- Email: [email protected]
Knowledge of guidelines for the management of COPD: a survey of primary care physicians
ARTICLE IN PRESS Respiratory Medicine (2004) 98, 932–937
Knowledge of guidelines for the management of COPD: a survey of primary care physicians Olivier T. Rutschmanna,*, Jean-Paul Janssensb, Bernard Vermeulenc, Fran-cois P. Sarasina a
Emergency Medicine Unit, Department of Medicine, Geneva University Hospital, 24 rue Micheli-du-Crest, 1221 Geneva 14, Switzerland b Division of Lung Diseases, Department of Medicine, Geneva University Hospital, 24 rue Micheli-du-Crest, 1221 Geneva 14, Switzerland c Emergency Medicine Centre, Geneva University Hospital, 24 rue Micheli-du-Crest, 1221 Geneva 14, Switzerland Received 16 October 2003; accepted 22 March 2004
KEYWORDS COPD; Guidelines; Survey; GOLD; Compliance; Primary care physicians
Summary Objectives: To evaluate primary care physicians’ knowledge of guidelines for the management of COPD. Method: Survey to 455 primary care physicians in private practice in the state of Geneva, Switzerland, and to 243 physicians practicing in Geneva University Hospital. Results: Although 75% of respondents identified that the prevalence of COPD was increasing and 33% recognized it as a major public health issue, only 55% of physicians used spirometric criteria to define COPD, and one-third knew the correct GOLD criteria. Fifty-two percent felt uncomfortable with smoking cessation counselling. Sixty-two percent administered influenza vaccination annually and 29% had immunized their patients against Pneumococcus. Beta2-agonists were the first-line treatment for 89% of physicians, but 10% overestimated their clinical benefit. Twenty-five percent of respondents used systematically inhaled corticosteroids, but 46% ignored their indications. Oral corticosteroids were used by 42% of physicians outside of acute exacerbations. Seventy-nine percent thought that oral steroids had a beneficial effect on stable COPD. Finally, pulmonary rehabilitation was underused by 72% of physicians. Conclusions: This study shows major gaps in the knowledge of all core elements of guidelines for the management of COPD and identifies targets for future educational programs. & 2004 Elsevier Ltd. All rights reserved.
Introduction
*Corresponding author. Tel.: þ 41-22-372-8131; fax: þ 41-22372-8140. E-mail address: [email protected] (O.T. Rutschmann).
Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity, mortality and disability worldwide and represents a huge economical burden for the healthcare system.1,2 Major efforts have been made in order to produce evidence-based
0954-6111/$ - see front matter & 2004 Elsevier Ltd. All rights reserved. doi:10.1016/j.rmed.2004.03.018
ARTICLE IN PRESS Knowledge of COPD guidelines by primary care physicians
clinical practice guidelines to help physicians diagnose and manage patients with COPD.3–6 Although these guidelines are widely available, evidence suggests that COPD remains an underdiagnosed disease, especially in early stages, which can have a negative impact on the benefit of therapeutic interventions. In addition, patients hospitalised for COPD have a high incidence of modifiable risk factors suggesting unsatisfactory management.7 We aimed to explore the knowledge of primary care physicians about current guidelines for the management of COPD and to identify parameters that could benefit from educational interventions.
Methods Study design This is a prospective observational cross-sectional study using a mailed anonymous self-administered survey targeting primary care physicians in the state of Geneva, Switzerland. The questionnaire was designed in order to explore the most relevant items of current clinical recommendations. It was elaborated following the GOLD initiative8 and the Swiss Respiratory Society guidelines.9 The Swiss
Table 1
933
Respiratory Society guidelines follow strictly the GOLD guidelines and use the same criteria for assessment and treatment of patients with COPD. Survey questions focused on four core elements of the guidelines: (1) epidemiology and identification of risk factors for COPD, (2) diagnostic criteria and procedures, (3) patient education and preventive measures, (4) treatment knowledge and practice. It was developed and validated by two senior general internal medicine physicians and by one senior lung disease specialist. There were 39 multiple choice questions: 10 questions on epidemiology and preventive measures (prevalence, importance of the problem, risk factors, influenza and pneumococcal vaccines), six on diagnosis (role of spirometry, spirometric criteria to define and grade the severity of COPD), seven on physicians’ knowledge of the potential benefit of therapeutic interventions (benefit on symptoms, quality of life, life expectancy of bronchodilatators, steroids, rehabilitation, smoking cessation or oxygen), and 16 on physicians’ prescription habits (proportion of patients receiving specific treatments: short or long-acting bronchodilatators, steroids). The last section of the survey pertained to physician practice characteristics and educational background (solo vs. group practice, number of patients with COPD seen every month, access to spirometry, board certification (Table 1)).
Physician and practice characteristics. Private practice
Hospital practice
Totaln
49 (26%) 141 (74%)
52 (43%) 70 (57%)
101 (32%) 212 (68%)
50, 30–73
33, 25–57
45, 25–73
116 (62%) 27 (14%) 33 (18%) 12 (6%)
50 (42%) 31 (26%) 32 (28%) 5 (4%)
166 (54%) 58 (19%) 65 (21%) 17 (6%)
Type of practice Individual Group
110 (58%) 81 (42%)
NA NA
Board certification Community and family medicine General internal medicine None In training
44 (23%) 122 (64%) 24 (13%) NA
3 (2%) 48 (40%) NA 71 (58%)
47 (15%) 170 (54%)
Access to spirometry
88 (47%)
117 (96%)
205 (66%)
Demographic variable Sex Female Male Age (median, range) Number of patients with COPD seen every month 0–5 6–10 11–20 421–50
n
The total does not always sum up to 315 (total of responders) due to the omission of few questions by some physicians.
ARTICLE IN PRESS 934
O.T. Rutschmann et al.
The survey and a cover letter was mailed to 455 primary care physicians. These were identified through the local medical association (Geneva Medical Association) register. In our health care system and in the urban environment of Geneva three groups of physicians are identified as primary care physicians. First, board certified general internal medicine physicians have a 5-year training, in general, internal medicine and are the primary care physician of a majority of people living in the state of Geneva. Second, board certified community and family physicians follow a 5-year curriculum including at least 2 years of general internal medicine. Both board certifications are delivered by the Swiss Medical Association. Finally, a small proportion of primary care physicians work as general practitioners without board certification from the Swiss Medical Association but are accredited by the State Medical Association. The survey was also mailed to 243 residents, fellows and staff physicians practicing in the Departments of Internal Medicine, Community Medicine, and Geriatrics of Geneva University Hospital. This hospital is a 1110 beds primary and tertiary care teaching hospital. Non-responders were sent a second mailing 3 months after the first. A prepaid return envelope was included.
Data analysis Data were analysed using SPSS 11.0 (SPSS Inc., Chicago, IL).
Results After two mailings, 45% (315/698) of the questionnaires were returned. The response rate was Table 2
42% (193/455) for physicians in private practice, and 50% (122/243) among hospital practicing physicians. Physicians’ characteristics of both groups are summarized in Table 1.
Epidemiology and risk factors Seventy-five percent of the responders consider that the prevalence of COPD is increasing and onethird recognize that it is a major public health issue (COPD is currently the fourth cause of death worldwide and prevalence and mortality are projected to increase during the next decades). Unanimously (98%), physicians identify cigarette smoking as the most important risk factor for the disease.
Diagnostic procedures and criteria Although GOLD guidelines define spirometry as the gold standard for diagnosis, only 82% of respondents consider spirometry as the most appropriate test when a diagnosis of COPD is suspected (Table 2). In addition, only 55% use explicit spirometric criteria to define COPD and only one-third know the correct diagnostic criteria according to GOLD (FEV1/FVCo70%) (Table 2). When asked which spirometric threshold values should be used to define severe COPD, only 19% of respondents identify the correct criteria (FEV1o50%).
Patient education and preventive measures Although 92% of physicians regularly discuss smoking cessation with their patients, more than half (52%) feel uncomfortable with smoking cessation counselling. In addition, 22% do not recognize that
Diagnostic procedure and criteria used to define COPD.
First choice exam used by survey respondents in order to confirm a suspected diagnosis of COPD (% of respondents) Spirometry 82% Chest X-ray 3% Arterial blood gas 4% Physical exam 11% Diagnostic criteria used to define COPD (% of respondents) Clinical criteria only Spirometric criteria Knowledge of GOLD spirometric criteria Knowledge of GOLD criteria defining severe COPD
41% 55% 33% 19%
Chest X-ray Arterial blood gas
2% 2%
ARTICLE IN PRESS Knowledge of COPD guidelines by primary care physicians
smoking cessation has a favourable impact on life expectancy and on disease progression. Although influenza vaccine can reduce serious illness and death by about 50% in patients with COPD, only 62% of physicians administer influenza vaccination annually to their patients with moderate COPD and 71% to patients with severe COPD. Reported immunization rates against pneumococcal infections are 29% and 47% for patients with moderate and severe COPD, respectively.
Treatment practice and knowledge Short or long acting beta2-agonists bronchodilatators are the first-line treatment for 26% and 53% of physicians, respectively. Forty-one percent of respondents systematically combine beta2-agonists with anticholinergic agents when treating patients with severe COPD. Despite this wide use which is concordant with the guidelines, 18% of physicians ignore the benefit of bronchodilatators on quality of life and 10% overestimate their impact on life expectancy. Twenty-five percent of physicians prescribe inhaled corticosteroids systematically to their patients with severe COPD, but 46% ignore the accepted indications for their use (COPD patients with FEV1o50% and repeated exacerbations). In addition, 15% think that inhaled steroids have a positive impact on life expectancy which has never been demonstrated. Although long-term treatment with oral corticosteroids is not recommended in GOLD and may be harmful, they are used by 42% of the responders outside of acute exacerbations, and 79% of physicians estimate that oral steroids may have a beneficial effect on stable COPD. Finally, pulmonary rehabilitation is underused despite its benefits on exercise tolerance and symptoms of dyspnoea and fatigue. Seventy-two percent of respondents never refer their patients with moderate COPD to rehabilitation programs. For patients with severe COPD, rehabilitation is never used by 38% of the physicians.
Discussion This study reports primary care physicians’ knowledge of the core element of recent guidelines for the management of COPD and their self-reported practice with COPD patients. In spite of the wide dissemination of international and national guidelines, this survey suggests that primary care physicians practicing in the state of Geneva do
935
not know the core elements of these guidelines and that their clinical practice is not in agreement with current recommendations. Although physicians recognize the importance of the problem, most of them do not use the recommended preventive measures (immunization, smoking cessation counselling), feel uncomfortable with counselling, do not know the diagnostic criteria for COPD, and poorly recognize the indications and the benefits of the treatments they give to their patients. In particular, they clearly underuse rehabilitation programs and overuse oral steroids outside of acute exacerbations. There was no difference between general internal medicine and community and family medicine specialists, between physicians in private vs. hospital practice, or between boardcertified physicians vs. those in training. This lack of difference may be explained by very similar training and continuous medical education across physicians. The large majority of general internists and community physicians practicing in Geneva were educated in the same medical school and were residents in the same hospital (Geneva University Hospital). Similarly, continuous medical education rounds are usually organized and followed by both groups together. Although several studies have explored the impact of guidelines on clinical practice and the adherence of practitioners to these recommendations,10–12 only few have explored these aspects for patients suffering from COPD.13 Our study is in accordance with data collected from the 1996 National Ambulatory Care Survey (a survey of office-based visits in the United States) showing that patients with COPD do not receive optimal care,14 but adds clues as to why physicians do not use adequately recommended diagnostic and therapeutic interventions. It identifies gaps in physicians’ knowledge that are potential targets for future educational efforts. As with most surveys, the main weakness of this study is the generalizability and the reliability of physicians’ responses. They may be affected by various parameters. First, this is a self-reported survey. Although the questionnaire was anonymous, responders may be tempted to idealize their practice. A prospective chart review could be a better way to confirm the reported gaps between recommendations and current practice. Second, it is impossible to rule out selection bias and to know whether responders differ from non-responders. One may suggest that responders are more concerned about COPD care and that the survey underestimates the misknowledge of current guidelines. The response rate (45%) is in the lower range of what is expected for this type of survey.
ARTICLE IN PRESS 936
Different hypothesis may be formulated to explain this low response rate. Our questionnaire was pretty long and required about 15 min to be completed which was a major obstacle for the non-responders who expressed why they did not return the survey. In addition, physicians are not used in Switzerland to be surveyed about their clinical practice. Therefore, our questionnaire may have been perceived as too intrusive. Various factors may explain why adherence to clinical practice guidelines and management of COPD are still suboptimal.15 When questioned about the gap between guidelines and their clinical practice, physicians point out that guidelines are frequently formulated as state-of-the-art reviews without clear-cut recommendations. In addition, physicians may rely on their own interpretation of the medical literature, on recommendations of local colleagues and on their own experience.16 Physicians need simple, patient-specific and user-friendly guidelines, which is rarely the case.17 Finally, effective guidelines should be compatible with current values and not too controversial.18 This study provides a strong incentive for the development of tailored educational efforts in order to increase physician adherence to current clinical guidelines. As passive dissemination of information is generally ineffective in altering clinical practice, the educational strategy should include at least one of the following interventions (shown to be effective): educational outreach visits, combinations of audit and feedback, reminders, local consensus processes, and interactive educational meetings.19 These strategies fit with primary care physicians’ expectations for more education, both for them and their patients, and for increased availability of simplified and clearer guidelines.10 Our study also underscores the gap that may exist between guidelines dissemination and implementation. Guidelines are usually produced by experts after a thorough literature review and are disseminated through medical journals and educational rounds. Erroneously, guidelines conceivers may consider that implementation will follow dissemination. In fact, the development and publication of a guideline does not ensure by itself changes in practice patterns.20–22 Therefore, the next logical step should be to devise a systematic plan for implementation of these guidelines and the development of performance measures. GOLD guidelines were widely disseminated through different channels (web, medical journals, medical associations, patients associations). Similarly, the Swiss guidelines were mainly disseminated through
O.T. Rutschmann et al.
publication in the Journal of the Swiss Medical Association and in other local medical journals. These guidelines were also widely presented in local and national scientific meetings. Despite these efforts for dissemination, neither a plan for implementation nor performance measures were developed. In conclusion, despite widely disseminated evidence-based clinical practice guidelines, current knowledge of primary care physicians and outpatient medical management of patients with COPD remain suboptimal. The impact of educational programs on primary care practice should be evaluated, and performance measures should be implemented.
References 1. Mannino DM, Homa DM, Akinbami LJ, Ford ES, Redd SC. Chronic obstructive pulmonary disease surveillanceFUnited States, 1971–2000. Respir Care 2002;47:1184–99. 2. Mannino DM, Homa DM, Akinbami LJ, Ford ES, Redd SC. Chronic obstructive pulmonary disease surveillanceFUnited States, 1971–2000. Morbidity & Mortality Weekly Report. Surveillance Summaries 2002;51:1–16. 3. Celli BR. ATS standards for the optimal management of chronic obstructive pulmonary disease. Respirology 1997; 2:S1–4. 4. Bach PB, Brown C, Gelfand SE, McCrory DC. Management of acute excaerbations of chronic obstructive pulmonary disease: a summary and appraisal of published evidence. Ann Intern Med 2001;134:600–20. 5. Snow V, Lascher S, Mottur-Pilson C. Evidence base for management of acute exacerbations of chronic obstructive pulmonary disease. Ann Intern Med 2001;134:595–9. 6. Anonymous. BTS guidelines for the management of chronic obstructive pulmonary disease. The COPD guidelines group of the standards of care committee of the BTS. Thorax 1997; 52: S1–28. 7. Garcia-Aymerich J, Barreiro E, Farrero E, Marrades RM, Morera J, Anto JM. Patients hospitalized for COPD have a high prevalence of modifiable risk factors for exacerbation (EFRAM study). Eur Respir J 2001;16:1037–42. 8. Pauwels RA, Buist AS, Calverley PM, Jenkins CR, Hurd SS. The GOLD Scientific Committee: global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. Nhlbi/who global initiative for chronic obstructive lung disease (gold) workshop summary. Am J Respir Crit Care Med 2001;163:1256–76. 9. Russi EW, Leuenberger P, Brandli O, et al. Management of chronic obstructive pulmonary disease: the Swiss guidelines. Official guidelines of the Swiss Respiratory Society. Swiss Med Weekly 2002;132:67–78. 10. Jackson R, Feder G. Guidelines for clinical guidelines. BMJ 1998;317:427. 11. Hobbs FDR, Erhardt L. Acceptance of guideline recommendations and perceived implementation of coronary heart disease prevention among primary care phycisians in five European countries: the Reassessing European Attitudes about Cardiovascular Treatment (REACT) survey. Fam Pract 2002;19:596–604.
ARTICLE IN PRESS Knowledge of COPD guidelines by primary care physicians
12. Di Lorio D, Henley E, Doughty A. A survey of primary care physician practice patterns and adherence to acute low back problem guidelines. Arch Fam Med 2000;9:1015–21. 13. Phanareth K, Hansen LS, Christensen LK, Laursen LC, Hansen EF. Treatment of acute severe asthma and chronic obstructive pulmonary disease in Danish hospitals. Do national recommendations improve on the quality of the treatment? Respir Med 2002;96:653–8. 14. Ramsey SD. Suboptimal medical therapy in COPD. Exploring the causes and consequences. Chest 2000;117:33S–7S. 15. Greco PJ, Eisenberg JM. Changing physicians’ practices. N Engl J Med 1993;329:1271–3. 16. Kelly MG, Elborn JS. British Thoracic Society. Admissions with chronic obstructive pulmonary disease after publication of national guidelines. Irish J Med Sci 2002;171:16–9. 17. Lipman T. Discrepancies exist between general practitioners’ clinical work and a guidelines implementation programme. BMJ 1998;317:604.
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18. Fairhurst K, Huby G. From trial data to practical knowledge: qualitative study of how general practitioners have accessed and used evidence about statin drugs in their management of hypercholesterolaemia. BMJ 1998;317: 1130–4. 19. Kendrick T. Why can’t GPs follow guidelines on depression? We must question the basis of the guidelines themselves. BMJ 2000;320:200–1. 20. Lomas J. Words without action? The production, dissemination, and impact of consensus recommendations. Annu Rev Public Health 1991;12:41–65. 21. Worrall G, Chaulk P, Freake D. The effects of clinical practice guidelines on patient outcomes in primary care: a systematic review. CMAJ 1997;156:1705–12. 22. Cabana MD, Rand CS, Powe NR, et al. Why don’t physicians follow clinical practice guidelines? A framework for improvement. JAMA 1999;282(15):1458–65.
Knowledge of guidelines for the management of COPD: a survey of primary care physicians Olivier T. Rutschmanna,*, Jean-Paul Janssensb, Bernard Vermeulenc, Fran-cois P. Sarasina a
Emergency Medicine Unit, Department of Medicine, Geneva University Hospital, 24 rue Micheli-du-Crest, 1221 Geneva 14, Switzerland b Division of Lung Diseases, Department of Medicine, Geneva University Hospital, 24 rue Micheli-du-Crest, 1221 Geneva 14, Switzerland c Emergency Medicine Centre, Geneva University Hospital, 24 rue Micheli-du-Crest, 1221 Geneva 14, Switzerland Received 16 October 2003; accepted 22 March 2004
KEYWORDS COPD; Guidelines; Survey; GOLD; Compliance; Primary care physicians
Summary Objectives: To evaluate primary care physicians’ knowledge of guidelines for the management of COPD. Method: Survey to 455 primary care physicians in private practice in the state of Geneva, Switzerland, and to 243 physicians practicing in Geneva University Hospital. Results: Although 75% of respondents identified that the prevalence of COPD was increasing and 33% recognized it as a major public health issue, only 55% of physicians used spirometric criteria to define COPD, and one-third knew the correct GOLD criteria. Fifty-two percent felt uncomfortable with smoking cessation counselling. Sixty-two percent administered influenza vaccination annually and 29% had immunized their patients against Pneumococcus. Beta2-agonists were the first-line treatment for 89% of physicians, but 10% overestimated their clinical benefit. Twenty-five percent of respondents used systematically inhaled corticosteroids, but 46% ignored their indications. Oral corticosteroids were used by 42% of physicians outside of acute exacerbations. Seventy-nine percent thought that oral steroids had a beneficial effect on stable COPD. Finally, pulmonary rehabilitation was underused by 72% of physicians. Conclusions: This study shows major gaps in the knowledge of all core elements of guidelines for the management of COPD and identifies targets for future educational programs. & 2004 Elsevier Ltd. All rights reserved.
Introduction
*Corresponding author. Tel.: þ 41-22-372-8131; fax: þ 41-22372-8140. E-mail address: [email protected] (O.T. Rutschmann).
Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity, mortality and disability worldwide and represents a huge economical burden for the healthcare system.1,2 Major efforts have been made in order to produce evidence-based
0954-6111/$ - see front matter & 2004 Elsevier Ltd. All rights reserved. doi:10.1016/j.rmed.2004.03.018
ARTICLE IN PRESS Knowledge of COPD guidelines by primary care physicians
clinical practice guidelines to help physicians diagnose and manage patients with COPD.3–6 Although these guidelines are widely available, evidence suggests that COPD remains an underdiagnosed disease, especially in early stages, which can have a negative impact on the benefit of therapeutic interventions. In addition, patients hospitalised for COPD have a high incidence of modifiable risk factors suggesting unsatisfactory management.7 We aimed to explore the knowledge of primary care physicians about current guidelines for the management of COPD and to identify parameters that could benefit from educational interventions.
Methods Study design This is a prospective observational cross-sectional study using a mailed anonymous self-administered survey targeting primary care physicians in the state of Geneva, Switzerland. The questionnaire was designed in order to explore the most relevant items of current clinical recommendations. It was elaborated following the GOLD initiative8 and the Swiss Respiratory Society guidelines.9 The Swiss
Table 1
933
Respiratory Society guidelines follow strictly the GOLD guidelines and use the same criteria for assessment and treatment of patients with COPD. Survey questions focused on four core elements of the guidelines: (1) epidemiology and identification of risk factors for COPD, (2) diagnostic criteria and procedures, (3) patient education and preventive measures, (4) treatment knowledge and practice. It was developed and validated by two senior general internal medicine physicians and by one senior lung disease specialist. There were 39 multiple choice questions: 10 questions on epidemiology and preventive measures (prevalence, importance of the problem, risk factors, influenza and pneumococcal vaccines), six on diagnosis (role of spirometry, spirometric criteria to define and grade the severity of COPD), seven on physicians’ knowledge of the potential benefit of therapeutic interventions (benefit on symptoms, quality of life, life expectancy of bronchodilatators, steroids, rehabilitation, smoking cessation or oxygen), and 16 on physicians’ prescription habits (proportion of patients receiving specific treatments: short or long-acting bronchodilatators, steroids). The last section of the survey pertained to physician practice characteristics and educational background (solo vs. group practice, number of patients with COPD seen every month, access to spirometry, board certification (Table 1)).
Physician and practice characteristics. Private practice
Hospital practice
Totaln
49 (26%) 141 (74%)
52 (43%) 70 (57%)
101 (32%) 212 (68%)
50, 30–73
33, 25–57
45, 25–73
116 (62%) 27 (14%) 33 (18%) 12 (6%)
50 (42%) 31 (26%) 32 (28%) 5 (4%)
166 (54%) 58 (19%) 65 (21%) 17 (6%)
Type of practice Individual Group
110 (58%) 81 (42%)
NA NA
Board certification Community and family medicine General internal medicine None In training
44 (23%) 122 (64%) 24 (13%) NA
3 (2%) 48 (40%) NA 71 (58%)
47 (15%) 170 (54%)
Access to spirometry
88 (47%)
117 (96%)
205 (66%)
Demographic variable Sex Female Male Age (median, range) Number of patients with COPD seen every month 0–5 6–10 11–20 421–50
n
The total does not always sum up to 315 (total of responders) due to the omission of few questions by some physicians.
ARTICLE IN PRESS 934
O.T. Rutschmann et al.
The survey and a cover letter was mailed to 455 primary care physicians. These were identified through the local medical association (Geneva Medical Association) register. In our health care system and in the urban environment of Geneva three groups of physicians are identified as primary care physicians. First, board certified general internal medicine physicians have a 5-year training, in general, internal medicine and are the primary care physician of a majority of people living in the state of Geneva. Second, board certified community and family physicians follow a 5-year curriculum including at least 2 years of general internal medicine. Both board certifications are delivered by the Swiss Medical Association. Finally, a small proportion of primary care physicians work as general practitioners without board certification from the Swiss Medical Association but are accredited by the State Medical Association. The survey was also mailed to 243 residents, fellows and staff physicians practicing in the Departments of Internal Medicine, Community Medicine, and Geriatrics of Geneva University Hospital. This hospital is a 1110 beds primary and tertiary care teaching hospital. Non-responders were sent a second mailing 3 months after the first. A prepaid return envelope was included.
Data analysis Data were analysed using SPSS 11.0 (SPSS Inc., Chicago, IL).
Results After two mailings, 45% (315/698) of the questionnaires were returned. The response rate was Table 2
42% (193/455) for physicians in private practice, and 50% (122/243) among hospital practicing physicians. Physicians’ characteristics of both groups are summarized in Table 1.
Epidemiology and risk factors Seventy-five percent of the responders consider that the prevalence of COPD is increasing and onethird recognize that it is a major public health issue (COPD is currently the fourth cause of death worldwide and prevalence and mortality are projected to increase during the next decades). Unanimously (98%), physicians identify cigarette smoking as the most important risk factor for the disease.
Diagnostic procedures and criteria Although GOLD guidelines define spirometry as the gold standard for diagnosis, only 82% of respondents consider spirometry as the most appropriate test when a diagnosis of COPD is suspected (Table 2). In addition, only 55% use explicit spirometric criteria to define COPD and only one-third know the correct diagnostic criteria according to GOLD (FEV1/FVCo70%) (Table 2). When asked which spirometric threshold values should be used to define severe COPD, only 19% of respondents identify the correct criteria (FEV1o50%).
Patient education and preventive measures Although 92% of physicians regularly discuss smoking cessation with their patients, more than half (52%) feel uncomfortable with smoking cessation counselling. In addition, 22% do not recognize that
Diagnostic procedure and criteria used to define COPD.
First choice exam used by survey respondents in order to confirm a suspected diagnosis of COPD (% of respondents) Spirometry 82% Chest X-ray 3% Arterial blood gas 4% Physical exam 11% Diagnostic criteria used to define COPD (% of respondents) Clinical criteria only Spirometric criteria Knowledge of GOLD spirometric criteria Knowledge of GOLD criteria defining severe COPD
41% 55% 33% 19%
Chest X-ray Arterial blood gas
2% 2%
ARTICLE IN PRESS Knowledge of COPD guidelines by primary care physicians
smoking cessation has a favourable impact on life expectancy and on disease progression. Although influenza vaccine can reduce serious illness and death by about 50% in patients with COPD, only 62% of physicians administer influenza vaccination annually to their patients with moderate COPD and 71% to patients with severe COPD. Reported immunization rates against pneumococcal infections are 29% and 47% for patients with moderate and severe COPD, respectively.
Treatment practice and knowledge Short or long acting beta2-agonists bronchodilatators are the first-line treatment for 26% and 53% of physicians, respectively. Forty-one percent of respondents systematically combine beta2-agonists with anticholinergic agents when treating patients with severe COPD. Despite this wide use which is concordant with the guidelines, 18% of physicians ignore the benefit of bronchodilatators on quality of life and 10% overestimate their impact on life expectancy. Twenty-five percent of physicians prescribe inhaled corticosteroids systematically to their patients with severe COPD, but 46% ignore the accepted indications for their use (COPD patients with FEV1o50% and repeated exacerbations). In addition, 15% think that inhaled steroids have a positive impact on life expectancy which has never been demonstrated. Although long-term treatment with oral corticosteroids is not recommended in GOLD and may be harmful, they are used by 42% of the responders outside of acute exacerbations, and 79% of physicians estimate that oral steroids may have a beneficial effect on stable COPD. Finally, pulmonary rehabilitation is underused despite its benefits on exercise tolerance and symptoms of dyspnoea and fatigue. Seventy-two percent of respondents never refer their patients with moderate COPD to rehabilitation programs. For patients with severe COPD, rehabilitation is never used by 38% of the physicians.
Discussion This study reports primary care physicians’ knowledge of the core element of recent guidelines for the management of COPD and their self-reported practice with COPD patients. In spite of the wide dissemination of international and national guidelines, this survey suggests that primary care physicians practicing in the state of Geneva do
935
not know the core elements of these guidelines and that their clinical practice is not in agreement with current recommendations. Although physicians recognize the importance of the problem, most of them do not use the recommended preventive measures (immunization, smoking cessation counselling), feel uncomfortable with counselling, do not know the diagnostic criteria for COPD, and poorly recognize the indications and the benefits of the treatments they give to their patients. In particular, they clearly underuse rehabilitation programs and overuse oral steroids outside of acute exacerbations. There was no difference between general internal medicine and community and family medicine specialists, between physicians in private vs. hospital practice, or between boardcertified physicians vs. those in training. This lack of difference may be explained by very similar training and continuous medical education across physicians. The large majority of general internists and community physicians practicing in Geneva were educated in the same medical school and were residents in the same hospital (Geneva University Hospital). Similarly, continuous medical education rounds are usually organized and followed by both groups together. Although several studies have explored the impact of guidelines on clinical practice and the adherence of practitioners to these recommendations,10–12 only few have explored these aspects for patients suffering from COPD.13 Our study is in accordance with data collected from the 1996 National Ambulatory Care Survey (a survey of office-based visits in the United States) showing that patients with COPD do not receive optimal care,14 but adds clues as to why physicians do not use adequately recommended diagnostic and therapeutic interventions. It identifies gaps in physicians’ knowledge that are potential targets for future educational efforts. As with most surveys, the main weakness of this study is the generalizability and the reliability of physicians’ responses. They may be affected by various parameters. First, this is a self-reported survey. Although the questionnaire was anonymous, responders may be tempted to idealize their practice. A prospective chart review could be a better way to confirm the reported gaps between recommendations and current practice. Second, it is impossible to rule out selection bias and to know whether responders differ from non-responders. One may suggest that responders are more concerned about COPD care and that the survey underestimates the misknowledge of current guidelines. The response rate (45%) is in the lower range of what is expected for this type of survey.
ARTICLE IN PRESS 936
Different hypothesis may be formulated to explain this low response rate. Our questionnaire was pretty long and required about 15 min to be completed which was a major obstacle for the non-responders who expressed why they did not return the survey. In addition, physicians are not used in Switzerland to be surveyed about their clinical practice. Therefore, our questionnaire may have been perceived as too intrusive. Various factors may explain why adherence to clinical practice guidelines and management of COPD are still suboptimal.15 When questioned about the gap between guidelines and their clinical practice, physicians point out that guidelines are frequently formulated as state-of-the-art reviews without clear-cut recommendations. In addition, physicians may rely on their own interpretation of the medical literature, on recommendations of local colleagues and on their own experience.16 Physicians need simple, patient-specific and user-friendly guidelines, which is rarely the case.17 Finally, effective guidelines should be compatible with current values and not too controversial.18 This study provides a strong incentive for the development of tailored educational efforts in order to increase physician adherence to current clinical guidelines. As passive dissemination of information is generally ineffective in altering clinical practice, the educational strategy should include at least one of the following interventions (shown to be effective): educational outreach visits, combinations of audit and feedback, reminders, local consensus processes, and interactive educational meetings.19 These strategies fit with primary care physicians’ expectations for more education, both for them and their patients, and for increased availability of simplified and clearer guidelines.10 Our study also underscores the gap that may exist between guidelines dissemination and implementation. Guidelines are usually produced by experts after a thorough literature review and are disseminated through medical journals and educational rounds. Erroneously, guidelines conceivers may consider that implementation will follow dissemination. In fact, the development and publication of a guideline does not ensure by itself changes in practice patterns.20–22 Therefore, the next logical step should be to devise a systematic plan for implementation of these guidelines and the development of performance measures. GOLD guidelines were widely disseminated through different channels (web, medical journals, medical associations, patients associations). Similarly, the Swiss guidelines were mainly disseminated through
O.T. Rutschmann et al.
publication in the Journal of the Swiss Medical Association and in other local medical journals. These guidelines were also widely presented in local and national scientific meetings. Despite these efforts for dissemination, neither a plan for implementation nor performance measures were developed. In conclusion, despite widely disseminated evidence-based clinical practice guidelines, current knowledge of primary care physicians and outpatient medical management of patients with COPD remain suboptimal. The impact of educational programs on primary care practice should be evaluated, and performance measures should be implemented.
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