Programme no. 130-OP
Down-prioritizing of COPD when working under time pressure - a qualitative study in primary care in Sweden.
Hanna Sandelowsky*1, Sonja Modin2, Ingvar Krakau3, Björn Ställberg4, Anna Nager5
1Department of Neurobiology, Care Sciences and Society, Centre for Family Medicine,KAROLINSKA INSTITUTET,Huddinge,Sweden, 2Department of Neurobiology, Care Sciences and Society, Centre for Family Medicine,KAROLINSKA INSTITUTET,Huddinge,Sweden, 3Department of Neurobiology, Care Sciences and Society, Centre for Family Medicine,KAROLINSKA INSTITUTET,Huddinge,Sweden, 4Department of Public Health and Caring Sciences,UPPSALA UNIVERSITY,Uppsala,Sweden, 5Department of Neurobiology, Care Sciences and Society, Centre for Family Medicine,KAROLINSKA INSTITUTET,Huddinge,Sweden
* = Presenting author
Objectives: To describe factors that hinder discussions about COPD between primary care physicians (PCPs) and their patients in Sweden.
Background: Under-diagnosis and insufficient management of chronic obstructive pulmonary disease (COPD) is common in primary health care.
Results: Time pressure, due to many patients or multi-morbidity is the main background factor for ‘Prioritizing under time pressure’, the core category in a theoretical model describing the core process of ‘Down-prioritizing of COPD’ by PCPs, at a doctor-patient encounter. The main categories in the model are: ‘Not becoming aware of COPD’, ‘Not becoming concerned due to clinical features’, ‘Insufficient local routines for COPD care’, ‘Negative personal attitudes and values about COPD’, ‘Managing diagnoses one by one’ rather than in a holistic way and ‘Interpreting patient’s motivation as low’.
Material/Methods: Semi-structured individual- and focus group interviews with 59 primary care physicians in Stockholm, Sweden, were conducted during 2012-2014. Data were analysed using Grounded Theory method.
Conclusion: During a patient-doctor encounter, a PCP is constantly experiencing time constraints leading to down-prioritizing of COPD. Down-prioritizing occurs if COPD is not mentioned in the record or there is a lack of local routines. If the PCP manages the different diagnoses one by one rather than uses a holistic consultation technique, the importance of COPD in patients’ health is not recognized. Even if the patients seem unmotivated, PCPs should use a proactive approach for appropriate information and management of COPD.
Points for discussion:
Deeper understanding of the impact of COPD in patients' lives is needed for improving COPD management. It requires both PCP related (i.e. educational programmes) and policy maker related (i.e. optimizing working conditions) interventions. Point for discussion: 1) Paying attention to middle-aged patients, smokers, patients with respiratory infections, and by routinely using validated COPD specific questionnaires increases awareness of COPD. 2) Nurse-led COPD appointments at primary health care centres improve COPD care, not least due to increased level of guideline adherence by PCPs. 3) It is important to identify and discuss the PCP's possible negative attitudes towards COPD and smoking. 4) COPD with its many comorbidities has a multifold impact on both patient and their families. As not only the best current control of the disease but also future risk reduction are goals for optimal COPD care, COPD may be better managed by using a holistic consultation technique. 5) PCPs should not abdicate their role as a medical expert even though the patient might seem unmotivated: Letting the patient’s agenda alone determine the terms of the consultation may result in negative long-term consequences.