Atlas Focus Report: Chronic Obstructive Pulmonary Disease

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.^{3, 4} COPD was the fifth leading cause of death and the fifth leading cause of disease burden in Australia in 2023.^{5, 6} It is also associated with substantial numbers of potentially preventable hospitalisations and costs to the healthcare system.⁶ 

Tobacco smoking is the most common risk factor for COPD.⁷Other factors such as exposure to particles from occupational dusts and fumes, air pollution, early life factors and genetic factors also contribute to the disease.^{1, 7}

The prevalence of COPD in Australia remained steady between 2011–12 and 2022.⁸ Rates of COPD are:

• Higher in regional/remote areas than in major cities, with inequities in access to health care contributing to poorer outcomes
• Approximately three times higher in the most socioeconomically disadvantaged areas compared to the least socioeconomically disadvantaged areas.⁶

While geographic differences in prevalence could affect rates of spirometry and medicines use, variation seen in this report did not fully reflect population prevalence.

COPD and First Nations people

First Nations people are overrepresented in Australian COPD figures, and in areas with higher COPD rates:

• Regional and remote areas⁹
• Areas with most socioeconomic disadvantage.¹⁰

The links between socioeconomic circumstances, structural disadvantage and intergenerational experiences of colonialism and racism are well established.¹⁰ These factors underlie several major determinants of health, including health behaviours such as smoking.¹⁰ 

The identification of First Nations people was not sufficiently accurate in the data source to allow representation in this report.

The current approach to COPD diagnosis and management is based on recommendations mainly drawn from non-Indigenous populations.² Applicability cannot be assumed and further evidence on the diagnosis and management of COPD is needed for First Nations people in Australia.² Most studies of respiratory health in First Nations people in Australia have been conducted in the Northern Territory, which limits generalisability to First Nations people living elsewhere.¹¹

At a glance

• Spirometry rates decreased nationally by 31% between 2015–16 and 2022–23
• Office-based spirometry decreased by 68% nationally, and laboratory-based spirometry decreased by 7%, between 2015–16 and 2022–23
• Spirometry is essential for accurate diagnosis of COPD¹
• About 50% of people with COPD may not know they have it,⁴ 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 practice¹²
  • Ensuring COPD diagnoses in primary care are confirmed by spirometry, with interpretation by telemedicine if needed to increase access, particularly outside of major cities¹²
  • 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 people,¹² with no gap payment
  • Identifying local referral pathways for spirometry if this is not provided at the general practitioner (GP) practice¹²
  • Practice Incentives Program (PIP) Quality Improvement (QI) Incentive initiative¹²
  • Education programs to support the uptake of COPD-X guidelines, including diagnosis with spirometry¹²
  • Prompts in medical software packages and clinical-decision support systems¹²
  • Increased consumer awareness of the need for spirometry.¹³

What this report examines

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

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. 

The data 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.

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

What did we find?

National trends

• Spirometry rates decreased 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 decreased 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 decreased by 68% nationally, compared with a 7% reduction in laboratory-based spirometry, between 2015–16 and 2022–23
• Rates of office-based spirometry decreased 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 decreased 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).

Why is spirometry important?

Early diagnosis can improve outcomes

Early recognition and diagnosis of COPD is critical to allow appropriate management and to reduce lung function decline, exacerbations and healthcare costs.^{1, 14} 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).¹⁵ COPD cannot be diagnosed based on clinical features or chest X-ray alone.¹⁵

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
• Patients in the community or those hospitalised for a suspected COPD exacerbation who have a clinical diagnosis of COPD that has not previously been confirmed with spirometry or for whom results cannot be accessed.¹⁵

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.⁴ Undiagnosed COPD affects one-quarter of patients taking any inhaled therapies, according to an international study of primary healthcare settings.¹⁶ Misdiagnosis is also common: 25–50% of patients labelled as having COPD did not have evidence of post-bronchodilator airflow obstruction on spirometry.¹⁶

Why are spirometry rates low?

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.¹⁷

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).¹⁸

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

• Loss of spirometry skills during COVID restrictions¹⁶
• Costs associated with complying with infection prevention and control protocols¹⁶
• Fewer face to face appointments¹⁹
• Ongoing concerns about the potential spread of infectious diseases to healthcare workers and patients during spirometry.²⁰

In addition, spirometry performed in public health facilities may not be captured through the MBS database.¹⁸ In areas where people are accessing spirometry at a public health facility, rates of spirometry displayed in this report may be an underestimate.

What can be done?

Possible approaches to increasing the use of spirometry include:

• Review of remuneration levels and models for spirometry in general practice¹²
• Interpretation provided by telemedicine if needed to increase access, particularly outside of major cities¹²
• Multidisciplinary chronic disease teams with specialist respiratory physician oversight, equipment and skills in the performance of spirometry¹⁸
• 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 people,¹² with no gap payment
• Identifying local referral pathways for spirometry if this is not provided at the GP practice¹²
• Practice Incentives Program (PIP) Quality Improvement (QI) Incentive initiatives for PHNs¹²
• Education programs about the need for spirometry¹²
• Prompts in medical software packages and clinical-decision support systems¹²
• Increased consumer awareness of the need for spirometry.¹³

See the COPD Clinical Care Standard for further information for clinicians and health services on improving use of spirometry. 

At a glance

• 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 asthma^{1, 2}
• The risks of triple therapy (particularly of pneumonia) outweigh the benefits in people with less severe symptoms of COPD¹
• Contributors to the increase may include:
  • addition of triple therapy combination inhalers on the PBS from 2018,²¹ 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 diagnosis¹³
  • diagnostic uncertainty, or misdiagnosis, due to a lack of spirometry^{22, 23}
  • prescriber factors.²⁴
• 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.^{1, 25}

*Abbreviations: ICS – inhaled corticosteroids, LAMA – long-acting muscarinic antagonist; LABA – long-acting beta₂-agonist

What this report examines 

This 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. Rates are 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.

What did we find?

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).

Inhaled corticosteroid in COPD

COPD guidelines recommend stepping up (or stepping down) therapy in response to symptoms and exacerbations.¹ 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.^{1, 2}  

In many cases, ICS are less effective in COPD than in asthma because the type of underlying inflammation is different.²⁴ Triple therapy also increases the risk of pneumonia in people with COPD.^{1, 26} 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.²⁷

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.²⁸ 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.²⁸ 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 diagnosis,²⁸ or co-existing asthma.²

Why has ICS use increased?

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

• Addition of triple therapy combination inhalers on the PBS from 2018,²¹ which increased affordability and convenience for patients
• Possible increase in number of patients with exacerbations or with more severe disease at the time of diagnosis¹³
• Time-pressure in primary care¹⁸
• Prescribers’ lack of awareness of current guidelines²⁹
• Assumption that if ICS are effective in asthma they will also be effective in COPD²⁴
• Perceived importance of ICS-responsive exacerbations in COPD is greater than it is in reality²⁴
• 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 both²², or misdiagnosis as asthma due to a lack of spirometry²³
• Coexistence of COPD and asthma (actual or perceived)²⁴
• Lack of confidence in bronchodilators to prevent exacerbations²⁴
• Less obvious benefits of long-acting bronchodilators, which may be meaningful in the long term²⁴
• Downplaying the impact of ICS adverse effects, based on the low-moderate doses used in asthma.²⁴

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.²⁴ 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.²⁵ 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.²⁴

Approaches to supporting appropriate pharmacological management include:

• Increase prescriber awareness of prescribing guidelines with multifaceted education programs that include audit and feedback^1,30
• Support consumers to ask about treatment options and to understand the risks and benefits of their medicines³¹
• Develop multidisciplinary chronic disease teams with specialist respiratory nurses and physiotherapists working collaboratively with the oversight of respiratory specialists.¹⁸

Two champions coming at a problem from different perspectives have led to a local solution addressing the low rates of spirometry testing for diagnosing COPD.

The problem

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

• GPs didn’t have a clear diagnosis to guide treatment
• Respiratory specialists didn’t have the spirometry results that, together with symptom severity, they need to prioritise patients in greatest need of urgent outpatient review. 

Respiratory Care WA establishes paediatric respiratory hubs

Rael Rivers, Executive Manager of Strategic Programs at Respiratory Care WA, was well aware of the lack of lung testing services both from advocacy work for the non-profit organisation and as a mother of three children with severe asthma. 'We first established the respiratory diagnostic hubs as a paediatric service, and later expanded them to include adults with COPD,' Ms Rivers said. 

A combination of funding makes free testing viable

The expense of equipment, consumables and staff for spirometry testing means a combination of philanthropic donations to Respiratory Care WA and MBS funding is required to make the service free for patients. Since the first hub opened in Perth in 2020, another four hubs have been established in Perth and a regional hub in Bunbury. An outreach service to the outer South West region has also been introduced, but the distances involved mean many remote areas of WA are still underserved for spirometry, she said.

Lack of spirometry was a safety and quality issue

Frustrated with seeing patients referred for specialist care for COPD who hadn’t undergone spirometry, Dr Li Ping Chung was determined to make testing mandatory before outpatient clinic appointments. Dr Chung, head of the WA Respiratory Health Network and a respiratory consultant at the Fiona Stanley Hospital in Perth, said a WA Health initiative to prioritise and minimise waiting time for public hospital-based specialist appointments was a starting point for the requirement. Lack of spirometry results at the time of referral to confirm and assess for severity of COPD in primary care meant some patients with severe COPD were waiting longer than they should for appointments.

The diagnosis of COPD is mostly made in primary care, with national and global guidelines stating the need for spirometry as the diagnostic test. ‘Yet, the literature tells us spirometry is consistently under-utilised,’ said Dr Chung.  As head of the WA Respiratory Health Network, Dr Chung also relayed to WA Health that the lack of spirometry testing was a safety and quality issue for the majority of patients, who are mostly managed in primary care. ‘The Heads of Respiratory Departments from all tertiary hospitals, as well as other respiratory experts, unanimously agreed that spirometry should be included as a crucial test from GPs to encourage uptake of appropriate testing in primary care and to guide how we prioritise and manage these patients,’ she said.

‘You wouldn’t send someone to an endocrinologist for poorly controlled diabetes without confirmation of diagnosis by getting a fasting blood glucose or glycated haemoglobin done, and yet for all these years we’ve accepted that we’ll take patients with suspected COPD without having a spirometry as the recommended diagnostic test.’

Dr Li Ping Chung
Head of the WA Respiratory Health Network, Department of Health and Respiratory Consultant, Fiona Stanley Hospital, WA

The requirement of spirometry for diagnosis in the COPD Clinical Care Standard (the Standard), released in 2024, was another lever for action. ‘It’s the number one quality statement in the Standard, and if we allow patients to be referred to a specialist without the right diagnostic test, we are ignoring it rather than taking steps to encourage the use of spirometry in primary care.’ 

Distinguishing asthma from COPD in a patient with breathlessness, cough and wheezing isn’t possible without spirometry, says Dr Chung. For a patient with ongoing respiratory symptoms, having a spirometry test can mean the difference between getting effective treatment or not. While inhaled corticosteroids are an early treatment option in asthma, in COPD they should be reserved for patients with frequent exacerbations and persistent symptoms, partly due to the increased risk of pneumonia. 

Demand pushes the system to get ready

Initially the proposal to introduce mandatory spirometry testing for patients making appointments with respiratory outpatient clinics was met with concerns about a lack of available services to provide the testing. ‘But once the demand is there, you’re in a better position to make the system ready,’ says Dr Chung.

The added demand helped make the expansion of the respiratory hubs to include adults with COPD possible for Respiratory Care WA, Ms Rivers said.

‘If you don’t mandate it, people don’t see the need and they just carry on their usual way with COPD.  For most patients, this means being started on a treatment before the right test is done, potentially a treatment they don’t need.’

Dr Li Ping Chung

The data files contain information for each indicator over an eight-year period, and are reported at national, state and territory, Primary Health Network and local area levels.

The technical note describes the analysis performed on the data to produce the reported rates.

Atlas Focus Report: COPD - technical note

The data specifications describe the databases and data codes used to extract the raw data.

Spirometry data specification

Pharmacotherapy data specification

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: 

1.  Yang I, George J, McDonald C, McDonald V, Ordman R, Goodwin A, et al. The COPD-X plan: Australian and New Zealand guidelines for the management of chronic obstructive pulmonary disease 2024. Version 2.75. [Internet]. Brisbane: Lung Foundation Australia; 2024. https://copdx.org.au/copd-x-plan (accessed May 2025).
2. Yang IA, Hancock K, George J, McNamara R, McDonald CF, McDonald VM, et al. COPD-X Handbook: Summary clinical practice guidelines for the management of chronic obstructive pulmonary disease (COPD) Milton, Queensland: Lung Foundation Australia, 2024.
3. Toelle BG, Xuan W, Bird TE, Abramson MJ, Atkinson DN, Burton DL, et al. Respiratory symptoms and illness in older Australians: the Burden of Obstructive Lung Disease (BOLD) study. Med J Aust. 2013 Feb 18;198(3):144-148.
4. Petrie K, Toelle BG, Wood-Baker R, Maguire GP, James AL, Hunter M, et al. Undiagnosed and Misdiagnosed Chronic Obstructive Pulmonary Disease: Data from the BOLD Australia Study. Int J Chron Obstruct Pulmon Dis. 2021;16:467-475.
5. Australian Institute of Health and Welfare. Deaths in Australia [Internet]. Canberra: AIHW; 2025. https://www.aihw.gov.au/reports/life-expectancy-deaths/deaths-in-australia/contents/leading-causes-of-death (accessed May 2025).
6. Australian Institute of Health and Welfare. Chronic obstructive pulmonary disease [Internet]. AIHW, 2024. https://www.aihw.gov.au/reports/chronic-respiratory-conditions/copd (accessed May 2025).
7. Adeloye D, Song P, Zhu Y, Campbell H, Sheikh A, Rudan I, et al. Global, regional, and national prevalence of, and risk factors for, chronic obstructive pulmonary disease (COPD) in 2019: a systematic review and modelling analysis. Lancet Respir Med. 2022 May;10(5):447-458.
8. Australian Bureau of Statistics. Chronic Obstructive Pulmonary Disease [Internet]. Canberra: ABS; 2022. https://www.abs.gov.au/statistics/health/health-conditions-and-risks/chronic-obstructive-pulmonary-disease/latest-release (accessed May 2025).
9. Australian Institute of Health and Welfare. Rural and remote health [Internet]. Canberra, AIHW, Australian Government. 2024. https://www.aihw.gov.au/reports/rural-remote-australians/rural-and-remote-health (accessed May 2025).
10. Australian Institute of Health and Welfare and National Indigenous Australians Agency. Measure 2.09 Socioeconomic indexes, Aboriginal and Torres Strait Islander Health Performance Framework website [Internet]. Canberra: Australian Institute of Health and Welfare & National Indigenous Australians Agency, 2024. Available from: https://www.indigenoushpf.gov.au/measures/2-09-socioeconomic-indexes (accessed May 2025).
11. Howarth TP, Jersmann HPA, Majoni SW, Mo L, Saad HB, Ford LP, et al. The ‘ABC’ of respiratory disorders among adult Indigenous people: asthma, bronchiectasis and COPD among Aboriginal Australians – a systematic review. BMJ Open Respir Res 2023;10:e001738. doi:10.1136/bmjresp-2023-001738.
12. Lung Foundation Australia. Transforming the agenda for COPD: A path towards prevention and lifelong lung health - Lung Foundation Australia’s Blueprint for Action on Chronic Obstructive Pulmonary Disease (COPD) 2022-2025. Milton, Queensland: Lung Foundation Australia. 2022.
13. Atlas Focus Report COPD Topic Expert Group. 2025.
14. Larsson K, Janson C, Stallberg B, Lisspers K, Olsson P, Kostikas K, et al. Impact of COPD diagnosis timing on clinical and economic outcomes: the ARCTIC observational cohort study. Int J Chron Obstruct Pulmon Dis. 2019;14:995-1008.
15. Australian Commission on Safety and Quality in Health Care. Chronic Obstructive Pulmonary Disease Clinical Care Standard. Sydney: ACSQHC; 2024. https://www.safetyandquality.gov.au/standards/clinical-care-standards/chronic-obstructive-pulmonary-disease-clinical-care-standard.
16. Perret J, Yip SWS, Idrose NS, Hancock K, Abramson MJ, Dharmage SC, et al. Undiagnosed and 'overdiagnosed' COPD using postbronchodilator spirometry in primary healthcare settings: a systematic review and meta-analysis. BMJ Open Respir Res. 2023 Apr;10(1).
17. Lim R, Smith T, Usherwood T. Barriers to spirometry in Australian general practice: a systematic review. Australian Journal of General Practice 52(9): 585–93. 2023.
18. Personal communication from state/territory health department. 2025.
19. Australian Institute of Health and Welfare. General practice, allied health and other primary cares services. Canberra: AIHW, Australian Government, 2025. https://www.aihw.gov.au/reports/primary-health-care/general-practice-allied-health-primary-care (accessed May 2025).
20. Borg BM, Osadnik C, Adam K, Chapman DG, Farrow CE, Glavas V, et al. Pulmonary function testing during SARS-CoV-2: An ANZSRS/TSANZ position statement. Respirology. 2022 Sep;27(9):688-719.
21. 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).
22. Cataldo D, Derom E, Liistro G, Marchand E, Ninane V, Peche R, et al. Overuse of inhaled corticosteroids in COPD: five questions for withdrawal in daily practice. Int J Chron Obstruct Pulmon Dis. 2018;13:2089-2099.
23. Liang J, Abramson MJ, Zwar NA, Russell GM, Holland AE, Bonevski B, et al. Diagnosing COPD and supporting smoking cessation in general practice: evidence-practice gaps. Med J Aust. 2018 Jan 15;208(1):29-34.
24. Quint JK, Ariel A, Barnes PJ. Rational use of inhaled corticosteroids for the treatment of COPD. NPJ Prim Care Respir Med. 2023 Jul 24;33(1):27.
25. Bhatt SP, Blauer-Peterson C, Buysman EK, Bengtson LGS, Palli SR. Trends and Characteristics of Global Initiative for Chronic Obstructive Lung Disease Guidelines-Discordant Prescribing of Triple Therapy Among Patients with COPD. Chronic Obstr Pulm Dis. 2022 Apr 29;9(2):135-153.
26. 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).
27. 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.
28. 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.
29. Harrison A, Borg B, Thompson B, Hew M, E D. Inappropriate inhaled corticosteroid prescribing in chronic obstructive pulmonary disease patients. Intern Med J 2017;47(11):1310–1313. 2017.
30. Bernardes CM, Ratnasekera IU, Kwon JH, Somasundaram S, Mitchell G, Shahid S, et al. Contemporary Educational Interventions for General Practitioners (GPs) in Primary Care Settings in Australia: A Systematic Literature Review. Front Public Health. 2019;7:176.
31. Australian Commission on Safety and Quality in Health Care. Top tips for safer health care. Sydney: ACSQHC, 2020. https://www.safetyandquality.gov.au/our-work/partnering-consumers/top-tips-safe-health-care#top-tips-booklet (accessed June 2025).