How do general practitioners implement decision-making regarding COPD patients with exacerbations? An international focus group study

Abstract

PurposeTo explore the decision-making of general practitioners (GPs) concerning treatment with antibiotics and/or oral corticosteroids and hospitalization for COPD patients with exacerbations.MethodsThematic analysis of seven focus groups with 53 GPs from urban and rural areas in Norway, Germany, Wales, Poland, Russia, the Netherlands, and Hong Kong.ResultsFour main themes were identified. 1) Dealing with medical uncertainty: the GPs aimed to make clear medical decisions and avoid unnecessary prescriptions and hospitalizations, yet this was challenged by uncertainty regarding the severity of the exacerbations and concerns about overlooking comorbidities. 2) Knowing the patient: contextual knowledge about the individual patient provided a supplementary framework to biomedical knowledge, allowing for more differentiated decision-making. 3) Balancing the patients’ perspective: the GPs considered patients’ experiential knowledge about their own body and illness as valuable in assisting their decision-making, yet felt that dealing with disagreements between their own and their patients’ perceptions concerning the need for treatment or hospitalization could be difficult. 4) Outpatient support and collaboration: both formal and informal caregivers and organizational aspects of the health systems influenced the decision-making, particularly in terms of mitigating potentially severe consequences of “wrong decisions” and concerning the negotiation of responsibilities.ConclusionFear of overlooking severe comorbidity and of further deteriorating symptoms emerged as a main driver of GPs’ management decisions. GPs consider a holistic understanding of illness and the patients’ own judgment crucial to making reasonable decisions under medical uncertainty. Moreover, GPs’ decisions depend on the availability and reliability of other formal and informal carers, and the health care systems’ organizational and cultural code of conduct. Strengthening the collaboration between GPs, other outpatient care facilities and the patients’ social network can ensure ongoing monitoring and prompt intervention if necessary and may help to improve primary care for COPD patients with exacerbations.

General practitioner strategies for managing patients with multimorbidity: a systematic review and thematic synthesis of qualitative research

“…Fourteen individual countries were represented across the 33 studies: Netherlands [48][49][50][51][52][53][54], England [55][56][57][58][59], Australia [60][61][62][63], Denmark [64][65][66][67], Norway [50,[67][68][69], Ireland [70][71][72], New Zealand [73][74][75], Canada [76,77], Wales [50,69], Sweden [67,78], Finland [67], Iceland [67], Portugal [79] and Scotland [80]. Together these studies included a total of 593 unique GP participants (range: 4-74 GPs).…”

Selected Aspects of Medical Care for Patients with Asthma and Chronic Obstructive Pulmonary Disease (COPD) in Poland

“…Although detailed diagnostics and cases of exacerbations require consultation with a respiratory specialist, GPs should be able to handle mild asthma cases with appropriate basic medical conduct [4]. This disparity between the requirements and reality may account for the occurrence of undiagnosed cases and the application of inappropriate treatment [1][2][3][4][5][6][7][8][9][10][11]13].…”

“…Although a wealth of literature exists which is devoted to this aim, the number of guidebooks and schools for patients and their families remains low [12]. There is limited evidence of effective training being provided for patients, or direct instruction being given by physicians: what little information is given seems to be minimally effective [13]. The knowledge possessed by the doctors and its regular updating, appear to be also imperfect [13].…”

“…There is limited evidence of effective training being provided for patients, or direct instruction being given by physicians: what little information is given seems to be minimally effective [13]. The knowledge possessed by the doctors and its regular updating, appear to be also imperfect [13]. Several such studies highlight the need for diligent and systematic training of the medical and paramedical personnel [2,3,6,13].…”

“…The knowledge possessed by the doctors and its regular updating, appear to be also imperfect [13]. Several such studies highlight the need for diligent and systematic training of the medical and paramedical personnel [2,3,6,13].…”