Primary care patients with mild or stable chronic obstructive pulmonary disease need more support in disease management: a secondary analysis of a cluster randomized controlled trial.

OBJECTIVE: Patient education based on the patient's individual needs and circumstances is known to be associated with positive changes in clinical outcomes in chronic obstructive pulmonary disease (COPD). We aimed to assess the levels of patients' subjective needs for information about COPD before and after their general practitioners had taken part in a COPD education. DESIGN: A secondary analysis of a cluster randomized controlled trial. SETTING: 22 PHCCs in Stockholm, Sweden. SUBJECTS: Randomly selected primary care patients with COPD in GOLD stages 2 and 3 (n = 293). OUTCOME MEASURES: Scores in the Lung Information Needs Questionnaire (LINQ) at baseline and 18 months, spirometry results, and self-reported, descriptive patient data. RESULTS: GPs' improved skills in COPD did not affect patients' self-management skills over time. In general, patients' information needs remained great in issues concerning diet, exercise and self-management. However, 43% of the patients reported reduced and 57% increased or unchanged information needs, over time. Reduced information needs were mainly associated with a high level of information needs at baseline (OR = 3.17 [95% CI 1.93-5.23], p < .01) and establishing contact with a physiotherapist (OR = 2.26 [95% CI 1.05-4.86], p = .038). Patients in a mild or stable phase of COPD with no recent exacerbations reported greater needs than those with unstable, deteriorated COPD. CONCLUSION: Patients' information needs are substantial in most areas of self-management of COPD, and seem to covary with the patient's current clinical status. Care providers should thus continuously be vigilant about offering all patients with COPD support and education. TRIAL REGISTRATION: Clinicaltrials.gov, 10 August 2014, Identifier NCT02213809.

Self-management skills are fundamental for patients living with a chronic condition such as chronic obstructive pulmonary disease (COPD).Improvements in general practitioners' (GPs) levels of knowledge about COPD management were not transferred to improvements in patients' self-management skills.Patients' needs for support in COPD were substantial, and moreover, they were not constant over time: the longer from the latest exacerbation, the less continuity of care and the greater needs for renewed support.To help patients master self-management of COPD and be better prepared for future deteriorations, health professionals should start COPD patient education early and continue with it regularly, regardless of the current clinical stage of the patient.

Patient outcomes following GPs' educations about COPD: a cluster randomized controlled trial.

This study aimed to compare patient outcomes following case method learning and traditional lectures as methods for continuing medical education (CME) about chronic obstructive pulmonary disease (COPD) for general practitioners (GPs) in Sweden. In a pragmatic cluster randomized controlled trial, COPD patients (n = 425; case method group n = 209, traditional lectures group n = 216) from 24 primary health care centers replied to questionnaires prior to and 18 months after a 2 × 2-h CME was given to GPs (n = 255). We measured changes in the scores of the Clinical COPD Questionnaire (CCQ), symptoms, needs for disease information, exacerbations, smoking, and use of pulmonary rehabilitation. The changes over time were similar for both CME methods. Patients who had used pulmonary rehabilitation increased from 13.2 to 17.8% (P = 0.04), and prevalence of smoking decreased from 28.9 to 25.1% (P = 0.003). In conclusion, neither of the used CME methods was superior than the other regarding patient outcomes. CME's primary value may lay in improving GPs' adherence to guidelines, which should lead to long-term positive changes in patient health.

COPD patients need more information about self-management: a cross-sectional study in Swedish primary care.

Objective: In Sweden, patients with chronic conditions, such as chronic obstructive pulmonary disease (COPD), often receive education at specialized nurse-led clinics at primary health care centers (PHCCs). Identifying patients' needs for information about COPD is the key to individualized care. This study aimed to assess self-reported needs for information about COPD in primary care patients with either moderate (GOLD 2) or severe (GOLD 3) COPD and identify patient characteristics and exacerbation patterns associated with the findings.Design: A cross-sectional study.Setting: Twenty-four PHCCs in Stockholm, Sweden.Subjects: Randomly selected primary care patients with COPD in GOLD stages 2 and 3 (n = 542).Main outcome measures: The Lung Information Needs Questionnaire (LINQ) was used to assess perceived information needs. Spirometry results and descriptive, self-reported data on patient factors such as exacerbation history, treatment, smoking, weight/height, comorbidities, health care contacts, education and symptoms were collected.Results: Overall, the greatest reported needs were for information about self-management and diet. GOLD 2 patients (68%) expressed greater needs for information than GOLD 3 patients (32%). We found significant associations between high information needs and patient-related factors such as 'No assigned GP' (OR = 4.32 [95% CI 2.65-7.05]) and 'No contact with COPD nurse in the past 12 months' (OR = 1.83 [95% CI 1.19-2.81]).Conclusion: COPD patients felt they knew too little about self-management of their disease. Low information needs were strongly associated with continuity in patient-GP consultations and moderately associated with contact with a COPD nurse. These associations were strongest in patients with moderate COPD.Key points: As patients with COPD often have multimorbidity, identifying patients' needs for information about COPD is essential to providing individualized patient education and care. In this study of 542 patients from 24 Swedish primary care centers, we found that:Patients with COPD, particularly those with moderate airflow limitation (i.e. GOLD 2) felt they needed more information about COPD than currently provided by health care professionals in primary care.Low information needs were strongly associated with continuity in patient-GP consultations and moderately associated with contact with a COPD nurse. GPs' part in COPD patient education should not be overlooked, as individualized COPD care relies on GPs' expertise in managing patients with multimorbidity.

Feasibility of referral to a therapist for assessment of psychiatric problems in primary care - an interview study.

BACKGROUND: Depression and anxiety disorders are common in primary care. Comorbidities are frequent, and the diagnoses can be difficult. The Mini-International Neuropsychiatric Interview (MINI) can be a support in the clinical examination of patients with complex problems. However, for family practitioners (FPs), time and perceptions about structured interviews can be barriers to the MINI. An inter-professional teamwork process where FPs refer a patient to a therapist for a MINI assessment represents one way in which to address the problem. The results are fed back to the FPs for diagnosis and treatment decisions. The purposes of this study were to explore if the process was feasible for FPs, patients and therapists in Swedish primary care, and to identify factors influencing the process, using the COM-B model. METHODS: FPs at two primary care centers (PHCC) in Stockholm were offered the opportunity to refer patients to in-house therapists. Semi-structured interviews or focus groups were conducted with 22 patients, 17 FPs and three therapists to capture their experiences and perceptions. Inductive content analysis for each group of participants was followed by triangulation across groups. Finally, the categories obtained were fitted to the components in the COM-B. RESULTS: Therapists at both PHCCs conducted the MINI. The intended process was adopted at one PHCC. At the second PHCC, the responsibilities for the diagnosis and treatment of patients referred were transferred to the therapist. The patients were satisfied, as they appreciated multi-professional examinations. The FPs' competence in psychiatry, actual access to therapists, beliefs that the referrals saved the FPs time and effort, and established habits influenced whether patients were referred. Existing routines and professional expectations for work content influenced the degree of cooperation between the therapists and the FPs. CONCLUSIONS: An inter-professional diagnostic process where FPs refer patients to a therapist for assessment and the results are fed back to the FPs can be feasible. Feasibility depends on access to a therapist, the perceptions of roles and competences among FPs and therapists, and strategies for supporting teamwork.

Effectiveness of traditional lectures and case methods in Swedish general practitioners' continuing medical education about COPD: a cluster randomised controlled trial.

OBJECTIVES: To study the effects of continuing medical education (CME) about chronic obstructive pulmonary disease (COPD) for general practitioners (GPs) by comparing two commonly used CME methods with each other and no CME (reference group). DESIGN: A pragmatic cluster randomised controlled trial with primary healthcare centres (PHCCs) as units of randomisation. SETTING, PARTICIPANTS AND INTERVENTIONS: 24 PHCCs in Stockholm County, Sweden, were randomised into two CME intervention arms: case method learning (CM) (n=12) and traditional lectures (TL) (n=12). A reference group without CME (n=11) was recruited separately. GPs (n=255) participated in the study arm to which their PHCC was allocated: CM, n=87; TL, n=93; and reference, n=75. Two 2-hour CME seminars were given in a period of 3 months. PRIMARY OUTCOME MEASURES: Changes in scores between baseline and 12 months on a 13-item questionnaire about evidence-based COPD management (0-2 points/question, maximum total score 26 points). RESULTS: 133 (52%) GPs completed the questionnaire both at baseline and 12 months. Both CM and TL resulted in small yet significantly higher total scores at 12 months than at baseline (CM, 10.34 vs 11.44; TL, 10.21 vs 10.91; p<0.05); there were few significant differences between these CME methods. At both baseline and 12 months, all three groups' scores were generally high on questions about smoking cessation support and low on those that measured spirometry interpretation skills, interprofessional care and management of multimorbidity. CONCLUSIONS: Neither short CM nor short TL CME sessions substantially improve GPs' skills in managing COPD. It is justified to challenge the use of these common CME methods as a strategy for improving GPs' level of knowledge about management of COPD and other complex chronic diseases characterised by multimorbidity. TRIAL REGISTRATION NUMBER: NCT02213809; Results.

COPD management by Swedish general practitioners - baseline results of the PRIMAIR study.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is a common cause of suffering and death. Evidence-based management of COPD by general practitioners (GPs) is crucial for decreasing the impact of the disease. Efficient strategies include early diagnosis, smoking cessation and multimodal treatment. AIM: To describe knowledge about and skills for managing COPD in GPs in Sweden. METHODS: Prior to COPD education (the PRIMAIR Study), GPs at primary health care centers (PHCCs) in Stockholm replied to 13 written, patient-case based, multiple choice and free-text questions about COPD. Their knowledge and practical management skills were assessed by assigned points that were analyzed with non-parametric tests. RESULTS: Overall, 250 GPs at 34 PHCCs replied (89% response rate). Total mean score was 9.9 (maximum 26). Scores were highest on 'management of smoking cessation', 'follow-up after exacerbation' and 'diagnostic procedures'. Spirometry was used frequently, although interpretation skills were suboptimal. 'Management of maintenance therapy', 'management of multimorbidity' and 'interprofessional cooperation' had mediocre scores. Scores were unrelated to whether there was a nurse-led asthma/COPD clinic at the PHCC. CONCLUSIONS: Swedish GPs' knowledge of COPD and adherence to current guidelines seem insufficient. A nurse-led asthma/COPD clinic at the PHCC does not correlate with sufficient COPD skills in the GPs. The relevance of this study to participants' actual clinical practice and usefulness of easy-to-access clinical guides are interesting topics for future investigation. To identify problem areas, we suggest using questionnaires prior to educational interventions. Key Points General practitioners (GPs) play a crucial role in providing evidence-based care for patients with chronic obstructive pulmonary disease (COPD) who are treated in primary care. Swedish GPs' knowledge about COPD and adherence to current guidelines seem insufficient. Areas in greatest need of improvement are spirometry interpretation, management of maintenance therapy, management of multimorbidity in patients with COPD and interprofessional cooperation.

The Mini-International Neuropsychiatric Interview is useful and well accepted as part of the clinical assessment for depression and anxiety in primary care: a mixed-methods study.

BACKGROUND: Psychiatric complaints are common among primary care patients, with depression and anxiety being the most frequent. Diagnosis of anxiety and depression can be difficult, potentially leading to over- as well as under-diagnosis. The diagnostic process can be facilitated by incorporating structured interviews as part of the assessment. One such instrument, the Mini-International Neuropsychiatric Interview (MINI), has been established and accepted in psychiatric care. The purpose of this study was to explore the experiences and perceptions of the paper-and-pen version of MINI version 6.0 among patients and staff in primary care centers in Sweden. METHODS: The MINI was introduced at three primary care centers and was conducted by either therapists or general practitioners. Patients presented with symptoms that could suggest depression or anxiety disorders. The duration of the interview was recorded. The experiences and perceptions of 125 patients and their interviewers were collected using a structured questionnaire. Global satisfaction was measured with a visual-analog scale (0-100). Semi-structured interviews were conducted with 24 patients and three therapists, and focus groups were held with 17 general practitioners. Qualitative content analysis was used for the interviews and focus groups. The findings across the groups were triangulated with results from the questionnaires. RESULTS: The median global satisfaction with the MINI was 80 for patients and 86 for interviewers. General practitioners appreciated that the MINI identified comorbidities, as one-third of the patients had at least two psychiatric diagnoses. The MINI helped general practitioners attain a more accurate diagnosis. Patients appreciated that the MINI helped them recognize and verbalize their problems and did not find it intrusive. Patients and interviewers had mixed experiences with the yes-no format of the MINI, and the risk of subjective interpretations was acknowledged. Patients, general practitioners and therapists stated that the MINI contributed to appropriate treatment. The MINI assessment lasted 26 min on average (range 12 to 60 min). CONCLUSIONS: The paper-and-pen version of the MINI could be useful in primary care as part of the clinical assessment of patients with problems suggestive of depression or anxiety disorders. The MINI was well accepted by patients, general practitioners and therapists.

Case Method in COPD education for primary care physicians: study protocol for a cluster randomised controlled trial.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is a common cause of morbidity and mortality worldwide. It is often undiagnosed and insufficiently managed. Effective forms of continuing medical education (CME) for primary care physicians (PCPs) are necessary to ensure the implementation of guidelines in clinical practice and, thus, improve patients' health. METHODS: In this study, we will measure the effects of CME by Case Method and compare them against those of traditional lectures and no CME at all through an unblinded, cluster randomised controlled trial (CRCT). Thirty-three primary health care centres (PHCCs) in Stockholm, Sweden, with a total of 180 PCPs will be involved. Twenty-two primary PHCCs, will be cluster-randomised into: an intervention group who will receive CME by Case Method (n = 11) and a control group who will receive traditional lectures (n = 11). The remaining PHCCs (n = 11) will be a reference group and will receive no CME. From the intervention and control groups, 460 randomly selected patients with COPD in GOLD stages 2 and 3 will participate, while no patients will be recruited from the reference group. For the patients, smoking status, actual treatment and urgent visits to a health provider due to airway problems will be registered. For the PCPs, professional competence (i.e. knowledge and management skills) in COPD, will be measured using a questionnaire based on current guidelines and guideline implementation problems in clinical practice which has previously been described by the authors. Data will be collected at baseline and at follow-up, which will be after 1.5 years for the patients, and 1 year for the PCPs. Statistical methods for individual-level and cluster-level analyses will be used. DISCUSSION: COPD is considered a particularly complex clinical challenge involving managing multimorbidity, symptom adaptation, and lifestyle problematisation. Case Method in CME for PCPs may contribute to a better understanding of the impact of COPD on patients' lives and, thus, improve their management of it. The present study is expected to contribute scientific knowledge about indicators for an effective CME in COPD that is tailor-made to primary care physicians. TRIAL REGISTRATION: ClinicalTrials.gov, identifier: NCT02213809 . Registered on 10 August 2014. Protocol version: Issue date: May 2014.

Time pressured deprioritization of COPD in primary care: a qualitative study.

OBJECTIVE: To identify factors that hinder discussions regarding chronic obstructive pulmonary disease (COPD) between primary care physicians (PCPs) and their patients in Sweden. SETTING: Primary health care centres (PHCCs) in Stockholm, Sweden. SUBJECTS: A total of 59 PCPs. DESIGN: Semi-structured individual and focus-group interviews between 2012 and 2014. Data were analysed inspired by grounded theory methods (GTM). RESULTS: Time-pressured patient-doctor consultations lead to deprioritization of COPD. During unscheduled visits, deprioritization resulted from focusing only on acute health concerns, while during routine care visits, COPD was deprioritized in multi-morbid patients. The reasons PCPs gave for deprioritizing COPD are: "Not becoming aware of COPD", "Not becoming concerned due to clinical features", "Insufficient local routines for COPD care", "Negative personal attitudes and views about COPD", "Managing diagnoses one at a time", and "Perceiving a patient's motivation as low''. CONCLUSIONS: De-prioritization of COPD was discovered during PCP consultations and several factors were identified associated with time constraints and multi-morbidity. A holistic consultation approach is suggested, plus extended consultation time for multi-morbid patients, and better documentation and local routines. KEY POINTS: Under-diagnosis and insufficient management of chronic obstructive pulmonary disease (COPD) are common in primary health care. A patient-doctor consultation offers a key opportunity to identify and provide COPD care. Time pressure, due to either high number of patients or multi-morbidity, leads to omission or deprioritization of COPD during consultation. Deprioritization occurs due to lack of awareness, concern, and local routines, negative personal views, non-holistic consultation approach, and low patient motivation. Better local routines, extended consultation time, and a holistic approach are needed when managing multi-morbid patients with COPD.

Family physicians' experiences when collaborating with district nurses in home care-based medical treatment. A grounded theory study.

BACKGROUND: This article concerns Swedish family physicians' (FPs) experiences collaborating with district nurses (DNs) when the DNs provide medical treatment for home care patients. The aim was to develop a model to illuminate this process from the FPs' perspective. METHODS: Semi-structured interviews were conducted with 13 FPs concerning one of their patients with home care by a DN. The interview focused on one patient's treatment and care by different care providers and the collaboration among them. Grounded theory methodology (GTM) was used in the analyses. RESULTS: It was essential for FPs to collaborate with and rely on DNs in the medical treatment of home care patients. According to the FPs, factors such as the disease, FPs' working conditions and attitude determined how much of the initiative in this treatment FPs retained or left to DNs. Depending on the circumstances, two different roles were adopted by the individual FPs: medical conductors who retain the initiative and medical consultants who leave the initiative to DNs. Factors as the disease, DNs' attitudes towards collaboration and DNs' working conditions influenced whether or not the FPs felt that grounds for relying on DNs were satisfactory. Regardless of the role of the FP, conditions for medical treatment were judged by the FPs to be good enough when the grounds for relying on the DN were satisfactory and problematic when they were not. CONCLUSIONS: In the role of conductor, the FP will identify when the grounds for relying on the DN are unsatisfactory and be able to take action, but in the role of consultant the FP will not detect this, leaving home care patients without appropriate support. Only when there are satisfactory grounds for relying on the DN, will conditions for providing home care medical treatment be good enough when the FP adopts a consultative role.

Family physicians' effort to stay in charge of the medical treatment when patients have home care by district nurses. A grounded theory study.

BACKGROUND: District nurses (DNs) provide home care for old persons with a mixture of chronic diseases, symptoms and reduced functional ability. Family physicians (FPs) have been criticised for their lack of involvement in this care. The aim of this study was to obtain increased knowledge concerning the FP's experience of providing medical treatment for patients with home care provided by DNs by developing a theoretical model that elucidates how FPs handle the problems they encounter regarding the individual patients and their conditions. METHODS: Semi-structured interviews were conducted with 13 Swedish FPs concerning one of their registered patients with home care by a DN, and the treatment of this patient. Grounded theory methodology (GTM) was used in the analyses. RESULTS: The core category was the effort to stay in charge of the medical treatment. This involved three types of problems: gaining sufficient insight, making adequate decisions, and maintaining appropriate medical treatment. For three categories of patients, the FPs had problems staying in charge. Patients with reduced functional ability had problems providing information and maintaining treatment. Patients who were "fixed in their ways" did not provide information and did not comply with recommendations, and for patients with complex conditions, making adequate decisions could be problematic. To overcome the problems, four different strategies were used: relying on information from others, supporting close observation and follow-up by others, being constantly ready to change the goal of the treatment, and relying on others to provide treatment. CONCLUSION: The patients in this study differed from most other patients seen at the healthcare centre as the consultation with the patient could not provide the usual foundation for decisions concerning medical treatment. Information from and collaboration with the DN and other home care providers was essential for the FP's effort to stay in charge of the medical treatment. The complexity of the situation made it problematic for the FP to make adequate decisions about the goal of the medical treatment. The goal of the treatment had to be constantly evaluated based on information from the DN and other care providers, and thus this information was absolutely crucial.

The medical care of patients with primary care home nursing is complex and influenced by non-medical factors: a comprehensive retrospective study from a suburban area in Sweden.

BACKGROUND: The reduced number of hospital beds and an ageing population have resulted in growing demands for home nursing. We know very little about the comprehensive care of these patients. The objectives were to identify the care, in addition to primary health care, of patients with primary-care home nursing to give a comprehensive view of their care and to investigate how personal, social and functional factors influence the use of specialised medical care. METHODS: One-third (158) of all patients receiving primary-care home nursing in an area were sampled, and 73 % (116) were included. Their care from October 1995 until October 1996 was investigated by sending questionnaires to district nurses and home-help providers and by collecting retrospective data from primary-care records and official statistics. We used non-parametric statistical methods, i.e. medians and minimum - maximum, chi2, and the Mann-Whitney test, since the data were not normally distributed. Conditional logistic regression was used to study whether personal, social or functional factors influenced the chance (expressed as odds ratio) that study patients had made visits to or had received inpatient care from specialised medical care during the study year. RESULTS: 56 % of the patients had been hospitalised. 73 % had made outpatient visits to specialised medical care. The care took place at 14 different hospitals, and more than 22 specialities were involved, but local care predominated. Almost all patients visited doctors, usually in both primary and specialised medical care. Patients who saw doctors in specialised care had more help from all other categories of care. Patients who received help from their families made more visits to specialised medical care and patients with severe ADL dependence made fewer visits. CONCLUSIONS: The care of patients with primary-care home nursing is complex. Apart from home nursing, all patients also made outpatient visits to doctors, usually in both primary and specialised medical care. Many different caregivers and professions were involved. Reduced functional capacity decreased and help from family members increased the chance of having received outpatient specialised medical care. This raises questions concerning the medical care for patients with both medical and functional problems.

Care by general practitioners and district nurses of patients receiving home nursing: a study from suburban Stockholm.

OBJECTIVES: To review the care by general practitioners (GPs), district nurses and assistant nurses of patients receiving home nursing. DESIGN: Retrospective data from questionnaires, records and official statistics. Statistical comparisons. SETTING: Primary health care from October 1995 to October 1996. SUBJECTS: One-third (158) of all patients receiving home nursing in a suburban area were sampled; 73% (116) participated. All patients of comparable age in one practice served as a control group. MAIN OUTCOME MEASURES: Number of and reasons for visits and other contacts. Nature of care. Relation between patient problems and care given. RESULTS: Most patients were seen by the nurses two to five times a month. They met their GPs less often than other patients. More measures were undertaken without direct contact between GP and patient. The most common measures concerned medication and the assessment of symptoms. Patients with cognitive problems seemed to get less active GP care. CONCLUSION: GPs played an active role in the care of patients receiving home nursing even though they seldom met them. Many patients were regularly assessed by the nurses, which might have diminished the need for doctor visits. The care of patients with cognitive problems needs further study.