Participant characteristics
Twenty-two GPs expressed interest to participate in a qualitative interview, of which one later declined and three did not respond to email or telephone communications. The 18 participants (6 male, 12 female) had varied experience in general practice ranging from 1.5 to 34 years and practised across a representative spread of Australian states and regions (Table 1). Mean interview duration was 32 minutes (range 22 to 46 minutes).
Table 1. Participant characteristics
Thematic analysis of the interview data identified six key themes that impacted GP care for patients following hospitalisation for AECOPD (Figure 1).
Figure 1. Factors impacting GP post-exacerbation comprehensive care of COPD patients. COPD = chronic obstructive pulmonary disease. COPD-X = Australia and New Zealand’s guidelines for the management of COPD. HCPs = healthcare professionals.
Theme 1: GPs’ priorities for Acute Exacerbations of COPD care were varied
All participants considered it important for COPD patients to have a follow-up appointment with their GP after an acute exacerbation, but they differed in terms of perceived priorities and what should happen during this visit and the timing of when it should occur. Some GPs felt the follow-up visit should focus on the patients’ recovery and medication review:
‘It’s important to help them [patients] and see if they’re improving or not and to make sure people are taking the medications and puffers as prescribed.’
(GP 10, 10 years’ experience)
Others showed a good understanding about exacerbations and considered prevention of exacerbations and readmissions as a priority:
‘… one exacerbation means, there’s a higher chance of getting another exacerbation.’
(GP 9, 8 years’ experience)
‘We have a good COPD management plan in place, including management of further exacerbations, as far as I’m aware it’s best practice to COPD.’
(GP 12, 10 years’ experience)
GPs also identified the follow-up visit after an AECOPD as an opportunity for the clinician to revisit their management and optimise care to prevent future exacerbations. Furthermore, with long-term doctor–patient relationships, GPs described they were well placed to deliver preventive care:
‘I think that often the hospital they’re trying to get the patient stable from that exacerbation but really our role is to be taken that as a risk factor for that patient and we know the patient the best, so then try and put in a plan in place to stop further exacerbations.’
(GP 11, 4 years’ experience)
A small number of GPs in this sample reported using therapeutic guidelines to guide their management of COPD. Among GPs who were aware of Australia’s COPD-X guidelines, perceptions varied. Some felt they were too broad or that it was challenging to find information they needed; others did not find them to be a helpful reference, while others felt the COPD-X ‘concise’ guide18 was less complicated and easier to use. More experienced GPs described they were not averse to guidelines, but were more comfortable with their own way of practice. However, they recognised the need for updating their knowledge to ensure practice remained in line with guidelines.
COPD action plans were seen as an important aspect of exacerbation management. Some felt they were very useful to help manage exacerbations and prevent hospital admissions:
‘Most of my patients are set up with a COPD action plan, I’ve never had a problem, once I’ve educated the patients with them following through, you make sure that the action plan is simple, straightforward, with my patients who’ve got flare ups of COPD, very rarely need to admit them.’
(GP 8, 26 years’ experience).
In contrast, others viewed action plans more negatively, perceiving that older adults with COPD were not interested in ‘an extra piece of paper’. Some GPs reported that they give verbal advice rather than a written plan. However, GPs commented that participating in the present study had prompted them to consider using written COPD action plans more in their future clinical practice.
Some participants felt barriers such as insufficient consultation time and health literacy restricted their implementation.
Theme 2: challenged by pharmacological management of COPD patients
Most GPs reported that they use a stepwise guide for pharmacological management:
‘… that’s the time I look at the guidelines basically.’
(GP 9, 8 years’ experience)
Despite the usefulness of the stepwise approach of the Australian COPD-X guidelines, GPs expressed difficulty in selecting the most appropriate medication and inhaler/device as many inhaled medications are available under each category (for example, long-acting muscarinic antagonist, long-acting beta-agonist, and corticosteroids):
‘I don’t understand them, there are too many, I don’t know the difference between one and another.’
(GP 12, 10 years’ experience)
Therefore, GPs restricted their selection of medications to the best known, or most familiar to them:
‘Very overwhelming. I wish there was just one of each, to be honest, I would really. I guess we’ll find our favourites and we just kind of stick with those.’
(GP 11, 4 years’ experience)
Participants further reflected on their decision making in respect to the medications best suited for patients and the challenges they faced in making these decisions.
Sometimes respiratory physicians commenced new medication, but GPs did not know the reason behind it, feeling it was confusing and complicated. As one GP explained:
‘Like half the time when they come back from respiratory specialist assessment, they’re on a medication I’ve never heard of. I find it’s complicated and I’m not sure what benefit they give … [or] necessarily better than the ones that I am familiar with. So, I find it confusing.’
(GP 12, 10 years’ experience)
GPs also reported difficulties. They struggled to keep up with new developments in medication and devices used in COPD. Interviews revealed that GPs get to know about medication from advertisements in medical journals or educational sessions sponsored by pharmaceutical companies. They recognised the need to become more knowledgeable in pharmacological management but preferred to have succinct, evidence-based information of COPD medications independent of the pharmaceutical industry:
‘Keeping up to date with all the new puffers and devices, that’s certainly a challenge.’
(GP 15, 21 years’ experience)
‘I found it initially as registrar training very overwhelming, so many drug reps come with all their products and big charts, I just couldn’t get my head around what or which one were better ones.’
(GP 17, 5 years’ experience)
Theme 3: maximising care within constrained consultation time
Follow-up appointments for COPD exacerbations were mostly limited to a standard consultation and limited by the availability of the GP. This varied by practice size and its location. GPs commented on time as a barrier for providing comprehensive review and management advice within a standard consultation. For example, one GP described:
‘It’s so difficult with the amount of stuff that you have to get through in a 15-minute appointment.’
(GP 11, 4 years’ experience)
COPD patients also commonly present with comorbidities, therefore the follow-up consultations were not always limited to COPD but also to manage other acute or chronic problems.
Participants felt providing the best possible care at follow-up visit, within the time available for a standard consultation, was a challenge. Addressing their patients’ needs, values, and expectations was a central concern for GPs. One GP explained that:
‘… patients have an agenda and the doctors have an agenda, and often they don’t align. Patient has a list of problems and I have a list of COPD things I want to look through and I can’t do that [in the time].’
(GP 11, 4 years’ experience)
Many GPs welcomed the role of practice nurses to support the management of patients following AECOPD care, but also highlighted the variability of their role within Australian general practices. Practice nurses were mostly involved with vaccination and spirometry, and some made contributions to patient education, smoking cessation counselling, and checking inhaler technique, but this varied widely.
Theme 4: timely communication between healthcare professionals was desired, but experiences were mixed.
Hospital discharge summaries were identified by GPs as key communication tools.
Most GPs were happy with the timeliness of electronically sent discharge summaries; however, they expressed mixed feelings regarding the content as it showed variation depending on where they worked and the hospital they dealt with. Few GPs were satisfied with the content:
‘It has improved tremendously over last two or three years, that’s because we get … hospital discharge summaries in our area, which has a message to the GP about what the follow-up plan is and what they want GPs to do, that’s actually very useful.’
(GP 15, 21 years’ experience)
In contrast, other GPs identified serious concerns with the discharge summaries they had received. It was suggested that the hospital should arrange the follow-up appointment prior to the discharge of the patient:
‘There are lot of areas they could improve, so to be honest, I find medication aspect is almost useless. Not so much in terms of what happened during the admission, and one of my real frustrations is to follow up, follow-up of the results.’
(GP 1, >25 years’ experience)
‘I don’t think the patient generally is told to make an appointment with the GP and it would be really great if the hospital staff could help the patient make a follow-up appointment with the GP before they left the hospital, because it just feels like good handover.’
(GP10, 10 years’ experience).
Throughout the interviews, GPs described their experiences of communication with outpatient hospital specialists as problematic. One GP described:
‘The hospital specialists, kind of revise and change things, sometimes without speaking to the community team or GP, then you don’t know, they haven’t spoken to us to understand the reasoning of why they’re on that medication, that’s quite frustrating.’
(GP 16, 10 years’ experience)
Care providers often have their own disciplinary view of what the patient needs and how they manage the patient. GPs explained the importance of collaboration among healthcare professionals rather than working independently. Interviewees commented that they prefer to have proper feedback from other health professionals who were involved with patient care as it would help to deliver better personalised care for patients. For example, another GP explained:
‘The correspondence from outpatient pulmonary rehab, a pretty brief summary but I don’t think we get much that’s directly addressing that person as an individual. I prefer it be individualised; it’ll make a world of difference.’
(GP 15, 21 years’ experience)
Theme 5: access to other healthcare services frustrated GPs’ ability to provide best practice care
GPs shared their frustrations of not being able to provide the best practice of care for COPD patients and expressed their concern regarding accessibility of referral services. Less priority given to GP referrals in the public sector, costs involved in private programmes, and limited availability of programmes were identified as barriers to pulmonary rehabilitation:
‘In terms of the private allied health, that’s quite expensive. So even if people have a team care arrangement and things, you know, at least $50 out of pocket, usually a position that’s just completely out of reach for my patients.’
(GP 10, 10 years’ experience)
Participants felt that many of these factors were capable of being addressed and, interestingly, felt that referrals for patients following AECOPD might be more appropriately organised by hospital staff before discharge.
Most GP participants also described difficulty accessing outpatient respiratory specialists when required. This included accessibility and affordability issues related to limited availability of respiratory specialists, long waiting period in the public sector, and private sector costs:
‘It’s very long waiting period to see the specialist, there are only one or two private respiratory specialists here. We’ve got a poor socioeconomic status, so not a lot of people can see them privately. In public hospital, there’s long waiting period to get in.’
(GP 14, 12 years’ experience)
Theme 6: patient compliance with care advice
GPs felt responsible for motivating patients to quit smoking but found it challenging when patients continued to smoke after the provision of support to quit. GPs felt that responsibility for their health ultimately lay with the patients. Some participants described problems regarding discontinuity of care because of patients seeing multiple GPs (as they do not register at a single practice in Australia). This disruption of informational and management continuity was felt to impact on the provision of best care:
‘They’re like, I go to that doctor for that, and I come to you for this, that’s super frustrating.’ (GP 12, 10 years’ experience)
‘I find it very, very difficult to chase information, I try to explain to patients with ten different doctors, you’re going to get ten different opinions, I’m not saying, and they all have, they have different merits. So, it’s really important to see one person, whoever you like, whoever you trust.’
(GP 17, 5 years’ experience)
