Chronic Obstructive Pulmonary Disease In General Practice Research Articles

Patients’ experiences with participating in a team-based person-centred intervention for patients at risk of or diagnosed with COPD in general practice

BackgroundSymptoms and complications of chronic obstructive pulmonary disease (COPD) can affect daily activities and quality of life, and patients with COPD require long-term follow-up by their general practitioner. Providing patients with or at risk of COPD practical skills and motivation to improve their self-management is important. On this background, an interdisciplinary follow-up program was designed based on the Guided Self-Determination counselling method to facilitate problem-solving and mutual decision-making between healthcare professionals and patients. The aim of the study was to explore patients and healthcare professionals` experiences with the Guided Self-Determination-program to investigate feasibility issues.MethodsA qualitative design was used to get insights in the experiences of receiving the Guided Self-Determination counselling program. In total, 13 patients with COPD (mean age 71.7 ± 7.7 years) 4 were current smokers, and 7 at risk of COPD (mean age 54.1 ± 9.9 years) all current smokers, received the Guided Self-Determination program. The researchers performed individual semi-structured telephone interviews after the 12 months Guided Self-Determination program with two patients at risk of COPD, four patients with COPD, three nurses, and five general practitioners. The intervention consisted of structured consultations with the nurse and patient in collaboration with the general practitioner at baseline and after 3, 6, and 12 months. The Guided Self-Determination method comprised facilitation of a mutual reflection process between the patient and the nurse to enhance self-management skills. Each consultation lasted for 60 min. The interviews were analysed using thematic analyses.ResultsTwo themes were identified: (1) A structured follow-up is challenging but motivating. (2) A counselling method that opens for conversation, but it requires resources.ConclusionsThe findings indicated that patients with or at risk of COPD experienced enhanced self-management skills after participating in a structured and systematic team-based follow-up in general practice with use of the Guided Self-Determination method. The regularity of the follow-up seemed to be important to succeed to help the patients making lifestyle changes to increase health benefits. However, the Guided Self-Determination method was experienced as time consuming among the general practitioners and nurses, and there are currently no available financial rates for this type of treatment in Norway which may be a barrier to further implementation.Trial registrationThe trial is registered in ClinicalTrials.gov (ID: NCT04076384).

One-minute sit-to-stand test as a quick functional test for people with COPD in general practice

Assessing changes in functional exercise capacity is highly relevant in the treatment of people with Chronic Obstructive Pulmonary Disease (COPD), as lung function is often static. In Denmark, most people with COPD are followed in general practice where traditional functional tests, like six-minute walk test, require too much time and space. Therefore, there is an urgent need for a quick functional exercise capacity test that can be performed in a limited setting, such as general practice. This study aimed to identify a quick test to measure functional exercise capacity in people with COPD and identify which factors could affect the implementation of such a test in general practice. A mixed method feasibility study composed of a literature review and qualitative interviews was used. Quick functional tests for people with COPD were identified and evaluated through the COSMIN methodology. For the interviews, 64 general practices were included, and 50 staff members and 14 general practitioners (GPs) participated in the interviews. Responses were categorized and thematically analyzed. The 1 min sit-to-stand-test (1 M STST) was found suitable for a general practice setting. The COSMIN methodology rated it “sufficient” in reliability (ICC 0.90–0.99), measurement error (MID 2.5–3), construct validity and responsiveness (AUC 0.72), and found a moderate to strong correlation in criterion validity (r = 0.4–0.75). Several GPs wished for a quick functional test and emphasized evidence, information, and limitations as essential when deciding on implementation. Other factors identified included time, other tests, and economy. 1 M STST is a valid test to assess functional exercise capacity in people with COPD. The test is quick and can easily be performed in a standard consultation, and several GPs wished for such a test.

Healthcare costs of patients with chronic obstructive pulmonary disease in Denmark \u2013 specialist care versus GP care only

BackgroundMany patients with chronic obstructive pulmonary disease (COPD) are treated in general practice only and have never received specialist care for COPD. They are seldom included in COPD cost studies but may account for a substantial proportion of the total costs.ObjectiveTo estimate and specify the total healthcare costs of patients who are treated for COPD in Denmark comparing those who have- and have not had specialist care for COPD.SettingDenmark, population 5.7 million citizens.MethodsVia national registers, we specified the total healthcare costs of all + 30-years-old current users of respiratory pharmaceuticals. We identified the patients with COPD and compared those with at least one episode of pulmonary specialist care to those with GP care only.ResultsAmong totally 329,428 users of respiratory drugs, we identified 46,084 with specialist-care- and 68,471 with GP-care-only COPD. GP-care-only accounted for 40% of the two populations’ total healthcare costs. The age- and gender-adjusted coefficient relating the individual total costs specialist-care versus GP-care-only was 2.19. The individual costs ranged widely and overlapped considerably (p25-75: specialist-care €2,175—€12,625, GP-care-only €1,110—€4,350). Hospital treatment accounted for most of the total cost (specialist-care 78%, GP-care-only 62%; coefficient 2.81), pharmaceuticals (specialist-care 16%, GP-care-only 27%; coefficient 1.28), and primary care costs (specialist-care 6%, GP-care-only 11%; coefficient 1.13). The total costs of primary care pulmonary specialists were negligible.ConclusionHealthcare policy makers should consider the substantial volume of patients who are treated for COPD in general practice only and do not appear in specialist statistics.

Caring for a patient with COPD in general practice

Catherine is an advanced nurse practitioner working in a large general practice in the north of England. She receives and treats patients with undifferentiated complaints and works alongside her medical colleagues. Today she is reviewing patients suffering from chronic disease. Paul is 58 years old. He suffers with severe Chronic Obstructive Pulmonary Disease (COPD) and lives with his wife Patricia and has two grown up daughters. He is an ex-smoker with a history of 40 pack years. He attends the clinic with his wife who is looking very anxious. In these times of global pandemic of the novel coronavirus he has already been tested for COVID-19 and found negative.

Breathlessness and opioid prescribing in COPD in general practice: a cross-sectional, observational study.

Chronic breathlessness is a disabling syndrome, prevalent in people with advanced chronic obstructive pulmonary disease (COPD). Regular, low-dose, oral sustained-release morphine is approved in Australia to reduce symptomatic chronic breathlessness. We aimed to determine the current prescribing patterns of opioids for chronic breathlessness in COPD in Australian general practice and to define any associated patient and practitioner characteristics.Five years (2011 to 2016) of the Bettering the Evaluation and Care of Health database, an Australian national, continual, cross-sectional study of clinical care in general practice were used. The database included 100 consecutive clinical encounters from almost 1000 general practitioners annually (n=488 100 encounters). Descriptive analyses with subsequent regression models were generated.Breathlessness as a patient-defined reason for encounter was identified in 621 of 4522 encounters where COPD was managed. Opioids were prescribed in 309 of 4522 encounters where COPD was managed (6.8%; (95% CI) 6.1–7.6), of which only 17 were prescribed for breathlessness, and the rest for other conditions almost entirely related to pain. Patient age (45–64 years versus age 80+ years, OR 1.68; 1.19–2.36), Commonwealth Concession Card holders (OR 1.70; 1.23–2.34) and socioeconomic disadvantage (OR 1.30; 1.01–1.68) were associated with increased likelihood of opioid prescription at COPD encounters. The rate of opioid prescriptions rose over the 5 years of study.In primary care encounters for COPD, opioids were prescribed in 6.8% of cases, but almost never for breathlessness. These data create a baseline against which to compare changes in prescribing as the treatment of chronic breathlessness evolves.

COPD patients prescribed inhaled corticosteroid in general practice: Based on disease characteristics according to guidelines?

In a primary care setting, our aim was to investigate characteristics of patients classified as having chronic obstructive pulmonary disease (COPD) and currently being prescribed inhaled corticosteroids (ICSs). The electronic patient record system in each participating general practice was searched for patients coded as COPD (ICPC, Second Edition code R95) and treated with ICS (ACT code R03AK and R03BA, that is, ICS in combination with a long-acting β2-agonist) or ICS as monotherapy. Data, if available, on demographics, smoking habits, spirometry, COPD medication, symptom score, blood eosinophils, co-morbidity and exacerbation history were retrieved from the medical records for all identified cases. Of all patients registered in the 138 participating general practices, 12.560 (3%) were coded as COPD, of whom 32% were prescribed ICS. The final study sample comprised 2.289 COPD patients currently prescribed ICS (98% also prescribed long-acting β2-agonist), with 24% being coded as both COPD and asthma. Post-bronchodilator spirometry was available in 79% (mean forced expiratory volume in 1 second 60% pred (standard deviation (SD) 23.3)), symptom severity score in 53% (mean Medical Research Council score 2.7 (SD 1.1)) and 56% of the COPD patients had had no exacerbation in the previous year (and 45% not within the 2 previous years). Blood eosinophils were measured in 67% of the patients. Information on severity of airflow limitation was missing in 15% of the patients, and the combined information on symptom severity and exacerbation history was missing in in 46%. Most of the patients (74%) were managed only by their general practitioner. Although only one-third of the COPD patients were prescribed ICSs, our findings from this study of a large cohort of patients prescribed ICSs for COPD in general practice suggest that more detailed assessment of diagnosis and disease characteristics is likely to improve the risk–benefit ratio of maintenance therapy with ICSs in COPD patients managed in primary care.

Identifying possible asthma\u2013COPD overlap syndrome in patients with a new diagnosis of COPD in primary care

The asthma–chronic obstructive pulmonary disease (COPD) overlap syndrome (ACOS) remains poorly characterised. Our aim was to describe an algorithm for identifying possible ACOS in adults with newly diagnosed COPD in primary care. General practitioners (n=241) consecutively recruited subjects ⩾35 years, with tobacco exposure, at least one respiratory symptom and no previous diagnosis of obstructive lung disease. Possible ACOS was defined as chronic airflow obstruction, i.e., post-bronchodilator (BD) forced expiratory volume 1/forced vital capacity (FEV1/FVC) ratio<0.70, combined with wheeze (ACOS wheeze) and/or significant BD reversibility (ACOS BD reversibility). Of 3,875 (50% females, mean age 57 years) subjects screened, 700 (18.1%) were diagnosed with COPD, i.e., symptom(s), tobacco exposure and chronic airflow obstruction. Indications for ACOS were found in 264 (38%) of the COPD patients. The prevalence of ACOS wheeze and ACOS BD reversibility was 27% (n=190) and 16% (n=113), respectively (P<0.001), and only 6% (n=39) of the COPD patients fulfilled both criteria for ACOS. Patients with any ACOS were younger (P=0.04), had more dyspnoea (P<0.001), lower FEV1%pred (67% vs. 74%; P<0.001) and lower FEV1/FVC ratio (P=0.001) compared with COPD-only patients. Comparing subjects fulfilling both criteria for ACOS with those fulfilling criteria for ACOS wheeze only (n=151) and those fulfilling criteria for ACOS BD reversibility only (n=74) revealed no significant differences. Irrespective of the applied ACOS definition, no significant difference in life-time tobacco exposure was found between ACOS- and COPD-only patients. In subjects with a new diagnosis of COPD, the prevalence of ACOS is high. When screening for COPD in general practice among patients with no previous diagnosis of obstructive lung disease, patients with possible ACOS may be identified by self-reported wheeze and/or BD reversibility.

Exacerbations and associated healthcare cost in patients with COPD in general practice

Acute exacerbations are a characteristic clinical expression of chronic obstructive pulmonary disease (COPD). The objective of this study was to investigate the occurrence rate, management, and healthcare costs of exacerbations in patients with COPD in Dutch general practice. Baseline data set from the COPD on Primary Care Treatment (COOPT) trial was used. Details on the occurrence and management of exacerbations were collected by systematic medical record review for the 2-year period preceding trial inclusion. The mean age of the 286 study subjects involved was 59.2 (SD 9.6) years, postbronchodilator FEV1 67.1% (SD 16.2) of predicted. Following ERS criteria, subjects suffered from: no (26%); mild (19%); moderate (40%); or severe (15%) airflow obstruction. The overall mean and median annual exacerbation rates were 0.88 (SD 0.79) and 0.5 (IQR 1.0), respectively. Exacerbation rate was not related to severity of airflow obstruction (p=0.628). Mean annual exacerbation costs per subject were 40 Euro, 53 Euro, 61 Euro and 92 Euro for the respective severity subgroups (p=0.012). The increase of costs in the more severe subgroups was mainly attributable to more physician consultations, diagnostic procedures, and prescription of reliever medication (e.g., bronchodilators, cough preparations). Occurrence of exacerbations did not depend on the severity of airflow obstruction, whereas the healthcare cost associated with exacerbations increased along with the severity of the disease.

The use of COPD maintenance therapy following spirometry in General Practice

BackgroundSeveral studies have shown that the use of pulmonary medication is widespread and often initiated without initial spirometry. Early detection of chronic obstructive pulmonary disease (COPD) by spirometry in General Practice is essential for an early and correct implementation of medical treatment.AimThe aim of the present study was to evaluate the use of regular therapy following diagnostic spirometry for COPD in General Practice from February 2008 to February 2009.MethodSpirometry data and results were linked through Statistics Denmark with information from the Register of Medicinal Product Statistics using the unique personal identification code. Data were analysed to evaluate the impact of screening on use of regular COPD therapy. Primary outcome was initiation of regular therapy following COPD diagnosis with spirometry.ResultsIn a population of 3,376 individuals at risk, 1,458 underwent spirometric assessment with 631 being diagnosed with COPD; 110 of those received regular therapy before assessment with this figure increasing to 161 after spirometry. Of 827 participants not receiving a COPD diagnosis, 36 received regular therapy prior to assessment and 42 received regular therapy after spirometry despite no established COPD diagnosis.ConclusionThere is a significant chance of receiving regular therapy after being diagnosed with COPD. However, a large proportion of subjects diagnosed with COPD did not receive regular therapy following diagnosis. Efforts should be made to ensure correct diagnosis and correct medical treatment according to guidelines in individuals with COPD.

Early detection of COPD in general practice: implementation, workload and socioeconomic status. A mixed methods observational study

Background:Chronic obstructive pulmonary disease (COPD) is underdiagnosed in general practice. Our aim was to implement a population-based approach for the early detection of COPD and to assess its impact on primary care workload and costs, and the influence of socioeconomic status (SES).Methods:An observational study with mixed methods was performed in 10 Dutch general practices of either low or moderate to high SES. The Respiratory Health Screening Questionnaire was posted during a three-month period to all persons aged 45, 55, and 65 years (one age group per month). The practices calculated the risk, and patients at high risk of COPD were invited for spirometry at the practice. The general practitioner used the spirometric results and a consultation to establish a clinical diagnosis. Qualitative and quantitative data on workload, cost, and barriers were evaluated.Results:Ten practices returned 293 (35.3%) COPD risk tests for the three age groups. Participants from low SES practices responded better than those from moderate to high SES practices (40.8% vs. 30.5%). In practices with low SES 17.9% of the tests indicated high risk compared with 16.1% in practices with moderate to high SES. Nine patients (23%) were newly diagnosed with COPD. The healthcare providers' extra workload averaged 18.5 hours during the three months for one standard practice. The average cost of this survey programme (three age groups in three months) was 荤520 for low SES practices and 荤398 for moderate to high SES practices. All healthcare providers affirmed that the extra workload in this survey model is acceptable and feasible when finances are compensated.Conclusions:Early detection of COPD is feasible in daily life primary care. In moderate to high SES practices the costs of detecting COPD were less than in low SES practices.

Early detection of COPD in general practice: patient or practice managed? A randomised controlled trial of two strategies in different socioeconomic environments

Background:The burden of chronic obstructive pulmonary disease (COPD) is high. Health benefits can be gained in primary care by early detection and preventive measures.Aims:To compare the effectiveness of two strategies for population-based early detection of COPD, taking into account different socioeconomic status (SES) settings.Methods:Practices were randomised on strategy and stratified on SES setting. The Respiratory Health Screening Questionnaire (RHSQ) was distributed to all participants. In the practice-managed condition, the practice was responsible for the whole procedure, while in the patient-managed condition, patients were responsible for calculating their RHSQ risk score and applying for a spirometry test. The main outcome measure was the rate of COPD diagnoses after screening.Results:More new COPD patients were detected in the practice-managed condition (36%) than in the patient-managed condition (18%). In low SES practices, more high-risk patients were found (16%) than in moderate-to-high SES practices (9%). Recalculated for a standard Dutch practice (2,350 patients), the yield would be 8.9 new COPD diagnoses, which is a 20% increase of known cases.Conclusions:The practice-managed variant of this screening procedure shows a substantial yield of new COPD diagnoses for both low and moderate-to-high SES practices.

Feasibility and impact of a computer-guided consultation on guideline-based management of COPD in general practice

Applying guidelines is a universal challenge that is often not met. Intelligent software systems that facilitate real-time management during a clinical interaction may offer a solution. To determine if the use of a computer-guided consultation that facilitates the National Institute for Health and Clinical Excellence-based chronic obstructive pulmonary disease (COPD) guidance and prompts clinical decision-making is feasible in primary care and to assess its impact on diagnosis and management in reviews of COPD patients. Practice nurses, one-third of whom had no specific respiratory training, undertook a computer-guided review in the usual consulting room setting using a laptop computer with the screen visible to them and to the patient. A total of 293 patients (mean (SD) age 69.7 (10.1) years, 163 (55.6%) male) with a diagnosis of COPD were randomly selected from GP databases in 16 practices and assessed. Of 236 patients who had spirometry, 45 (19%) did not have airflow obstruction and the guided clinical history changed the primary diagnosis from COPD in a further 24 patients. In the 191 patients with confirmed COPD, the consultations prompted management changes including 169 recommendations for altered prescribing of inhalers (addition or discontinuation, inhaler dose or device). In addition, 47% of the 55 current smokers were referred for smoking cessation support, 12 (6%) for oxygen assessment, and 47 (24%) for pulmonary rehabilitation. Computer-guided consultations are practicable in general practice. Primary care COPD databases were confirmed to contain a significant proportion of incorrectly assigned patients. They resulted in interventions and the rationalisation of prescribing in line with recommendations. Only in 22 (12%) of those fully assessed was no management change suggested. The introduction of a computer-guided consultation offers the prospect of comprehensive guideline quality management.

Effect of ethnicity on the prevalence, severity, and management of COPD in general practice

Chronic obstructive pulmonary disease (COPD) remains a major cause of mortality and hospital use. Little is known in the UK about the variation in COPD prevalence, severity, and management depending on ethnicity. To examine differences by ethnicity in COPD prevalence, severity, and management. Cross-sectional study using routinely collected computerised data from general practice in three east-London primary care trusts (Newham, Tower Hamlets, and City and Hackney) with multiethnic populations of people who are socially deprived. Routine demographic, clinical, and hospital admission data from 140 practices were collected. Crude COPD prevalence was 0.9%; the highest recorded rates were in the white population. Severity of COPD, measured by percentage-predicted forced expiratory volume in 1 second, did not vary by ethnicity. South Asians and black patients were less likely than white patients to have breathlessness, indicated by a Medical Research Council dyspnoea grade of ≥4 (odds ratio [OR] 0.7 [95% confidence interval (CI) = 0.6 to 0.9] and 0.6 [95% CI = 0.4 to 0.8]). Black patients were less likely than white patients to receive inhaled medications. Influenza and pneumococcal vaccine rates were highest among groups of South Asians (OR 3.0 [95% CI = 2.1 to 4.3] and 1.8 [95% CI = 1.4 to 2.3] respectively). Both minority ethnic groups had low referral rates to pulmonary rehabilitation. In Tower Hamlets, black patients were more likely to be admitted to hospital for respiratory causes. Differences in COPD prevalence and severity by ethnicity were identified, and significant differences in drug and non-drug management and hospital admissions observed. Systematic ethnicity recording in general practice is needed to be able to explore such differences and monitor inequalities in healthcare by ethnicity.

Municipality screening of citizens with suspicion of chronic obstructive pulmonary disease

Up to 436,000 adult Danes suffer from chronic obstructive pulmonary disease (COPD), with only one third diagnosed at this time. The Danish National Board of Health recommends early detection of COPD, focusing on smokers/ex-smokers over 35 years of age with at least one lung symptom. A governmental prevention committee has suggested that the municipalities, in addition to general practice, should be a potential arena responsible for early detection of COPD. We undertook a pilot study to investigate the feasibility and effectiveness of early detection of COPD in municipalities following the recommendations of the Danish National Board of Health.MethodsThe Municipality of Esbjerg offered spirometry to Danish citizens at risk of COPD without a previous diagnosis of the disease, following the National Board of Health’s recommendations. Citizens with evidence of airway obstruction (forced expiratory volume in one second [FEV1]/forced vital capacity [FVC] <70%) were advised to visit their general practitioner for diagnosis. These citizens were followed up by telephone interview 3 months later.ResultsOf 152 citizens sampled (50% females, mean age 58 years, 51% smokers) 51.3% had evidence of airway obstruction, with 87% being mild to moderate in terms of severity. Seven of ten citizens (71%) then visited their general practitioner, with 85% of these being diagnosed with COPD. The number of smokers embarking on smoking cessation or quitting smoking increased following COPD screening, with the highest frequency in participants with evidence of airway obstruction.ConclusionIn addition to early detection of COPD in general practice, early detection of airway obstruction in defined risk populations in Danish municipalities seems feasible and effective for identifying new patients with COPD. However, additional research is needed in larger samples to confirm the results of the present study.

Predictors of accuracy of diagnosis of chronic obstructive pulmonary disease in general practice

To compare the clinical diagnosis of chronic obstructive pulmonary disease (COPD) with results of post-bronchodilator spirometry in general practice, and examine practitioner, practice and patient characteristics associated with agreement between clinical and spirometric diagnoses. General practitioners from practices in Sydney identified eligible patients aged 40-80 years seen in the past year and prescribed respiratory medications whom they regarded as having COPD. Between November 2006 and April 2008, we collected information on the GPs and their practices, and demographic information, smoking status, comorbidities, respiratory medicines use, vaccination status, quality of life and spirometry results for participating patients. Frequency of COPD diagnosis on spirometry; odds ratios for characteristics associated with agreement between clinical and spirometric diagnoses. 56 GPs from 44 practices participated in the study. Of 1144 eligible patients, 445 were recruited (mean age, 65 years; 49% male). Of these, 257 (57.8%) had post-bronchodilator spirometry consistent with COPD ± asthma, 16 (3.6%) had asthma only, 82 (18.4%) had normal spirometry, and 90 (20.2%) had other spirometric diagnoses. Having a spirometer in the practice was not predictive of agreement between clinical and spirometric diagnoses. Older patient age was significantly associated with correct diagnosis, while higher numbers of comorbidities were associated with misdiagnosis. A substantial proportion of patients clinically identified as having COPD in general practice do not have the condition according to spirometric criteria, with inaccurate diagnosis more common in patients with comorbidities. Policy and practice change is needed to support the use of spirometry in primary care.

Trends in the epidemiology of chronic obstructive pulmonary disease in England: a national study of 51 804 patients.

Patients with chronic obstructive pulmonary disease (COPD) constitute a substantial burden to healthcare services. Analysis of national healthcare datasets offers the possibility to advance understanding about the changing epidemiology of COPD. To investigate the epidemiology of physician-diagnosed COPD in general practice. Cross-sectional study. A total of 422 general practices in England contributing to the QRESEARCH database. Data were extracted on 2.8 million patients, including age, sex, socioeconomic status, and geographical area. Trends over time for recorded physician diagnosis of COPD were analysed (2001-2005). There was little change over time in the incidence rate of COPD (2005: 2.0 per 1000 patient-years, 95% confidence interval [CI] = 2.0 to 2.1), but a significant increase in lifetime prevalence rate (2001: 13.5 per 1000 patients [95% CI = 13.4 to 13.7]; 2005: 16.8 [95% CI = 16.7 to 17.0]; P<0.001). In 2005, 51 804 individuals or one in 59 people in England were recorded with physician-diagnosed COPD. The most deprived people (31.1 per 1000 patients; 95% CI = 30.6 to 31.7) and those living in the north east of England (29.2 per 1000 patients; 95% CI = 28.4 to 30.1) had the highest prevalence. The observed reduction in the rate of smoking by patients with COPD (overall decrease: 2.5%; P<0.001) varied according to socioeconomic group (most affluent: 6.5% decrease, most deprived: 1.3% decrease). Given the peak in the incidence rate of COPD, we may be approaching the summit of COPD incidence and prevalence in England. However, the number of people affected remains high and poses a major challenge for health services, particularly those in the north east of the country and in the most deprived communities in England. The very limited decrease in smoking rates among the more deprived groups of patients with COPD is also a cause for concern.

Smoking cessation in patients with COPD in daily general practice (SMOCC): Six months' results

Background. Chronic Obstructive Pulmonary Disease (COPD) forms an increasing health problem. Despite smoking cessation improving the prognosis of the disease, many patients persist smoking. The present study presents the results of a smoking cessation counseling protocol in general practice (Smoking Cessation in patients with COPD in general practice (SMOCC)). Methods. A randomized controlled trial of patients with COPD compared smoking cessation counseling according to an intensified minimal intervention strategy with usual care. In total 43 general practices with 392 patients participated in Nijmegen, The Netherlands, in 2001-2002. Results. Significantly more smokers in the experimental group made a quit attempt (44.9% versus 36.5%) and actually quitted smoking than in the control group (16.0% versus 8.8%). The motivation to stop smoking at baseline was not associated with smoking cessation. Conclusion. The SMOCC strategy doubled the self-reported quit rates and was complied well by the general practitioners. Implementation in general practice is recommended.

Attaining a correct diagnosis of COPD in general practice

Chronic obstructive pulmonary disease (COPD) is common. Diagnosis should include objective evidence of airways obstruction and spirometry is recommended in guidelines and the general medical services contract in the UK. We assessed the impact of spirometry in general practice. We determined by questionnaire the availability, staff training, use and the interpretation results of spirometry in 72% of general practices in Wales. We reviewed the diagnosis of COPD previously made in two general practices without spirometry. Most practices had a spirometer (82.4%) and used it (85.6%). Confidence in use and interpretation of results varied widely: 58.1% were confident in use and 33.8% confident in interpretation. Spirometry was performed more often if confident in use and interpretation (both P<0.001) and was related to greater training periods (P<0.001). Spirometric confirmation of COPD varied widely (0-100%, median 37%). Of the 125 patients previously diagnosed with COPD 61 had spirometric confirmation, while 25 had reversible obstruction (range 210-800 mls), 34 had normal and 5 had restrictive spirometry. Despite incentives to perform spirometry in general practice, lack of adequate training in use and interpretation suggests use is confounded and the diagnosis of COPD is likely to be made on imprecise clinical grounds.

The influence of COPD on health-related quality of life independent of the influence of comorbidity

Background and objective The goal of this study was to determine the influence of chronic obstructive pulmonary disease (COPD) on health-related quality of life (HRQL) independent of comorbidity. Methods Patients with COPD in general practice, ⩾40 years, were selected. To recruit controls, a random sample of persons without COPD and ⩾40 years, was taken. HRQL was assessed with the SF-36 and comorbidity was determined by questionnaire. Results The influence of COPD on HRQL independent of comorbidity (represented by adjusted regression coefficients) was significant for physical functioning (−27.6), role functioning due to physical problems (−21.6), vitality (−14.4), and general health (−25.7), and was minor and not significant for social functioning (−5.6), mental health (−1.3), role functioning due to emotional problems (−2.7), and bodily pain (−2.5). Comorbidity contributed significantly to the HRQL of all domains (−7.6 to −27.1). Conclusion COPD patients can be impaired in all domains of HRQL. However, impairments in physical functioning, vitality, and general health are related to COPD and to some extent to comorbidity, while impairments in social and emotional functioning do not seem to be related to COPD, but only to comorbidity.

Guidelines for COPD: do they give answers to controversies of COPD management?

General Practice/Family Medicine (GP/FM) has an important role in the management of chronic obstructive pulmonary disease (COPD), which is receiving an increasing interest in primary care. A literature review was made with the aim of comparing the clinical practice guidelines for COPD with a relevance to GP/FM and exploring any potential sources of discrepancy among their recommendations. We searched the computerized database MEDLINE (PubMed) (from 1990 to 2001) using a combination of key words. Six leading journals (New England Journal of Medicine, Lancet, JAMA, BMJ, Thorax and Chest) were thoroughly searched manually. All clinical practice guidelines for COPD and research papers in relation to their dissemination or their implementation in General Practice, written in English, French or German were included in our review. Each paper was independently reviewed twice. The reviewers examined the guidelines and research papers for specific components regarding the management of COPD in GP. 24 articles fulfilled our review criteria. We found significant disagreement among clinical practice guidelines regarding the assessment of COPD. Furthermore, evidence based knowledge in GP, as this was reflected from the selected research papers, often contrasted with the recommendations. Key issues from these discrepancies are presented and discussed. Although interest in the management of COPD in primary care is on the increase, evidence based clinical practice guidelines for COPD in General Practice is still a neglected subject.