Unmet needs of people with end-stage chronic obstructive pulmonary disease: recommendations for change in Australia.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is an increasing cause of mortality. However, people with COPD are unlikely to receive care that meets the needs of themselves or their carers at the end of life. AIMS: To explore the needs of people with end-stage COPD in South Australia and develop recommendations for a model of care. METHODS: Three related studies were undertaken: in Study 1, 15 people with advanced COPD and their carers were interviewed twice, 6 months apart; Study 2 investigated views of an Expert Panel and Study 3 conducted focus groups and interviews with service providers and community groups to examine service availability and accessibility. RESULTS: This project demonstrated that the needs of people with COPD are not being met. There was an absence of a coordinated pathway for support. Care was fragmented, episodic and reactive. The role of carers was poorly recognised. Health professionals identified the lack of a clear transition to an end-stage and significant barriers to obtaining support for activities of daily living. Communication issues were identified in all studies, including the absence of advance care planning conversations. CONCLUSIONS: A flexible model of care is needed that assists people with COPD to navigate the health system. This should be patient centred and coordinated across primary, acute and community sectors. Neither respiratory nor palliative care services alone can adequately support people with COPD. The integration of a multidisciplinary palliative approach within a chronic disease management strategy will be central for the best care for people living with advanced COPD.

Assessing case records using monitor criteria developed from consensus guidelines.

OBJECTIVE: To develop criteria to enable the monitoring of general practitioner (GP) case records using consensus guidelines for conditions commonly managed in general practice and to measure how well the case records of a non random sample of GPs conformed to these criteria. METHOD: An iterative process was used to develop criteria from consensus guidelines for 19 conditions. Criteria were also developed to enable monitoring of the structure and content of the patient case record. A non random sample of GPs in Adelaide was approached to allow measurement of the content of their case records against these criteria. This measurement was undertaken by allied health professionals. An overall percentage score of conformity with the criteria was created for 10 acute, and six chronic conditions and for the patient case record review. These were rank ordered and Kendall's rank order correlation coefficients were used to compare the results in these three areas of practice. RESULTS: Criteria were successfully developed for each condition. Thirty-one GPs had their patient case records assessed. There was substantial variability between these practitioners in their conformity to the criteria. Kendall's rank order coefficients found statistically significant correlation between the results for acute and chronic conditions, and between acute conditions and the patient case record review section. CONCLUSION: It is feasible to develop criteria that enable measurement of the conformity of GP case records to these criteria. The overall level of conformity, together with the substantial variability found between practitioners suggest that there is a need for GPs to address this area of their practice.

Development of consensus guidelines for conditions commonly managed in general practice. Royal Australian College of General Practitioners.

OBJECTIVE: Initially, the project objective was to develop audit protocols for commonly managed conditions in general practice. However, as the nature of the project evolved these objectives changed to developing consensus guidelines. METHOD: An iterative process was undertaken using mail-outs to gain items for potential inclusion in an audit protocol. This resulted in a change of direction to management guidelines. Consensus, as to the validity of inclusion of items in each guideline, was then achieved by continuing to use an iterative process. RESULTS: Guidelines for 30 presenting complaints were developed. Because a number of differential diagnoses were possible for each complaint, a total of 105 guidelines were developed. A total of 263 general practitioners participated. CONCLUSION: The concept of discriminant actions was developed. It was agreed that this described the clinical decision making that occurs in the general practices of participating practitioners. It is feasible to use an iterative method undertaken by mail to develop consensus guidelines for conditions that are commonly managed by general practitioners.