TY - JOUR

T1 - How do general practitioners implement decision-making regarding COPD patients with exacerbations?

T2 - An international focus group study

AU - Laue, Johanna

AU - Melbye, Hasse

AU - Halvorsen, Peder A

AU - Andreeva, Elena A

AU - Godycki-Cwirko, Maciek

AU - Wollny, Anja

AU - Francis, Nick A

AU - Spigt, Mark

AU - Kung, Kenny

AU - Risør, Mette Bech

PY - 2016

Y1 - 2016

N2 - 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.

AB - 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.

KW - Administration, Oral

KW - Adrenal Cortex Hormones/administration & dosage

KW - Ambulatory Care

KW - Anti-Bacterial Agents/administration & dosage

KW - Attitude of Health Personnel

KW - Clinical Decision-Making

KW - Cooperative Behavior

KW - Cross-Cultural Comparison

KW - Delivery of Health Care, Integrated

KW - Disease Progression

KW - Europe

KW - Focus Groups

KW - General Practitioners/psychology

KW - Health Care Surveys

KW - Health Knowledge, Attitudes, Practice

KW - Hong Kong

KW - Hospitalization

KW - Humans

KW - International Cooperation

KW - Lung/drug effects

KW - Patient Participation

KW - Practice Patterns, Physicians'

KW - Pulmonary Disease, Chronic Obstructive/diagnosis

KW - Rural Health

KW - Severity of Illness Index

KW - Uncertainty

KW - Unnecessary Procedures

KW - Urban Health

U2 - 10.2147/COPD.S118856

DO - 10.2147/COPD.S118856

M3 - Journal article

C2 - 27994450

VL - 11

SP - 3109

EP - 3119

JO - International Journal of COPD

JF - International Journal of COPD

SN - 1176-9106

ER -