Management of COPD exacerbations in primary care: a clinical cohort study.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) exacerbations are associated with lung function decline, lower quality of life, and increased mortality, and can be prevented by pharmacological treatment and rehabilitation. AIMS: To examine management including examination, treatment, and planned follow-up of COPD exacerbation visits in primary care patients and to explore how measures and management at exacerbation visits are related to subsequent exacerbation risk. METHODS: A clinical population of 775 COPD patients was randomly selected from 56 Swedish primary healthcare centres. Data on patient characteristics and management of COPD exacerbations were obtained from medical record review and a patient questionnaire. In the study population of 458 patients with at least one exacerbation, Cox regression analyses estimated the risk of a subsequent exacerbation with adjustment for age and sex. RESULTS: During a follow-up period of 22 months, 238 patients (52%) had a second exacerbation. A considerable proportion of the patients were not examined and treated as recommended by guidelines. Patients with a scheduled extra visit to an asthma/COPD nurse following an exacerbation had a decreased risk of further exacerbations compared with patients with no extra follow-up other than regularly scheduled visits (adjusted hazard ratio 0.60 (95% confidence interval 0.37 to 0.99), p=0.045). CONCLUSIONS: Guidelines for examination and emergency treatment at COPD exacerbation visits are not well implemented. Scheduling an extra visit to an asthma/COPD nurse following a COPD exacerbation may be associated with a decreased risk of further exacerbations in primary care patients.

Communication and self-management education at nurse-led COPD clinics in primary health care.

OBJECTIVE: The aim of the study was to explore the structure, content in communication and self-management education in patients' first consultations at nurse-led chronic obstructive pulmonary disease (COPD) clinics in primary healthcare. METHOD: Thirty consultations performed by seven registered nurses were videotaped; structure and content in the consultation was analyzed using Pendleton's Consultation Map. Nurses' self-management education was assessed from the content of the conversation: whether important and relevant information and self-management education was given, and how investigations were performed. RESULTS: Each consultation lasted for a mean time of 37.53 min. Communication about reasons for consultations concerned mainly medical and physical problems and to a certain extent patients' perceptions. Teaching about self-management and smoking cessation was of an informative nature. Two consultations ended with shared understanding, and none of the patients received an individual treatment-plan. CONCLUSION: Nurses rarely planned the consultations on an individual basis and rarely used motivational dialogue in self-management education and in smoking cessation. PRACTICE IMPLICATIONS: The findings could be used to help nurses to reflect on how to improve the structure of the visit, self-management education, smoking cessation and patient communication.