Changed terms for drug payment influenced GPs’ diagnoses and prescribing practice for inhaled corticosteroids

BACKGROUND Inhaled glucocorticosteroids (ICS) are first-line anti-inflammatory treatment in asthma, but not in chronic obstructive pulmonary disease (COPD). To restrict ICS use in COPD to cases of severe disease, new terms for reimbursement of drug costs were introduced in Norway in 2006, requiring a diagnosis of COPD to be verified by spirometry. OBJECTIVES To describe how GPs' diagnoses and treatment of patients who used ICS before 2006 changed after a reassessment of the patients that included spirometry. METHODS From the shared electronic patient record system in one group practice, patients ≥ 50 years prescribed ICS (including in combination with long-acting beta2-agonists) during the previous year were identified and invited to a tailored consultation including spirometry to assure the quality of diagnosis and treatment. GPs' diagnoses and ICS prescribing patterns after this reassessment were recorded, retrospectively. RESULTS Of 164 patients identified, 112 were included. Post-bronchodilator spirometry showed airflow limitation indicating COPD in 55 patients. Of the 57 remaining patients, five had a positive reversibility test. The number of patients diagnosed with asthma increased (from 25 to 62) after the reassessment. A diagnosis of COPD was also more frequently used, whereas fewer patients had other pulmonary diagnoses. ICS was discontinued in 31 patients; 20 with mild to moderate COPD and 11 with normal spirometry. CONCLUSION Altered reimbursement terms for ICS changed GPs' diagnostic practice in a way that made the diagnoses better fit with the treatment given, but over-diagnosis of asthma could not be excluded. Spirometry was useful for identifying ICS overuse.