Enhancing COPD Management in Primary Care Settings

Jill A. Foster, MD, MPH; Barbara P. Yawn, MD, MS, MSc, FAAFP; Maziar Abdolrasulnia, PhD; Todd Jenkins, MPH; Stephen I. Rennard, MD, FCCP; Linda Casebeer, PhDs

Disclosures
In This Article

Results

A total of 943 physicians responded to the survey. For analysis, the sample was restricted to private and hospital-based primary care physicians currently engaged in direct patient care (N = 784). To determine the generalizability of results, demographic characteristics of respondents were compared to the AMA Physician Masterfile[24] and are presented in Table 1 . Although slight differences were noted in years since graduation, the overall sample was reasonably representative of US primary care physicians.

Respondents were engaged in family practice (54%), internal medicine (41%), and general practice (5%), with 20% practicing in rural settings. On average, physicians had 17 years of practice experience and estimated that 12% of their patients had COPD . Spirometry was available in 64% of the physicians' practices; however 34% of physicians with a practice spirometer indicated that it was not routinely used.

Confidence and Optimism

Using a 10-point Likert scale (1 = Not at all confident; 10 = Very confident) to assess confidence in detecting, diagnosing, and providing up-to-date COPD management, 32%, 38%, and 30% of respondents, respectively, expressed high confidence (score ≥ 8). Fewer physicians (15%) expressed high optimism (score ≥ 8) about effectively preventing and treating COPD with current interventions.

Guideline Awareness and Exposure to CME

Fewer than half of physicians (45%) reported being aware of either the GOLD or ATS/ERS guidelines for COPD diagnosis and management. Among physicians who were aware of COPD guidelines, fewer than half (46%) reported using them to guide clinical decision-making. Physicians were also asked to rate their exposure to COPD-focused CME within the past year using a 10-point scale (1 = far too little; 5 = just right; 10 = far too much). Recent CME exposure was considered insufficient (score ≤ 4) by 60% of physicians.

Barriers to Optimal Chronic Obstructive Pulmonary Disease Care

Primary care physicians rated nonadherence (46%) and low awareness of COPD symptoms (25%) as the most important patient-related barriers to optimal COPD care. The tendency of smokers to avoid medical care (16%) and the presence of competing comorbid conditions (13%) were also considered important barriers by significant minorities. When asked about the most important practice-related barriers, 39% of respondents selected low physician suspicion of COPD in patients with minimal symptoms, and 25% selected insufficient resources for patient education and self-management skill training. The complexity and inconvenience of spirometry testing and low reimbursement for COPD patient care were chosen by 19% and 17% of respondents, respectively.

Differences Among Primary Care Specialties

Because differences between the adult primary care specialties may affect COPD management, the practice characteristics and perceptions of internal medicine physicians and those of family and general practitioners were compared ( Table 2 ). Internal medicine physicians reported higher portions of patients with COPD in their practices (P < .01), were more frequently aware of COPD practice guidelines (P = .04), and had greater confidence in their ability to diagnose (P < .01) and manage COPD (P = .02). Internists also viewed impediments to optimal COPD care differently, expressing greater concern about low reimbursement and less concern about early recognition than family and general practice physicians (P = .01). No significant differences between the specialty groups were observed in access to spirometry or optimism about current COPD interventions.

Chronic Obstructive Pulmonary Disease Detection and Diagnosis

Two patient scenarios were created to assess physicians' approaches to the evaluation of cardinal COPD symptoms in high-risk patients. Selected responses categorized by practice specialty and guidelines awareness are summarized in Table 3 . For a 58-year-old current smoker with persistent dyspnea and normal chest radiograph, 91% indicated that spirometry was the test they would choose to further evaluate symptoms. Notably, 6% of physicians selected peak flow measurement to assess this patient's symptoms, and 2% would not perform any additional diagnostic studies.

A 61-year-old male who smokes cigarettes and has subtle respiratory symptoms as a secondary problem was also presented. When physicians were asked if they would order spirometry for this patient, 66% indicated that they would and were more likely to do so if they used COPD guidelines (P < .01), or routinely used a practice-based spirometer (75% vs 59%, P < .01). Among the 2 specialty groups, internists were significantly more likely to order spirometry (P < .01), a difference that remained significant after controlling for guideline use (P < .01).

Physicians were asked to make a diagnosis using history, physical examination, and information about forced expiratory volume in 1 second (FEV1) and FEV1/forced expiratory vital capacity (FVC) before and after bronchodilator administration. Eighty-eight percent of physicians interpreted the parameters as COPD and 65% diagnosed COPD and selected a stage consistent with GOLD classification.[9]

Chronic Obstructive Pulmonary Disease Management and Treatment

For the patient with subtle symptoms and spirometry-confirmed mild COPD, 20% of physicians elected not to treat further. When treatment was chosen, inhaled corticosteroids were preferred (32%), followed by a short-acting bronchodilator (24%), and a long-acting bronchodilator (23%). For a second patient with acute cough and dyspnea, most physicians chose to treat empirically using antibiotics with a short-acting bronchodilator (47%), without a bronchodilator (12%), or with a long-acting bronchodilator (9%), while 33% elected a chest radiograph to guide therapy. When this patient had persistent dyspnea, physicians who had initially chosen a short-acting bronchodilator had no clear preference in their choice of a long-acting bronchodilator (36%), combination short-acting beta-agonist/anticholinergic (33%), or an inhaled steroid (29%) as subsequent therapy. Within this subset, physicians who were COPD guideline users exhibited a distinct pattern, showing a significant preference for a long-acting bronchodilator rather than inhaled steroids (P < .01).

Smoking Intervention for Chronic Obstructive Pulmonary Disease

For a motivated patient with dyspnea, 91% of physicians indicated that they would provide detailed smoking cessation counseling and encourage establishment of a quit date. Consistent with the US Public Health Service's '5As' approach,[25] 77% would also arrange follow-up by their office staff, with higher rates observed among guideline-using physicians (P = .01). Referral to a local smoking cessation program would also be consistent with the 5As and was chosen by 5% of physicians.

Learning Preferences

CME activities and clinical practice guidelines were identified by 34% and 30% of physicians as the 2 most important resources to help them provide optimal patient care. Expert opinion and articles describing new trial findings were considered to be of lesser importance. Physicians were then asked which of several CME delivery methods was most important, considering convenience, efficiency, and personal learning style. Live activities were selected as the most important delivery mechanism by 39% of physicians, but many physicians also favored educational activities that were available on-line (26%) or as printed materials (20%). Physicians were most interested in having CME provide more practical strategies that were relevant for daily practice (41%) and content that was more patient-centered (28%).

Mapping

COPD mortality data plotted by county (Figure 1) revealed several areas with the highest quartile of rates, notably the Appalachian Mountain region, Maine, Nevada, and north-central Florida. Smaller clusters were also identified in areas such as the Ozark Mountain region of Missouri and Arkansas, central Wyoming, northern California, and southwestern Oregon. Pulmonology practices were most commonly located in urban areas, with fewer located in the aforementioned higher burden areas. Kentucky, West Virginia, and Tennessee were among the 10 states with the highest current smoking prevalence rates, corresponding to the Appalachian COPD cluster pattern with pulmonologist practice locations. Ten highest state-level current smoking rates in cross-hatching.

Figure 1.

Crude COPD mortality rates per 100,000 population by county (1999-2002).

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