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

Discussion

Primary care physicians manage the majority of individuals in the United States with COPD.[10] In many areas of the country where COPD mortality is high such as Nevada and the Appalachian Mountain region, access to pulmonary specialists is limited. Consequently, primary care physicians skilled in detecting, diagnosing, and treating COPD are essential to address this major public health problem. Although one third of primary care physicians surveyed in this study were highly confident, findings from this study point to a desire and need for additional training to improve COPD management skills. Physicians indicated that CME programs and clinical practice guidelines were the most important mechanisms for improving their patient care skills; however, the majority indicated that they'd had insufficient exposure to CME activities related to COPD. Awareness of GOLD guidelines among primary care physicians has increased from 46%in 2003[11] to 60% in 2006 and is encouraging but suggests that dissemination efforts must continue and improve.

The findings from this study found significant differences between family practitioners and internists that may be relevant to COPD programs design. Family physicians were more likely to consider their CME exposure inadequate and were less frequently aware of COPD guidelines. Perhaps related to limited educational opportunities, family physicians also expressed lower confidence in their ability to detect and care for patients with COPD. Family medicine residencies provide greater focus on ambulatory care compared to the more hospital-based internal medicine residencies that may also include more extensive training in pulmonary medicine and spirometry. The observed differences may also reflect a lack of CME programs to improve COPD care that are specifically tailored for family physicians.

Improving COPD detection. In day-to-day practice, manifestations of COPD may be not be readily apparent. Patients often minimize, ignore, and defer medical attention for early COPD.[7] Physicians in this study seemed aware of this problem and ranked low patient and physician awareness of COPD as leading impediments to optimal care, but still appeared to rely on overt respiratory complaints to recognize COPD. COPD detection may be further hindered by common co-morbidities resulting from long-term smoking, chronic inflammation, and functional decline which may have similar manifestations or may distract attention from respiratory symptoms. To address these problems, CME programs should address not isolated COPD, but COPD in the more complex context of the whole person. Teaching physicians how to elicit early indices of COPD through strategic interview questions or the use of questionnaires such as that developed by Price and colleagues[26] may further improve detection rates, particularly if reinforced by periodic public and health professional awareness campaigns.

Improving COPD diagnosis. A sizeable number of physicians responding to this survey currently use on-site spirometry to evaluate suspected COPD and express high confidence in their diagnostic abilities. For the majority of physicians, however, considerable obstacles to obtaining and interpreting spirometry exist, limiting their ability to reliably establish a COPD diagnosis.

One third of surveyed physicians indicated that they would not order spirometry for a middle-aged smoking patient with chronic sputum production, but not dyspnea. According to GOLD guidelines, spirometry is indicated for this patient; however, an Agency for Healthcare Research and Quality (AHRQ) report suggests that reserving spirometry for patients with overt dyspnea is more cost-effective.[27] Whether physicians would be more likely to order spirometry for overt dyspnea was not clearly determined by this study, but would be useful to better understand determinants of spirometry testing.

A small number of surveyed physicians chose peak flow measurement as an initial assessment of dyspnea, but actual use may be more common. Although peak flow meters currently have no defined role in COPD assessment, they are inexpensive and readily available in many primary care practices. Continued education about their appropriate use and limitations in evaluating respiratory symptoms may be useful.

To reliably diagnose COPD, primary care physicians should be skilled in ordering spirometry appropriately and interpreting the results. A complete spirometry report contains numerous parameters, however GOLD definitions of COPD center on post-bronchodilator FEV1 and FEV1/FVC measurements. Accordingly, we examined physicians' ability to interpret these measures and found that two thirds made a diagnosis consistent with GOLD staging classification. Unexpectedly, guideline use and practice spirometry use did not improve physician's diagnostic accuracy relative to this benchmark. In fact, those with on-site spirometry were somewhat more likely to interpret the given data as asthma or normal lung function. Although the spirometry data presented showed a bronchodilator response that was not significant by GOLD criteria, they did highlight the challenges of interpreting bronchodilator responsiveness among patients with suspected COPD. If complete pre- and post-bronchodilator spirometry data had been presented, as would occur in a standard report, it seems likely that physicians would have had greater difficulty identifying the underlying diagnosis.

Currently, spirometry training is not a standard component of medical school training.[28] As a result, CME may be an important mechanism for solidifying pulmonary diagnostic skills. Since several hours of training may be optimal, tiered programming may be useful. One level might focus on hand-on experiences and emphasize obstructive lung disease patterns since these are prevalent in primary care practices. Advanced offerings at a subsequent date that examined more complex spirometry patterns would further refine and update skills. To help ensure the quality of primary care spirometry, access to experts who could review testing would also be beneficial.

Improving treatment. Inhaled bronchodilators are the cornerstone of COPD management and can increase exercise capacity and improve health status when used regularly. Primary care physicians in this study exhibited highly varied treatment preferences. A striking finding was the common selection of inhaled corticosteroids for both suspected and spirometry confirmed COPD. GOLD guidelines recommend using these for patients with recurrent exacerbations or moderate COPD adjunct therapy to a long-acting bronchodilator. Yet, more than one fourth of surveyed physicians chose inhaled steroids in contexts that did not meet these criteria. This may represent confusion with asthma management paradigms.

Physicians in this study also seemed unclear about the appropriate role of long-acting bronchodilators. In GOLD, these agents are the preferred initial therapy for individuals with persistent dyspnea, yet, only 35% of physicians chose a long-acting bronchodilator when a short-acting agent had failed. A third of physicians also chose a combination short-acting bronchodilator. Although this therapy may be more effective than a single short-acting agent and may be slightly less expensive, comparison trials with long-acting bronchodilators are lacking and this combination does not have a defined place in the GOLD treatment hierarchy. Continued education about the appropriate use of inhaled steroids and the relative advantages of available bronchodilator options may be helpful.

Patient education and rehabilitation. Patients with COPD typically need education to help them adequately understand their disease and develop effective self-management skills. Similarly patients with any degree of activity-limiting dyspnea are likely to substantially benefit from pulmonary rehabilitation referral. This study did not examine how physicians approach these important aspects of care, but results indicate that many physicians perceived that resources to support these tasks were inadequate. Providing physicians with patient-directed tools or services that help overcome this significant resource gap may help improve care.

Educational program delivery. Physicians in this study showed greatest preference for live CME programs to enhance their professional development. This option is often convenient for both educators and physicians located in metropolitan areas, but may be much less accessible in many key regions with a high COPD burden. The high ratings that were also given to online activities suggest that COPD education programs delivered through Internet or other distance learning technologies may be an important mechanism for reaching many primary care physicians.

Study limitations. This study used a survey as a surrogate measure of primary care physicians' actual practice patterns in the out-patient setting. Survey methodology using case-vignettes is both cost and time efficient and has been shown to provide good insight into physicians' actual practice patterns. On the other hand, the stated focus on COPD may have constrained this survey's ability to accurately gauge perceptions and clinical decisions, particularly those relating to COPD diagnosis. Relevant factors such as patients' health insurance status and medication costs on physician choices, were beyond the scope of this study, but may be strong determinants of clinical choices that merit further evaluation. This study was cross-sectional in nature, and while associations such as the one observed between self-identified guideline use and the use of long-acting bronchodilators were found, longitudinal observations are needed to draw causal inferences.

Finally, the 2005 GOLD guideline, which was used as a benchmark for this survey, is an evolving document and contains definitions and recommendations that have sometimes sparked controversy. During active data collection for this study, an updated edition of the guidelines was published with significant changes to disease definitions and diagnostic recommendations. This context should be kept in mind when evaluating the clinical decision patterns observed in this study.

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