Apathy undermines primary care COPD treatment model

A lack of urgency among patients about mild COPD symptoms may explain why a primary care-based interdisciplinary model of care based on COPD-X guidelines has failed to show benefit, Australian researchers say.

There were few takers for a  program that offered newly-diagnosed patients access to smoking cessation support, pharmacist medication reviews and home-based pulmonary rehab, according to study investigators.

Conducted in 43 GP practices, the RADICALS (Review of Airway Dysfunction and Interdisciplinary Community-based care of Adult Long-term Smokers) trial found that only 31% of the 157 recruited patients completed the intervention. The primary outcome of health-related quality of life showed no difference over 12 months of follow up between the intervention group and COPD patients who received usual care from the GP.

Published in the European Respiratory Journal, the findings from a study involving  272 patients over 40 who were smokers and newly diagnosed with COPD. Patients were randomised to usual care (115 patients) or to an intervention underpinned by Australian COPD-X guidelines.

Under the co-ordination of a GP, patients were offered face-to-face individualised smoking cessation support by research assistant and a home medicines review (HMR) by an accredited consultant pharmacist that focused on improving COPD inhaler technique and medication knowledge. Patients were also referred for an eight-week home-based pulmonary rehabilitation program (HomeBase), delivered by a specifically trained physiotherapist.

The primary endpoint of St George’s Respiratory Questionnaire score was slightly improved in the intervention group compared to control at six months but the difference was not statistically or clinically significant. Similarly, there was no significant difference in scores at 12 months and no changes in secondary outcomes of lung function (FEV1) and COPD Assessment Test scores.

Uptake of the intervention was poor with only 49/157 patients completing the medication reviews and rehab programs and 43% of patients not doing any.

The study investigators said the poor uptake may be explained by patients lacking motivation due to having mild disease

“It is likely that COPD was not a priority for either GPs or participants for discussions during consultations and for subsequent interventions if patients had only mild symptoms,” they wrote.

“This model could potentially be more effective in primary care by targeting those with symptoms and with better intervention fidelity.”

They said the poor uptake and outcomes may also be due to systemic barriers ,with patients having to see several different healthcare providers and relying on good co-operation and communication between healthcare professionals to implement each other’s recommendations.

“There were delays in delivering the multi-component intervention due to the multiple steps involved e.g. spirometry results review … organising of patient visits to discuss results, eventual referral to HMR and/or HomeBase by GP following patient consent, and GP follow-up visit to implement pharmacist HMR report recommendations,” they noted.

Future studies should factor in the real-world challenges of recruitment, time considerations, and diagnostic and referral processes in the primary care setting, they suggested.

“Patient needs, preferences and personal goals should be carefully assessed and considered to inform subsequent intervention program tailoring,” the study authors concluded.

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