreviations Used

COPD: chronic obstructive pulmonary disease
CPSBC: College of Physicians and Surgeons of British Columbia
EMR: electronic medical record
FP: family practitioner
GP: general practice
ICD: International Classification of Diseases
ICS: inhaled corticosteroids
LABA: long acting beta2 adrenergic agonist
LAMA: long acting muscarinic antagonist
MSP: Medical Services Plan
NP: nurse practitioner
PSP: Practice Support Program
SABA: short acting beta2 adrenergic agonist
SAMA: short acting muscarinic antagonist

Data definitions

Who received this Portrait?

Clinicians meeting all of the following criteria received an individual prescribing Portrait:

• General practice (GP) physicians or nurse practitioners (NP).
• GPs were family practitioners (FP), who were registered by the BC Medical Services Plan (MSP) as an active practice, or physicians registered primarily as GP-emergency medicine and FP-emergency medicine physicians, and
• NPs were registered by the BC MSP as an active practice; and
• had ≥100 prescriptions (for any drug) filled at a community pharmacy in 2021, according to PharmaNet claims data; and
• did not opt out of the Portrait program.

Physicians registered to receive this Portrait by mail must have:

• a valid mailing address in BC according to the College of Physicians and Surgeons of British Columbia’s public physician information.

How were patients assigned to this Portrait?

Patients were included in a clinician Portrait if they met all of the following criteria:

• filled a first prescription for an inhaled COPD medication (Table 1) in a community pharmacy during the Portrait period, after at least 365 days without previous COPD medication; and
• were age 35 years or older on the date of the first prescriptions for an inhaled COPD medication, and
• were BC residents based on continuous BC MSP enrollment
• were COPD patients, based on a modification of previously validated algorithm² used in Canadian claim data; and
• did not have asthma
  • defined as asthma classification before their first COPD medication, based on a modification of previously validated algorithm³ used in Canadian claim data (Table 1), or
  • an asthma diagnosis (in inpatient or outpatient setting, including the emergency department) on or in the 14 days before their COPD medication start;
• and were not discharged from a hospital or an emergency department in the 14 days before starting the treatment

ICS patients were included in a clinician’s Portrait if they met all of the following criteria:

• filled a prescription for an inhaled ICS medication in combination with inhaled LABA or LAMA or both (Table 1) in a community pharmacy during the Portrait period; and
• were age 35 years or older on the date of the first prescriptions for an inhaled COPD medication, and
• were BC residents based on continuous BC MSP enrollment, and
• were COPD patients, defined as above, before their last prescription filled in Portrait period, and
• did not have asthma, defined as above, before their last prescription filled in Portrait period, and
• were not discharged from a hospital or an emergency department in the 14 days before the prescription was filled.

Data for patients who are federally insured (e.g., Veterans, RCMP, Armed Forces and beneficiaries of Non-Insured Health Benefits) or First Nations Health Benefits (PharmaCare Plan W) were not available.

Clinicians may have received a Portrait with masked or missing elements (i.e., no blue red bars shown) because they met the above requirements but prescribed between 1 and 5 prescriptions for that section element of the Portrait. Portrait’s data access agreement requires the suppression of data elements that contain <6 individuals. To comply with the agreement, the total number of patients may be presented as a range (e.g., 1-20 patients), and percentages were rounded to the nearest 5%. Clinicians with no prescriptions (“0 prescriptions”) will have this element displayed.

Table 1: Identifying patients with COPD and asthma

What prescriptions were included in this Portrait?

Filling events of inhaled COPD medication prescriptions were extracted from PharmaNet claims data and included all prescriptions filled at a community pharmacy in BC with a clinician’s prescribing number. Reversed prescription claims, out-of-province prescriptions, or drugs dispensed in hospital were not included.

Inhaled COPD medications included SABA, SAMA, SABA/SAMA combinations, LABA, LAMA, LABA/LAMA combinations, ICS, ICS/LABA combinations, and ICS/LAMA/LABA combinations (Table 2).

Initial therapy was defined as the first prescription of an inhaled COPD medication after at least 365 days without a COPD medication. It also includes any additional COPD medication prescribed in the following 6 .

ICS therapy was identified as any product containing inhaled corticosteroids, dispensed alone or with another inhaled medication within 3 months (91 days). In case more than one prescription was filled within the 3-month period, we did not included patients if more than one prescriber was responsible for these prescriptions.

Table 2: Inhaled Medications^Note

Note: Not all listed brand names may be indicated for COPD treatment, however, we included all these medications in our analysis, as we selected COPD medications based on generic names

How was “Optimal” determined?

Based on the best available evidence, Inhaled corticosteroids are not recommended as initial therapy for COPD, which is why we set the optimal target as zero (0). Please refer to Therapeutics Letter: Minimizing inhaled corticosteroids for COPD¹ for a more detailed assessment of the evidence.
Note: we attempted to exclude patients with asthma from this Portrait based on available data; however, the accuracy of these data depends on the completeness and precision of patient encounter coding.

How was “Median BC prescriber with a similar practice” calculated?

In calculating median BC prescriber, we accounted for the number of new users of COPD medications prescribed by you. Therefore, the median varies between different clinicians. It was calculated from the median prescribing patterns of BC primary care clinicians included in Portrait, using the following formula:

References and additional information

1. Therapeutics Initiative. Therapeutics Initiative. Minimizing inhaled corticosteroids for COPD. Therapeutics Letter. 2023 (October); 145:1-2.
2. Gershon AS, Wang C, Guan J, Vasilevska-Ristovska J, Cicutto L, To T. Identifying individuals with physcian (misspelling in the original manuscript/AF) diagnosed COPD in health administrative databases. COPD. 2009;6(5):388–94.
3. Gershon AS, Wang C, Guan J, Vasilevska-Ristovska J, Cicutto L, To T. Identifying patients with physician-diagnosed asthma in health administrative databases. Can Respir J 2009;16(6):183-188.

Research component

The research objective is to determine the impact of the Portrait on clinician prescribing. This impact will be evaluated at an aggregated level over the coming year by comparing pooled prescribing data from clinicians in the early mailing group to pooled prescribing data from clinicians in the delayed group. All prescribing data analyzed for this evaluation will not contain names, only encrypted patient and clinician numbers. No clinician or patient will be identified in any reports or publications. Portrait’s data access agreement requires the masking of data elements when <6 individuals (patients or clinicians) are included. Ethics approval for this evaluation will be obtained from the University of British Columbia Clinical Ethics Review Board. This evaluation is being led by Drs. Colin Dormuth and Greg Carney, University of British Columbia, Faculty of Medicine, Department of Anesthesiology, Pharmacology, & Therapeutics.

If you have any questions or would like further information with respect to this evaluation, you may contact the Portrait team at (604) 822-4887 or email Portrait@ti.ubc.ca

FAQ

Can I request the names of my patients included in this Portrait?

No. Portrait’s data access agreement only permits access to encrypted patient identifiers. There is no way for us to identify individual patients in the data or to provide you with a list. However, other resources may be available for you. Contact your Practice Support Program (PSP) regional team to discuss how they might help you use your EMR to identify these patients.

I have a unique/specialized practice and do not believe that my data should be compared to GPs. Shouldn’t my comparison cohort be other clinicians with practices similar to mine?

Our ability to accurately include clinicians depends on how each clinician is listed in the BC MSP data. For example, to be included in the program, a clinician must be defined as a Nurse Practitioner or a General Practitioner with a licence status of Private Practice in the MSP data; beyond that, it is difficult to accurately identify any individual’s specific work environment, as many clinicians work in multiple locations. We try to keep Portraits relevant to recipients by having a minimum prescribing criterion for each Portrait topic. Clinicians who prescribe no or very little of the drug in question typically will not receive a Portrait.

Creating accurate comparison cohorts is difficult for the same reasons. We often include the BC median as a point of interest when it is feasible, but we know that many clinicians have unique or specialized practices and this comparator is not ideal. Hopefully, as we continue to build and refine the Portrait program, we will be able to provide comparisons that are more relevant to a variety of practices.

Portraits are really intended to be a tool for you to reflect upon and consider your own prescribing. Rest assured that we are not directly comparing your prescribing to any particular cohort. You are the only one who ever sees your own Portrait data, and you can decide for yourself whether you think your prescribing is in line with the evidence given your unique clinical setting. You will only receive future Portraits for which you have prescribed more than the minimum inclusion criteria, so you shouldn’t receive anything that is irrelevant to your practice.

Why does my Portrait show ranges of patients that I treated (1-20, 20-30, etc.), and not exact numbers?

Clinicians may have received a Portrait with masked or missing elements (i.e., no blue red bars shown) because they met the above requirements but prescribed between 1 and 5 prescriptions for that section element of the Portrait. Portrait’s data access agreement requires the suppression of data elements that contain <6 individuals. To comply with the agreement, the total number of patients may be presented as a range (e.g., 1-5 patients), and percentages were rounded to the nearest 5%. Clinicians with no prescriptions (“0 prescriptions”) will have this element displayed.

I don’t see my question here. Where can I find more information?

Please check out our program FAQ section. We also welcome your feedback. Questions can be directed to our Portrait team by phone (604) 822-4887 or email Portrait@ti.ubc.ca.