D1.1 General Practitioner

As the primary healthcare provider, the general practitioner (GP) is uniquely placed to identify smokers and help them quit, diagnose COPD in its early stages and coordinate care as the disease progresses (Johnston 2011).  Improving GP uptake of spirometry for COPD diagnosis and recommendation of evidence-based behavioural treatments, including smoking cessation and pulmonary rehabilitation, are key to better management of COPD in Australian primary care.

Smoking cessation: A doctor’s advice is an important motivator for smoking cessation, especially if the doctor is the family physician. The GP can help initiate the cycle of change by repeated brief interventions. Since relapse to smoking is common, GPs should make enquiries about smoking status routinely at each visit. There are several smoking cessation programs that have been developed for use in general practice. The GP is also the appropriate health profes­sional to recommend or prescribe nicotine replacement therapy and pharmacological and/or non-pharmacological treatment of nicotine addic­tion (for a detailed discussion of smoking cessation interven­tions, see section P).

Early diagnosis: Most people visit a GP about once a year. Simple questions relating to smoking history, daily cough and degree of breathlessness should lead to lung function testing. A study in 31 general practice clinics in Melbourne found that although GPs recognised the value of spirometry in differentiating between asthma and COPD, most general practices only used spirometry in diagnostically difficult cases leading to more accurate diagnosis of asthma (69%), but substantial underdiagnosis of COPD (14%) (Abramson 2012). Spirometry needs to be more widely used to improve the accuracy of respiratory diagnoses in general practice.

A national survey of Australian GPs in 2014 identified reactive, relatively passive and delayed approach to diagnosis of COPD, potentially delayed smoking cessation advice and under-utilisation of pulmonary rehabilitation. Less than half of the GP respondents reported using COPD management guidelines (Bereznicki 2017).

In a cluster-randomised controlled trial of general practices in the UK, routine practice identified fewer new cases of COPD, while an active targeted approach to case finding including mailed screening questionnaires before spirometry was found to be a cost-effective way to identify undiagnosed patients and had the potential to improve their health (Jordan 2016).

Coordinate investigation and management: GPs will manage patients with mild to moderate COPD. Referral to a respiratory physician may be indicated to confirm the diagnosis, exclude complications and aggravating factors, and to help develop a self-management plan (section C, Box 6).

Coordinate care in advanced disease: GPs play a crucial role coordinating services provided by a range of healthcare professionals and care agencies (the “multidisciplinary team”).

A cluster randomised controlled trial of an interdisciplinary COPD intervention in 43 Australian primary care clinics coordinated by general practitioners (GPs) and involving smoking cessation support, home medicines review (HMR) by a consultant pharmacist and home-based pulmonary rehabilitation delivered by a specially trained physiotherapist did not improve Health Related Quality of Life (HRQoL), symptom severity or lung function in a cohort of patients with predominantly mild COPD (Liang 2019) [evidence level II]. Uptake of the intended intervention components by both GPs and patients was suboptimal (31% completed the full intervention, 26% partially completed the intervention). Exploratory analyses of the 31% who received the intended full intervention showed statistically and clinically significant differences in HRQoL over usual care at 6 months (adjusted mean difference 5.22, 95% CI 0.19 – 10.25; p=0.042).