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

Abstract

Purpose

To explore the decision-making of general practitioners (GPs) concerning treatment with antibiotics and/or oral corticosteroids and hospitalization for COPD patients with exacerbations.

Methods

Thematic analysis of seven focus groups with 53 GPs from urban and rural areas in Norway, Germany, Wales, Poland, Russia, the Netherlands, and Hong Kong.

Results

Four 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.

Conclusion

Fear 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.

Keywords:

• COPD exacerbation
• antibiotics
• oral corticosteroids
• hospitalization
• primary care
• decision-making

Supplementary material

Patient stories

1. A 60-year-old male patient with moderate COPD has called your practice and asked for medicine, due to increased coughing and shortness of breath the last week. He quit smoking a year ago. You have prescribed anticholinergics for inhalation as maintenance medication. Now he thinks a course of antibiotics might be helpful. He was treated with amoxicillin and prednisolone last winter 9 months ago, and recovered after a few weeks.

2. A 70-year-old female patient, still smoking, visits your practice. She was hospitalized due to her COPD 1 year ago. She uses a combination of inhaled corticosteroids and long acting beta2 agonists, and short acting beta2 agonists on demand. She had a common cold a week ago. Now she has no fever, but breathes heavily and rather fast. She had to sit in her bed last night, and she feels somewhat exhausted. Although you hear wheezes all over her chest, you do not think the obstruction is very severe. You believe her illness is worsened by her anxiety, but consider admitting her to hospital.

Disclosure

The authors report no conflicts of interest in this work.