Bronchodilator overuse in hospitalized patients: Does the availability of spirometry data impact management?

From the 2021 HVPAA National Conference

Faiza Amin (Indiana University Health Physicians), Areeba Kara

Background

Bronchodilators (BD) are used as adjunctive treatment in obstructive lung disease and are associated with substantial costs – up to $449.35 per patient. While the diagnosis of COPD and asthma requires airflow obstruction on spirometry, several studies have described the underutilization of spirometry in diagnosing COPD.

Objective

The availability of spirometry data, while limited, is expected to guide appropriate BD use. Our objective was to assess how spirometry results impact the use of BDs in an inpatient setting.

Methods

An electronic query retrieved patients > 18 years who were admitted to our institution and received ≥1 dose of any BD in any dosage or delivery mechanism for ≥2 consecutive days between 2018-2019. Bronchodilators included albuterol, ipratropium, albuterol with ipratropium, levalbuterol and tiotropium. The site is a Midwestern, tertiary care, academic site. The protocol was approved by the local IRB. Among these patients, those with spirometry data available within a year of the hospitalization were identified. We compared those with airflow obstruction (AFO) (defined as FEV1/FVC <0.70) to those without obstruction.

Results

Over the study period, 6,946 patients received BDs while hospitalized. Of these, 146 (2.1%) had spirometry performed within the last year with 133 (91%) interpretable studies. Spirometry was consistent with AFO in 67 (50.4%) and showed no obstruction in the remaining 66 (49.6%). Patients with AFO were older (67.2 vs 62.7 years), more likely to smoke (85.3% vs 64.2%), had a lower BMI (27.7 vs 31.7), and more likely to be on BDs prior to hospitalization (85.3% vs 68.6%) (p ≤.02 for all). Mean lengths of stay were higher in patients with AFO but these differences were not statistically significant. There were no differences in the mean number of BD doses per day between the two groups. The majority of patients were discharged with prescriptions for bronchodilators with no differences between those who did and did not have AFO.

Conclusions

Spirometry data was available for few patients who were prescribed BDs during hospitalization. As expected, patients with AFO were older and with a history of smoking. Even when spirometry data was available, the presence or absence of AFO was not associated with the dosing frequency of BDs or the likelihood of being discharged with a prescription for BDs.

Clinical Implications

Our findings may represent the role of cognitive biases in diagnostic decision making- with each hospitalization in which a patient receives bronchodilators and is discharged with bronchodilators increasing the likelihood of subsequent similar management. There may also be a role for making spirometry data more easily accessible to help with decision-making.

Our work is limited by its retrospective nature which poses difficulty in assessing the appropriateness of bronchodilator use in those without obstruction. We relied on an electronic query for the presence of spirometry and must confirm the accuracy of this data.

Bronchodilator use should be limited in the absence of clear indications. Clinicians should carefully review available spirometry data and assess the need and benefit of bronchodilator use to reduce unnecessary costs and potential adverse effects.

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