Keywords: COPD, general practitioner, guideline refferal, decision-making, qualitative research

Background:

Chronic obstructive pulmonary disease (COPD) is complex, heterogeneous and prevalent disease, with most patients receiving care by their general practitioner (GP). Studies show that a substantial part of the COPD population seen by a GP qualifies for referral to a pulmonologist, due to a poor health status, or perceived disease burden. COPD-guidelines provide criteria to help GPs identify eligible patients for referral. Nonetheless, in clinical practice the timing and clinical status of a patient at moment of referral frequently deviates from these recommendations. Insights in the decision-making process of GPs regarding referral to a pulmonologist lags.

Research questions:

What attitudes and perceptions do GPs have regarding the referral of patients with COPD to pulmonologists, and how do recommendations from the Dutch GP COPD guideline impact these referrals?

Method:

Semi-structured interviews were conducted with purposeful sampled Dutch GPs. Recordings were transcribed verbatim, and the data was analysed using thematic analysis by two researchers independently. Multiple research group meetings were held to identify and structure the themes.

Results:

A representative sample consisting of fourteen GPs, with variety in age, years of experience, expertise level of the GP and urbanisation degree of the practice, participated in the study. Seven themes were identified as influencing in referral decision-making: ‘Professional roles in COPD care’, ‘Accessible care options without referral’, ‘Medical factors supporting or hindering referral’, ‘Perceived benefit of referral based on patient’s and GP’s appreciation of a pulmonologist’s judgment’, ‘Additional options in secondary care’, ‘Assumed patient perception of referral’, and ‘Trust in partnership with the pulmonologist’.

Conclusions:

Findings suggest that a complex sequence of decisions and considerations influence whether GPs will or will not refer patients with COPD to pulmonologists. Some factors are patient-independent, and others are patient-dependent. Recommendations from The GP guidelines seem to have only a limited impact on referral decisions.

Points for discussion:

Guideline recommendations appeared to have limited influence on referral decisions for patients with COPD. To what extent is this recognisable in clinical practice, and how problematic is this?

Would COPD care improve if patient-independent influences on referral decisions were minimized?

What is the most effective strategy to improve guideline-recommended referrals of patients with COPD to a pulmonologist?