Triple therapy rates have skyrocketed, and inequality appears to be driving gaps in care, the report found.
COPD spirometry rates have dropped 31% while triple therapy jumped 130% since 2015, prompting concerns about misdiagnosis and overtreatment.
The covid pandemic appears to have played a major role in the decline in spirometry tests, with Medicare data showing rates dropped from 4144 to 2848 per 100,000 patients between 2015-16 and 2022-23.
In particular, the Australian Commission on Safety and Quality in Health Care’s report found that office-based tests – which roughly reflected general practice rates – plummeted 78%.
Costs, time, training and infection-prevention protocols were important drivers of this decline, according to Dr Lee Fong, GP and medical advisor to the Commission.
Around one in 13 Australians over the age of 40 have the incurable lung condition, but around half of these may not know they have it, the Atlas Focus Report into COPD said.
Dr Fong said spirometry was essential for an accurate diagnosis and would clarify whether the patient had COPD or asthma, and what the best treatment was for them.
The report suggested misdiagnosis was common, noting 25-50% of patients labelled as having COPD didn’t have evidence of post-bronchodilator airflow obstruction when tested with a spirometer.
Dr Fong urged GPs to check whether their patients with suspected COPD had the diagnosis confirmed with spirometry.
“Map out your options for spirometry, whether it’s restarting [testing in your practice], public or private referral, or talk to your PHN,” Dr Fong said.
But he added that the responsibility to fix this gap wasn’t on GPs’ shoulders alone, and the large disparity between test rates in major cities and regional and rural Australia suggested systemic changes were needed to improve care.
The report found that: “Across all reporting periods, major cities and inner regional areas had higher rates of spirometry and prescriptions dispensed for COPD, compared to outer regional and remote areas.”
Dr Fong said a subtle addition of “ideally” to the prevention and control of infection guidelines in November loosened restrictions around testing.
“Ideally pulmonary function tests including spirometry should be performed in a room that is closed off to other internal spaces and involve only one patient at a time [emphasis added],” the Commission’s guidelines now say.
The other important step was to make sure patients on triple therapy were meeting COPD-X Plan guideline criteria, Dr Fong said.
The combination medication, which include inhaled corticosteroids (ICS) with long-acting dual bronchodilators (LAMA and LABA), are indicated for patients with severe COPD with frequent exacerbations and with significant symptoms despite optimal dual therapy; and for those with co-existing asthma.
But the report found triple therapy was more commonly dispensed on the PBS than any of the other treatment options across most states and territories, while prescriptions dispensed for single COPD therapy with LAMA or LABA dropped by 55%.
The report pointed to several possible drivers of the increase, including the addition of these inhalers to the PBS in 2018, a growth in the number of patients with exacerbations or severe disease when diagnosis and misdiagnosis or uncertainty due to the lack of spirometry.
While the authors said there wasn’t data to suggest how appropriate triple therapy prescribing for COPD was in Australia overall, they pointed to several international studies that suggested a portion may be inappropriate.
For example, US data found 62% of patients prescribed triple therapy didn’t meet the criteria, and 50-80% of COPD patients were given ICS-containing medication when generally less than 30% have frequent exacerbations.
The Commission said the risks of triple therapy for COPD in patients who had less severe disease outweighed the benefits, in particular, the increased risk of pneumonia.
“The lightbulb moment was reading that the inflammation that happens in asthma is primarily eosinophilic,” Dr Fong said. “That’s why when somebody’s got asthma, if they’ve got even fairly mild to moderate symptoms, we’re super quick to put them on inhaled corticosteroids.”
“On the other hand, the pathology in COPD is different,” he said. “The inflammation in the airways of a patient with COPD is predominantly neutrophilic. It doesn’t respond very well to inhaled corticosteroids.”
The COPD patients that did respond well to inhaled corticosteroids had high eosinophil counts, he added.
Dr Fong said that this realisation underscored why giving inhaled corticosteroids was “just a waste of time” for most people with COPD, and that PBS restrictions were about clinical need rather than a cost-saving measure.
This wasn’t a case of doctors intentionally doing the wrong thing.
“There actually might be some really good reasons for that,” Dr Fong said. “For example, in rural and remote areas where access to medical review – and access to the actual puffers themselves – might be extremely limited, and if the doctor only flies in two times a year, then talking about a stepwise approach [may not be practical],” Dr Fong said.
A spokeswoman for GSK said the reported highlighted the “significant burden this disease places on people with COPD and the healthcare system in Australia”.
“Raising awareness of COPD and improving diagnosis rates are critical steps in ensuring patients receive the care they need to better manage their condition,” she said.
“It is important to note that the data presented in the report reflects trends in number of prescriptions and is not necessarily indicative of specific treatment pathways for patients.”
The company was committed to the quality use of medicines and ensuring best practices, and supported a stepwise approach to managing the condition, she said.
“Respiratory physicians and GPs play a critical role in identifying and managing COPD, and we encourage continued efforts to raise awareness, improve early diagnosis (including the appropriate use of spirometry), and tailor treatments to the needs of individual patients. GSK remains dedicated to partnering with Australian healthcare professionals to reduce the burden of COPD and deliver better outcomes for patients.”
A spokeswoman for Chiesi echoed these sentiments.
“As a 90-year-old research-driven company, Chiesi is committed to quality use of medicines and supports the guideline concordant use of these inhalers by healthcare professionals who care for and prescribe them to their patients with COPD,” she said.
GPs can sign up to can receive a personalised and confidential report comparing their individual MBS data for spirometry referrals with their peers, which will be available late 2025.
Australian Atlas of Healthcare Variation (Atlas) Focus Report: COPD, 25 June 2025
