A case scenario study for the assessment of physician’s behavior in the management of COPD: the WHY study

Abstract

PurposeCOPD diagnosis is mainly based on clinical judgment of physicians. Physicians do not also refer to COPD guidelines in their daily practice. This study aimed to assess attitudes of physicians regarding COPD diagnosis, treatment, and follow-up and to identify the factors influencing physicians’ decisions in clinical practice.Patients and methodsFifty physicians were selected from 12 EuroStat NUTS 2 regions and asked to assess seven fictitious case scenarios. The following five scenarios described patients with COPD: Case Global Initiative for Chronic Obstructive Lung Disease (GOLD) A-smoker and Case GOLD A-nonsmoker were previously undiagnosed patients presenting with dyspnea, Case GOLD D-smoker and GOLD B-exsmoker were COPD patients presenting with exacerbation, Case GOLD B-smoker was a previously diagnosed COPD patient with dyspnea in stable phase, Case asthma–COPD overlap syndrome, and Case obesity hypoventilation syndrome. Patients’ history, physical examination findings, pulmonary function tests, and X-ray images were prepared before the study by an experts’ committee and provided to the physicians upon their request, until they reached a final decision. The physicians completed a questionnaire including information about their clinical practices and institutions.ResultsAccording to the GOLD 2015 recommendations, of the physicians, 44% performed guideline-concordant diagnosis in the first five scenarios, who were all COPD patients, and 6% performed guideline-concordant diagnosis in all cases. There was a negative correlation between high workload and making a guideline-concordant diagnosis (P=0.038, rho =−0.417). Even when the physicians made a guideline-concordant diagnosis of COPD, only a minority (10%–22%) used the GOLD classification. Logistic regression analysis revealed that working in a tertiary health care center was a significant factor in favor of establishing a guideline-concordant diagnosis of COPD (P=0.029, OR =6.139 [95% CI: 1.20–31.32]).ConclusionManagement of COPD patients in Turkey does not generally follow the GOLD criteria but is rather based on physicians’ clinical experience. Heavy workload appears to adversely affect the correctness of clinical decisions.

A case scenario study on adherence to COPD GOLD recommendations by general practitioners in a rural area of southern Italy: The “progetto PADRE”

“…In line with the results reported by Kilinc and colleagues [39], the examination of prescriptions carried out by our GPs indicates that management of COPD patients in Valle Telesina does not generally follow the GOLD criteria but is rather based on physicians' clinical experience. This raises the suspicion that at least some of them have used empirically the treatable traits approach.…”

“…The great confusion generated by the continuous changes made to the GOLD recommendations, with the major shift represented by the exclusion of severity of airflow limitation as one of the major factors in guiding therapy, is the likely explanation of the difficulties encountered by GPs in prescribing therapies consistent with the algorithm proposed by GOLD strategy. Another possibility underlying the not consistency of COPD treatment with guidelines recommendations could be related to heavy workload of GPs as suggested by a recent Turkish investigation [39].…”