Improving general practitioners’ management of COPD : a challenge in Swedish primary health care

Abstract

Background and aim: General practitioners (GPs) who possess a high level of knowledge about chronic obstructive pulmonary disease (COPD) and good skills in managing COPD, other chronic conditions, and multimorbidity are prerequisites for optimal COPD care. However, there is a substantial discrepancy between COPD guidelines and practice. The general aims of this doctoral project were to describe the problem of underdiagnosis of COPD in Swedish primary care, explain reasons for underdiagnosis and deprioritization of COPD from a GP’s point of view, and investigate whether continuing medical education (CME) can improve GPs’ level of knowledge about and skills in managing COPD.

Material and methods: This mixed method implementation research project included four papers derived from three studies conducted in Stockholm County primary care. Study 1 (Paper I) was a quantitative, descriptive, epidemiological, targeted case-finding study. It used medical records and spirometry results from 138 patients diagnosed with respiratory tract infections in urgent primary care to determine the prevalence of undiagnosed COPD and factors associated with it. Study 2 (Paper II) was a qualitative study using grounded theory methods. It explored obstacles to bringing up COPD at patient-doctor consultations. Data were collected via focus group and individual interviews with 59 GPs. Study 3 resulted in two papers. Paper III presented the study protocol for the PRIMAIR study, a three-armed cluster-randomized controlled trial with two levels of outcomes (physicians, patients). Paper IV described the GP results of PRIMAIR. Twenty-four PHCCs were randomized into two CME intervention arms: case method learning (CM) (n=12) and traditional lectures (TL) (n=12). A reference group without CME (n=11) was recruited separately. GPs (n=255) participated in the study arm to which their PHCC was allocated: CM, n=87; TL, n=93; and reference, n=75. Two 2-hour CME sessions were given in a period of 3 months. GPs’ pre- and post-CME levels of knowledge were measured with a 13-item questionnaire (0-2 points per question, total maximum score 26 points).

Results: In Study 1, the prevalence of previously undiagnosed COPD in the 138 patients was 27% (95% CI ±7%); 44.7% were in stage 1 (mild, FEV1≥80% of predicted), 52.6% in stage 2, (moderate, 50%≤FEV1<80% of predicted), 2.6% in stage 3 (severe, 30%≤FEV1<50% of predicted), and 0% in stage 4 (very severe, FEV1 <30% of predicted). We observed a significant association between COPD and being ABSTRACT ≥55 years (OR = 10.9 [95% CI 3.8-30.1]) and between COPD and smoking intensity (>20 pack years) (OR = 3.2 [95% CI 1.2-8.5]). Sex, current smoking status, and type of infection were not significantly associated with COPD. Study 2 revealed that time-pressured patient-doctor consultations led to deprioritization of COPD. During unscheduled visits, deprioritization resulted from focusing only on acute health concerns, whereas during routine care visits, COPD was deprioritized in multimorbid patients. GPs’ reasons for deprioritizing COPD were: not becoming aware of COPD, not becoming concerned due to clinical features, insufficient local routines for COPD care, negative personal attitudes and views about COPD, managing diagnoses one at a time, and perceiving patient motivation as low. The study 3 protocol article (Paper III), presented in-depth information about disease knowledge (COPD), CME and pedagogical research, cluster statistics, and the plans for implementing PRIMAIR. In the paper on PRIMAIR’s GP outcomes (Paper IV), 133 GPs (52%) completed the questionnaire both at baseline and 12 months. Both pedagogical methods resulted in small yet significantly higher total questionnaire scores in level of COPD knowledge at 12 months: CM, 10.34 (baseline) vs. 11.44 (12 months); TL, 10.21 vs. 10.91 (p<0.05). There were few significant differences between the two CME methods. Both intervention arms had significantly better results than the reference group. At both baseline and 12 months, all three groups (CM, TL, reference group) had relatively high scores on questions about smoking cessation support and low scores on those that measured spirometry interpretation skills, interprofessional care, and management of multimorbidity.

Conclusion: It is crucial for GPs to identify patients at high risk of COPD and offer them spirometry testing to detect COPD early, as it may help motivate patients to quit smoking. To reduce the risk of deprioritizing COPD in patient-doctor consultations, we suggest that GPs actively apply a holistic consultation approach and that policy makers and PHCCs offer extended consultation time for multimorbid patients. It is difficult to improve the generally low levels of knowledge about COPD in GPs, at least via short CME sessions. For GPs, CME is career-long, cumulative experience, which makes it challenging to evaluate single CME interventions. More time for GPs’ work and professional development regarding management of patients with COPD, other chronic diseases, and multimorbidity is crucial to public health.