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Atlas Focus Report: Chronic obstructive pulmonary disease (COPD)

This Australian Atlas of Healthcare Variation focus report examines recent rates of MBS-subsidised spirometry and PBS-subsidised COPD medicines for people over 35 years. The findings from this report help identify areas for improvement into the diagnosis and treatment of COPD.

Key findings

31% decrease

in national rate of spirometry

Spirometry rates lower

outside major cities

130% increase

in national rate of triple therapy

Triple therapy higher

in lower socioeconomic areas

Report Summary

Rates of MBS-subsidised spirometry for people 35 years and over between 2015–16 and 2022–23:

  • fell nationally by 31%, suggesting an essential test for accurate diagnosis of COPD is underused
  • fell more for office-based than laboratory-based procedures (68% and 7%, respectively)
  • were lower outside major cities, despite the higher prevalence of COPD in regional and remote areas.

Rates of PBS-subsidised prescriptions dispensed for COPD triple therapy (ICS with LAMA and LABA)* for people 35 years and over between 2015–16 and 2022–23:

  • increased nationally by 130%
  • were higher than any other examined pharmacotherapy options for COPD in most states and territories, despite guidelines stating it should be reserved for COPD patients with frequent exacerbations and with significant symptoms despite optimal dual therapy; and for those with co-existing asthma.

*Triple therapy includes three types of medications including ICS – inhaled corticosteroids (ICS), long-acting muscarinic antagonist (LAMA) and long-acting beta2-agonist (LABA).

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What is chronic obstructive pulmonary disease? 

Chronic obstructive pulmonary disease (COPD) is a progressive and debilitating respiratory condition that can be life limiting.  COPD symptoms can include persistent coughing, shortness of breath, and wheezing.

About 1 in 13 people over 40 years of age in Australia are thought to have COPD, but about 50% may not know they have it.1, 2 COPD was the fifth leading cause of death and the fifth leading cause of disease burden in Australia in 2023.3, 4 It is also associated with substantial numbers of potentially preventable hospitalisations and costs to the healthcare system.4  

Tobacco smoking is the most common risk factor for COPD.5 Other factors such as exposure to particles from occupational dusts and fumes, air pollution, early life factors and genetic factors also contribute to the disease.5, 6
 

Diagnosis and treatment of COPD

Early diagnosis and proactive management of COPD can improve symptoms, quality of life and precent serious complications for patients. 

Did you know?

            Half of people with COPD may not know they have it

Concerningly, Australian estimates suggest approximately 50% of people living in Australia with COPD may not know that they have it.2 Undiagnosed COPD affects one-quarter of patients taking any inhaled therapies, according to an international study of primary healthcare settings.7 Misdiagnosis is also common: 25–50% of patients labelled as having COPD did not have evidence of post-bronchodilator airflow obstruction on spirometry.7

There are two key elements to diagnosing and treating COPD:

  • spirometry: a test that measures how well your lungs are working
  • pharmacotherapy: a type of therapy that uses one or more medicines to improve, treat or prevent symptoms, such as inhaled corticosteroids (ICS).
     

Clinical commentary

Spirometry

Spirometry for people 35 years and over

Spirometry is essential for accurate diagnosis of COPD as it differentiates it from other lung diseases with similar symptoms and ensures correct treatment (including appropriate use of ICS). 8 COPD cannot be diagnosed based on clinical features or chest X-ray alone.8

Spirometry should be conducted in people over 35 years of age who present with one or more recurrent respiratory symptoms and at least one risk factor for COPD, and in people hospitalised for suspected COPD which has not previously been confirmed with spirometry or their results can’t be accessed.

  • Spirometry rates fell nationally by 31% between 2015–16 and 2022–23
  • Office-based spirometry fell by 68% nationally, and laboratory-based spirometry fell by 7%, between 2015–16 and 2022–23
  • Spirometry is essential for accurate diagnosis of COPD6
  • About 50% of people with COPD may not know they have it2, potentially indicating underuse of spirometry
  • Delayed diagnosis of COPD reduces the opportunity to slow disease progression and manage symptoms to improve quality of life
  • Possible approaches to increasing the use of spirometry include:
    • Review of remuneration models for spirometry in general practice9
    • Ensuring COPD diagnoses in primary care are confirmed by spirometry, with interpretation by telemedicine if needed to increase access, particularly outside of major cities9
    • Supporting respiratory diagnostic hubs for people with chronic lung symptoms and/or risk factors for chronic respiratory disease, targeting socioeconomically disadvantaged areas, remote areas and populations with high COPD burden, including First Nations people9, with no gap payment
    • Identifying local referral pathways for spirometry if this is not provided at the general practitioner (GP) practice9
    • Practice Incentives Program (PIP) Quality Improvement (QI) Incentive initiative9
    • Education programs to support the uptake of COPD-X guidelines, including diagnosis with spirometry9
    • Prompts in medical software packages and clinical-decision support systems9
    • Increased consumer awareness of the need for spirometry10.

This report examines the number of Medicare Benefits Schedule (MBS) subsidised spirometry services per 100,000 people aged 35 years and over between 2015–16 and 2022–23. 

The report presents trend data and visualisations for:

  • Australia and its states and territories
  • Remoteness and socioeconomic status levels
  • Primary Health Networks (PHNs)
  • Local areas (SA3s)
  • Office-based (11505 and 11506) and laboratory-based (11503, 11507, 11509 and 11512) spirometry.

An office-based spirometry test can occur in general practice. A laboratory-based spirometry test is typically performed by a respiratory scientist under specialist supervision. Data are reported according to where patients live, not where the service was conducted. 

National trends 
  • Spirometry rates fell nationally by 31% between 2015–16 and 2022–23
  • In 2015–16, there were 551,506 services (4,114 per 100,000 people) compared to 452,712 services in 2022–23 (2,848 per 100,000 people)
  • In 2015–16, there was an eight-fold difference between the local area with the highest rate of spirometry and the local area with the lowest rate, compared to 2022–23, when there was a ten-fold difference.
State and territory trends
  • Rates of spirometry fell in all states and territories between 2015–16 and 2022–23
  • The largest decrease was 52% in the Northern Territory and the smallest decrease was 10% in Victoria
  • Queensland had the highest rate in 2015–16 (5,198 per 100,000 people) and New South Wales had the highest rate in 2022–23 (3,201 per 100,000 people)
  • The Australian Capital Territory had the lowest rate in 2015–16 (2,502 per 100,000 people) and the Northern Territory had the lowest rate in 2022–23 (1,488 per 100,000 people).
Setting: office-based, laboratory-based 
  • Office-based spirometry fell by 68% nationally, compared with a 7% reduction in laboratory-based spirometry, between 2015–16 and 2022–23
  • Rates of office-based spirometry fell across all states and territories between 2015–16 and 2022–23
  • Queensland had the highest rate of office-based spirometry in 2015–16 (2,449 per 100,000 people) and in 2022–23 (836 per 100,000 people)
  • Victoria had the lowest rate of office-based spirometry in 2015–16 (660 per 100,000 people) and in 2022–23 (237 per 100,000 people)
  • Queensland had the highest rate of laboratory-based spirometry in 2015–16 (2,749 per 100,000 people) and New South Wales had the highest rate of laboratory-based spirometry in 2022–23 (2,612 per 100,000 people)
  • The Australian Capital Territory had the lowest rate of laboratory-based spirometry in 2015–16 (1,797 per 100,000 people) and the Northern Territory had the lowest rate of laboratory-based spirometry in 2022–23 (1,151 per 100,000 people).
Remoteness
  • Spirometry rates were consistently lower in remote areas compared to major cities and regional areas.
Socioeconomic status
  • The most socioeconomically disadvantaged areas in major cities consistently had the highest rates of spirometry compared to all regional and remote areas of all socioeconomic status levels.
Primary Health Networks (PHNs)
  • Spirometry rates fell in all PHNs between 2015–16 and 2022–23
  • The largest decrease between 2015–16 and 2022–23 was 52% in Gold Coast PHN and in the Northern Territory PHN, and the smallest decrease was 0.4% in South Western Sydney PHN
  • Brisbane South PHN had the highest rate in 2015–16 (5,845 per 100,000 people) and South Western Sydney PHN had the highest rate in 2022–23 (4,345 per 100,000 people)
  • The Australian Capital Territory PHN had the lowest rate in 2015–16 (2,502 per 100,000 people) and the Northern Territory PHN had the lowest rate in 2022–23 (1,488 per 100,000 people).

Barriers to using spirometry in Australian general practice include:

  • Time and cost – lack of time to perform spirometry and high cost of initial purchase of a spirometer, and performing spirometry, compared to reimbursement
  • Perception of limited clinical benefit or use in diagnosing respiratory disease, and/or preference to treat clinically rather than use spirometry for diagnosis
  • Lack of trained staff
  • Poor availability – lack of spirometry onsite or reasonable offsite option
  • Patient barriers – cost, time, feeling unwell
  • Limited spirometry interpretation skills.11

In addition, some GPs may use simple peak flow testing in an effort to reduce patient costs and increase efficiency (note that this is not a reliable method for COPD diagnosis).12

The COVID-19 pandemic created major additional barriers to spirometry in primary care, including: 

  • Loss of spirometry skills during COVID restrictions7
  • Costs associated with complying with infection prevention and control protocols7
  • Fewer face to face appointments13
  • Ongoing concerns about the potential spread of infectious diseases to healthcare workers and patients during spirometry.14

In addition, spirometry performed in public health facilities may not be captured through the MBS database.12 In areas where people are accessing spirometry at a public health facility, rates of spirometry displayed in this report may be an underestimate.

Possible approaches to increasing the use of spirometry include:

  • review of remuneration levels and models for spirometry in general practice9
  • ensuring COPD diagnosis in primary care are confirmed by spirometry, with interpretation provided by telemedicine if needed to increase access, particularly outside of major cities9
  • multidisciplinary chronic disease teams with specialist respiratory physician oversight, equipment and skills in the performance of spirometry12
  • supporting respiratory diagnostic hubs for people with chronic lung symptoms and/or risk factors for chronic respiratory disease, targeting socioeconomically disadvantaged areas, remote areas and populations with high COPD burden, including First Nations people9, with no gap payment
  • identifying local referral pathways for spirometry if this is not provided at the GP practice9
  • Practice Incentives Program (PIP) Quality Improvement (QI) Incentive initiatives for PHNs9
  • education programs about the need for spirometry9
  • prompts in medical software packages and clinical-decision support systems9
  • increased consumer awareness of the need for spirometry10.

The Atlas Focus Report: COPD was developed in consultation with a topic expert group that provided clinical advice for the report. Members of the group included: 

Dr Lee Fong (Chair)General Practitioner; Medical Advisor, Australian Commission on Safety and Quality in Health Care, NSW
Ms Debbie RigbyAdvanced Practice Pharmacist and Clinical Executive Lead, National Asthma Council Australia, QLD
Dr Kerry L Hancock FRACGP (Hon)General Practitioner; Honorary Research Fellow / Clinical Adviser, Allergy and Lung Health Unit, Melbourne School of Population and Global Health, The University of Melbourne, VIC
Dr Li Ping ChungRespiratory Physician and Clinical Lead for Complex Airways Disease, Department of Respiratory Medicine, Fiona Stanley Hospital; Clinical lead for Respiratory Health Network, Division of Clinical Excellence, Department of Health, WA
Prof Subash HeraganahallyDirector and Head, Respiratory and Sleep Service, Royal Darwin Hospital, NT
Dr Tammy KimptonGeneral Practitioner, Scone Medical Practice; Director, Australian Medical Council Limited, NSW

Triple therapy

Triple therapy for people 35 years and over

COPD guidelines recommend stepping up (or stepping down) therapy in response to symptoms and exacerbations.6 Triple therapy (ICS with LAMA and LABA) should be reserved for COPD patients with frequent exacerbations and with significant symptoms despite optimal dual therapy; and for those with co-existing asthma.6, 15

In many cases, ICS are less effective in COPD than in asthma because the type of underlying inflammation is different.16 Triple therapy also increases the risk of pneumonia in people with COPD.6, 17 The increase in pneumonia risk from using triple therapy compared to dual therapy with LABA with LAMA or single therapy with a LAMA is estimated at an additional 16 cases per 1,000 COPD patients with dyspnoea and/or exercise intolerance.18

Triple therapy used sooner in Australia than in other countries

An international study showed that Australian patients with COPD progressed to triple therapy faster, and were prescribed triple therapy as their initial maintenance therapy more often, than those in several European countries.19 The average time from initial COPD diagnosis to first prescription of triple therapy was 26 months in Australia, compared to 36, 46 and 61 months in France, Italy and the United Kingdom, respectively.19 Single inhaler triple therapy was not available at the time of the study, and hence earlier use of triple therapy was not influenced by the availability of combination triple therapy inhalers. 

Initial treatment with triple therapy may still follow guidelines if patients have severe COPD at diagnosis19, or co-existing asthma.15

  • Triple therapy (ICS with LAMA and LABA) dispensing increased nationally by 130% between 2015–16 and 2022–23
  • Triple therapy should be reserved for COPD patients with frequent exacerbations and with significant symptoms despite optimal dual therapy; and for those with co-existing asthma6, 15
  • The risks of triple therapy (particularly of pneumonia) outweigh the benefits in people with less severe symptoms of COPD6
  • Contributors to the increase may include:
    • Addition of triple therapy combination inhalers on the PBS from 201820, which increased affordability and convenience for patients
    • A possible increase in number of patients with exacerbations or with more severe disease at the time of diagnosis
    • Diagnostic uncertainty, or misdiagnosis, due to a lack of spirometry21, 22
    • Prescriber factors.16
  • Evidence from other countries suggests overuse of triple therapy in COPD, and measures to increase awareness of guidelines may be warranted to support appropriate prescribing.6, 23

The report examines Pharmaceutical Benefits Scheme (PBS) prescriptions dispensed for ICS with LAMA and LABA (via single or multiple inhalers) for people with COPD between 2015–16 and 2022–23 based on the number of prescriptions dispensed per 100,000 people aged 35 years and over. 

For more information about the data, see the data resources. 

The report presents trend data and visualisations for:

  • Australia and its states and territories
  • Remoteness and socioeconomic status levels.
  • Primary Health Networks (PHNs)
  • Local areas (SA3s).

Data were reported according to where patients live, not where the prescription was dispensed and were age and sex-standardised to allow comparisons between geographic areas with different age and sex structures.

The data were sourced from the PBS. Data quality issues – for example, prescriptions dispensed through the Remote Area Aboriginal Health Services Program – could influence the variation seen.

While this report focuses on prescriptions dispensed for ‘ICS with LAMA and LABA’, age and sex-standardised data for other examined COPD pharmacotherapy options, including single therapy with a LAMA or a LABA, dual therapy with a LAMA with LABA, and other inhaled steroid therapy with ICS or ICS with LABA are available in the dashboard and data files.

National trends 
  • The rate of triple therapy (ICS with LAMA and LABA) dispensing increased nationally by 130% between 2015–16 and 2022–23
  • In 2015–16, there were 353,102 prescriptions dispensed for triple therapy (2,501 per 100,000 people) while in 2022–23, there were 996,099 prescriptions dispensed (5,750 per 100,000 people)
  • In 2015–16, there was a ten-fold difference between the local area with the highest rate and the local area with the lowest rate, compared to an eleven-fold difference in 2022–23.
State and territory trends 
  • Rates of triple therapy dispensing increased in all states and territories
  • The largest increase was 175% in Queensland and the smallest increase was 113% in Victoria
  • The Northern Territory had the highest rate in 2015–16 (3,072 per 100,000 people) and Tasmania had the highest rate in 2022–23 (6,938 per 100,000 people)
  • The Australian Capital Territory had the lowest rate in 2015–16 (1,761 per 100,000 people) and in 2022–23 (4,829 per 100,000 people).
Remoteness
  • Rates of triple therapy dispensing were consistently lower in remote areas compared to major cities and regional areas.
Socioeconomic status
  • In 2022–23, rates of triple therapy dispensing were lower in areas of most socioeconomic disadvantage.
Primary Health Networks (PHNs)
  • Rates of triple therapy dispensing increased in all PHNs between 2015–16 and 2022–23
  • The largest increase was 252% in Northern Queensland PHN and the smallest increase was 67% in North Western Melbourne PHN
  • Western NSW PHN had the highest rate in 2015–16 (3,765 per 100,000 people) and in 2022–23 (8,846 per 100,000 people)
  • Northern Sydney PHN had the lowest rate in 2015–16 (1,271 per 100,000 people) and in 2022–23 (2,476 per 100,000 people).

Possible contributors to the increase in use of triple therapy include:

  • Addition of triple therapy combination inhalers on the PBS from 201820, which increased affordability and convenience for patients
  • Possible increase in number of patients with exacerbations or with more severe disease at the time of diagnosis10
  • Time-pressure in primary care12
  • Prescribers’ lack of awareness of current guidelines24
  • Assumption that if ICS are effective in asthma they will also be effective in COPD16
  • Perceived importance of ICS-responsive exacerbations in COPD is greater than it is in reality16
  • Uncertainty between asthma and COPD as the diagnosis, due to a lack of use or access to spirometry, and a choice of ICS to cover both21, or misdiagnosis as asthma due to a lack of spirometry22
  • Coexistence of COPD and asthma (actual or perceived)16
  • Lack of confidence in bronchodilators to prevent exacerbations16
  • Less obvious benefits of long-acting bronchodilators, which may be meaningful in the long term16
  • Downplaying the impact of ICS adverse effects, based on the low-moderate doses used in asthma.16

Is the increase appropriate?

Studies assessing the appropriateness of triple therapy prescribing in COPD in Australia are not available; however, based on studies from other countries it is likely that a proportion may be inappropriate.16 A large study from the United States found that 62% of COPD patients prescribed triple therapy did not meet the guidelines criteria of exacerbation history, and that patients using single inhaler triple therapy were less likely to meet prescribing guideline criteria than patients using multiple inhaler triple therapy.23 In addition, approximately 50–80% of COPD patients were prescribed ICS-containing pharmacotherapy – which is substantially higher than the proportion of COPD patients with frequent exacerbations (generally less than 30%), suggesting overuse.16

Approaches to supporting appropriate pharmacological management include:

  • Increase prescriber awareness of prescribing guidelines with multifaceted education programs that include audit and feedback6,25
  • Support consumers to ask about treatment options and to understand the risks and benefits of their medicines26
  • Develop multidisciplinary chronic disease teams with specialist respiratory nurses and physiotherapists working collaboratively with the oversight of respiratory specialists.12

Success Story

A two-pronged solution for COPD testing: respiratory hubs and mandatory spirometry in WA

A two-pronged solution for COPD testing: respiratory hubs and mandatory spirometry in WA

Limited access to a testing option that is free for patients meant that some patients with suspected COPD were unable to access spirometry.

Read more

About the data

The data on spirometry were sourced from the MBS database and were age and sex-standardised to allow comparisons between geographic areas with different age and sex structures. Data quality issues – for example, the reliability of services being billed to the MBS – could influence the variation seen.

Data were reported according to where patients live, not where the prescription was dispensed and were age and sex-standardised to allow comparisons between geographic areas with different age and sex structures.

The data were sourced from the PBS. Data quality issues – for example, prescriptions dispensed through the Remote Area Aboriginal Health Services Program – could influence the variation seen.

While this report focuses on prescriptions dispensed for ‘ICS with LAMA and LABA’, age and sex-standardised data for other examined COPD pharmacotherapy options, including single therapy with a LAMA or a LABA, dual therapy with a LAMA with LABA, and other inhaled steroid therapy with ICS or ICS with LABA are available in the dashboard and data files.

  • Spirometry data file
  • LAMA or LABA data file
  • LAMA with LABA data file
  • ICS or ICD with LABA data file
  • ICS with LAMA and LABA data file 

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  12. Personal communication from state/territory health department. 2025.
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  17. Miravitlles M, Auladell-Rispau A, Monteagudo M, Vazquez-Niebla JC, Mohammed J, Nunez A, et al. Systematic review on long-term adverse effects of inhaled corticosteroids in the treatment of COPD. Eur Respir Rev. 2021 Jun 30;30(160).
  18. Mammen MJ, Lloyd DR, Kumar S, Ahmed AS, Pai V, Kunadharaju R, et al. Triple Therapy versus Dual or Monotherapy with Long-Acting Bronchodilators for Chronic Obstructive Pulmonary Disease. A Systematic Review and Meta-analysis. Ann Am Thorac Soc. 2020 Oct;17(10):1308-1318.
  19. Quint JK, O'Leary C, Venerus A, Myland M, Holmgren U, Varghese P, et al. Prescribing Pathways to Triple Therapy: A Multi-Country, Retrospective Observational Study of Adult Patients with Chronic Obstructive Pulmonary Disease. Pulm Ther. 2020 Dec;6(2):333-350.
  20. Pharmaceutical Benefits Scheme. Schedule of Pharmaceutical Benefits - summary of changes effective 1 June 2018. Canberra: Australian Government Department of Health and Aged Care, 2018. https://www.pbs.gov.au/publication/schedule/2018/06/2018-06-01-general-soc.pdf (accessed May 2025).
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Last updated: 12 March 2026