Does multimorbidity result in de-prioritisation of COPD in primary care?

The first main finding of this study was that COPD patients with multimorbidity tend to see the general practitioner and COPD nurse more often for COPD check-ups than those without multimorbidity. Our results are not consistent with de-prioritisation of COPD because of multimorbidity. However, we do not know the amount of time devoted to COPD during the consultations or the quality of disease management. The second main finding was that having exacerbations was positively associated with having routine COPD check-ups by the GP.

COPD patients with a higher number of comorbid diseases were more likely to have routine check-ups by the GP, or by both GP and COPD nurse, for monitoring of COPD. Patients with multimorbidity were more frequent care users, potentially resulting in surveillance bias such that there are more opportunities to make other diagnoses, such as hypertension (although all patients with COPD will have their blood pressure tested), which may be more likely recorded due to frequent testing, thus inflating the total number of diagnoses. More visits to a GP due to multimorbidity increases the opportunity to discuss COPD and this could in part explain the higher magnitude association of multimorbidity with COPD being mentioned. This is mainly relevant for GP visits and not COPD nurse visits, where we did not identify evidence of de-prioritisation.

As in previous studies, comorbidity was common in COPD patients7,8. Of the individual comorbid diseases, only hypertension was statistically significantly associated with receiving more frequent routine check-ups for COPD. Hypertension is likely to be the most common comorbidity in COPD patients1, as here 57% of the patients had the diagnosis. Although hypertension is common in the general population, it appears to occur even more frequently in COPD patients9. Hypertension is associated with the increased systemic inflammation in COPD10 but has not been found to increase mortality11 or risk of exacerbations7. However, it is an important risk factor for other cardiovascular diseases.

We found a positive, but not statistically significant, association between depression and having routine check-ups. Some 21% of the patients in the study had a diagnosis of depression in their medical records sometime during the study period. COPD has been found to increase the risk of developing depression, and comorbid depression has been associated with an increased risk of exacerbations and mortality in COPD patients12. Many patients have had persistent depressive symptoms for several years13.

COPD patients with comorbid diabetes have been found to have an increased risk of severe exacerbations14. In our study, a positive association was found between diabetes and having check-ups only by a GP or a COPD nurse, but an inverse for having check-ups by both. One possible explanation for this could be that patients with diabetes often have annual check-ups by a specialised diabetes nurse, which may result in fewer check-ups by a COPD nurse. The logistic regression analysis indicated inconclusively that patients with diabetes may have a somewhat reduced number of check-ups by a GP, when not considered mutually exclusive, as in the multinomial models. It remains possible to speculate that the pattern of management is different for these patients in a way that de-prioritises COPD over diabetes: a Danish primary care study, found that patients with coexisting COPD and diabetes had annual control visits for their COPD less frequently than patients with only COPD15.

At least one exacerbation during the previous 6 months, was positively associated with having routine check-ups of COPD by the GP or by both GP and COPD nurse. Having a history of exacerbations is recognised to be an important risk factor for having additional exacerbations16,17 and for deterioration of the disease1. Several comorbid conditions are also associated with an increased risk of exacerbations, such as heart disease3 and asthma18. The focus of long-term COPD management is recommended to be on symptom relief and preventing future exacerbations1. The results of this study suggest that primary healthcare is giving more attention to COPD management if patients have had more frequent exacerbations, which complies with this recommendation.

More than half of the patients in the study did not have any routine check-ups by the GP during the previous 2 years. One-third did not have check-ups by a GP or nurse. Some of these patients may have had COPD check-ups in secondary care, but as this would only add to the number of consultations it would provide no additional evidence of COPD de-prioritisation in primary care. Patients without check-ups in primary care had less comorbidity, less frequent exacerbations, and less severe air-flow limitation. This could be seen as an example of giving care according to need in a primary healthcare setting struggling to keep up with the rising demands of an aging population. In healthier individuals with less severe COPD disease outcomes, COPD received less attention. The future consequences of this omission of routine check-ups for less severe COPD requires further research.

In a 2016 qualitative study in Sweden, GPs were interviewed about their views on the management of COPD in multimorbid patients5. They stated that COPD was less likely to be discussed during check-ups if the patient had few symptoms of COPD, whereas a history of recurrent respiratory infections or obvious airway symptoms would most likely lead to a discussion about COPD. This is consistent with our finding that patients with exacerbations were more likely to have routine check-ups by the GP than those without exacerbations. However, in contrast with this qualitative study, we could not confirm any de-prioritisation of COPD because of multimorbidity in our study population.

As we identified routine check-ups by the GP through a text reference to COPD symptoms or management in the medical records, we did not have any information about how time was divided between COPD and the patient’s other chronic diseases. Hence, we could not assess the prioritisation of COPD relative to other chronic diseases. We defined de-prioritisation as not having at least one COPD-related check-up by a GP during a 2-year period, as this is recommended by national guidelines. However, having one check-up does not indicate intensive management of COPD. Neither were we able to separate previously planned visits from those when patients sought care for another reason and also discussed COPD at this time.

Having check-ups by a COPD nurse was not statistically significantly associated with comorbidity, exacerbations, or lung function, but there were statistically significant differences between the county councils that were included in the study. This may be because of differences in local procedures, and patients attending the nurse-led COPD clinic specifically because of a COPD diagnosis, in contrast with a check-up by the GP that could involve managing several conditions during a single consultation.

The shortage of permanently employed GPs and its consequences is an often-discussed question in primary health care in Sweden. In this study, we could not find consistent associations between staffing problems and how COPD was managed at the PHCCs. Nor could we find any association with whether they were private or operated by the county council. In larger centres, there was a greater likelihood for patients receiving check-ups by both GP and nurse. Presence of asthma/COPD clinics, which most centres had, significantly increased the chances of having check-ups by a COPD nurse.

Adherence to guidelines is still often used to measure the quality of care19. In multimorbid patients a holistic approach is preferable, and clinical judgement becomes more important in GPs’ work when the patient’s individual needs are not well-served by single-disease guidelines20. During some consultations, one condition might receive less attention than another, based upon the patient’s current needs and preferences and the doctor’s and patient’s prioritisation of them. The NICE guidelines for multimorbidity aim to improve quality of life by shared decision-making2. Hence, routine check-ups of multimorbid COPD patients do not necessarily involve reviewing all conditions every time.

A strength of this study was the sample size of over 700 patients with a doctor’s diagnosis of COPD, randomly selected from 76 primary health care centres providing real-world data from clinical practice with good external validity.

The use of both medical records and self-completion questionnaires was a strength, allowing for information about the patient’s own experience of symptoms to be combined with information from records. Data on exacerbations came from self-completion questionnaires and was dependent on patients’ recollection, and therefore a time period of the previous 6 months was chosen.

A limitation of the study was that not all patients had spirometry data in their records, or data on exacerbations and BMI in their questionnaires, which reduced the number of patients included in the analysis. The excluded patients had similar distributions for age, sex, and exacerbations, compared to the patients with spirometry data.

Some 59% completed the questionnaire. The non-respondents were slightly younger and more often women. Thus, the study participants tended to be older, and thus more likely to have a comorbidity, which may have affected the results.

Among the 76 PHCCs, 71 (93%) completed the questionnaire about organisational characteristics, somewhat reducing the number of patients included in this analysis.

Another limitation was the limited number of comorbid diseases included in the analyses, but they were chosen on a theoretical basis and should illustrate the association. Given the direction of association with priority, we do not think that adding more diseases would reverse this. A previous study found that increasing the number of conditions considered, increased the prevalence of multimorbidity21.

The comorbid conditions were noted as present or not in the record review, during or before the studied period. We have not considered their severity or duration. This is of potential concern, especially for depression as it is not necessarily a long-term diagnosis even though COPD patients often have persistent symptoms of depression13.

An alternative interpretation of the findings of more frequently mentioned COPD during consultations among those with multimorbidity is that there is de-prioritisation of COPD treatment—or other influences—such that worse disease characteristics result in more frequent mentions of COPD. To address this concern, we adjusted for both lung function and COPD exacerbations. This made little difference to the results, but as the measurement of exacerbations was not a particularly fine grain (at least once during the previous 6 months), there is a possibility of residual confounding.

A limitation to the validity of our data may have been the occasions when COPD was assessed but the assessment was not described in the medical records, and therefore not detected in the review. Also, we do not know how much time was spent on COPD during the check-up, if the patients themselves brought up COPD, or what the consultation resulted in.

COPD patients in primary care more often had routine check-ups if they had greater disease severity, multimorbidity, or frequent exacerbations, suggesting that those in need of attention received it. However, we do not know the extent or quality of the consultation time devoted to COPD, justifying further research into the quality of COPD management in patients with comorbid diseases.

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