Practice Management and Chronic Obstructive Pulmonary Disease in Primary Care

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Abstract

The aim of this study was to observe how chronic obstructive pulmonary disease (COPD) is diagnosed and treated in primary care settings and to identify best practices. Researchers interviewed or visited physicians and staff at 25 primary care practices across the United States, focusing on small practices. All interviewers used a standard interview tool to capture anecdotal and quantitative data. It was discovered that primary care physicians underuse spirometry as a diagnostic tool, even when available in the office or clinic. Formal smoking-cessation programs are uncommon, as are outcomes measurements through clinical monitoring. Physicians reported not having enough time to improve performance, mainly owing to an average 15-minute patient visit allotment. Practice inefficiencies are responsible for many clinical shortcomings in COPD management. Although improving clinical understanding is important, it is equally important that overburdened and rushed primary care practices optimize workflow. This can be accomplished through better use of support staff and improved scheduling of spirometry testing in order to implement clinical guidelines without interfering with other essential practice tasks.

Section snippets

Methods

The research team included 10 practice-management experts and consultants, briefed on COPD and equipped with a standard discussion guide, who surveyed 25 practices in the United States about their management of patients with the disease. Measured by the number of full-time equivalents, practices had an average of 16 employees and <5 physicians. The study focused on smaller practices because they best reflect the most common mode of healthcare delivery in the United States (Table 1).2 In

Results

Of the 25 practices, 6 (24%) used spirometry for diagnosis, which is considered essential in managing respiratory disease.3 The remaining 19 (76%) practices, however, relied solely on smoking history, the nature of symptoms (chronic or episodic), and past diagnoses to differentiate COPD from asthma and other respiratory diseases. A total of 24% of the practices used spirometry after diagnosis to quantify the severity of disease. Physicians did not routinely measure outcomes suggested by

Possible Solutions

Even within the constraints of a 15-minute (or shorter4) patient visit, practices can make workflow alterations to improve patient care—that is, to diagnose and treat COPD according to clinical guidelines. Effective solutions are not related only to improving clinical knowledge; they are more practical than medical. Physicians must adjust their routines so that guidelines can be followed without disturbing patient flow. The study researchers recommend the following solutions based on medical

Summary

Primary care physicians struggle to address the logistic challenges presented by complex COPD care. Spirometry is an underused diagnostic tool for COPD in primary care, partly owing to a lack of clinical knowledge and to time and workflow constraints. Smoking cessation and outcome measurements receive limited attention in many primary care practices, usually because of time constraints, lack of reimbursement, and physician frustration. Specific changes in workflow, use of staff, and

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    Thus, we obtained some discordance between clinician diagnosis of COPD or chronic bronchitis at enrollment and post-bronchodilator spirometry at the study end. However, spirometry is still uncommonly used for the diagnosis of COPD in managed care plans in the US,18 and some inaccuracy of COPD diagnosis has been reported from studies utilizing post-bronchodilator pulmonary function testing.19,20 However, as the CASA-Q has been developed and validated in both patient groups, whether obstructed or not, this is not a limitation for assessing the responsiveness of the instrument.

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    The main reasons given for the failure to use spirometry were that spirometry is not necessary for the diagnosis of COPD or there are logistical limitations to the access of the patients to lung function laboratories. An US survey,27 which sought to identify management problems that constrain the ability of primary care physicians to better diagnose and manage COPD, documented that physicians do not believe that they have time to adequately assess the disease using spirometry; specifically, they feel that they have little or no chance to affect patients' smoking-cessation rates because of the rigid and compact schedule required of the modern medical practice. Another Italian study, which evaluated whether office spirometry by GPs is feasible and may improve the diagnosis of asthma and COPD,28 documented that a conventional evaluation of patients with symptoms of chronic airways obstruction including a detailed questionnaire and physical examination is not inferior to a conventional evaluation plus office spirometry, although a type II error cannot be excluded, since the enrolment of participating patients reached only about half of the goal determined by a priori sample size calculations.

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The original study and analysis presented here was funded by Boehringer Ingelheim and Pfizer Inc. Dr. Moore is an employee of Physicians Practice, which received an unrestricted educational grant from Boehringer Ingelheim and Pfizer Inc to create and conduct this study.

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