Enhancing COPD management in primary care settings

Abstract

Context: Primary care physicians provide care for the majority of patients with mild-to-moderate chronic obstructive pulmonary disease (COPD). Although clinical practice guidelines have been developed for COPD, their influence on primary care practice is unclear.

Objective: To examine primary care decision making, perceptions, and educational needs relating to COPD.

Design: A survey centered on COPD case-vignettes was developed and distributed to a random sample of physicians in adult primary care specialties.

Results: From 943 respondents, 784 practicing primary care physicians were used in analysis. On average, physicians estimated that 12% of their patients had COPD. Although 55% of physicians were aware of major COPD guidelines, only 25% used them to guide decision-making. Self-identified guidelines showed that users were more likely to order spirometry for subtle respiratory symptoms (74% vs 63%, P < .01), to initiate therapy for mild symptoms (86% vs. 77%, P < .01), and to choose long-acting bronchodilators for persistent dyspnea (50% vs 32%, P < .01).

Conclusions: Practice guidelines and CME programs are both valued resources, but have not yet adequately reached many physicians. Because guidelines appear to influence clinical decision-making, efforts to disseminate them more broadly are needed. Future education should present COPD assessment algorithms tailored to primary care settings, assess and strengthen spirometry interpretation skills, and discuss a reasoned approach to medication management. Patient-centered content that accurately reflects the nature of primary care practice may enhance physician's learning experience. Internet-based and distance learning formats may be essential for reaching physicians in many high-need areas.

Figure 1

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