title: How do general practitioners implement decision-making regarding COPD patients with exacerbations? An international focus group study.
abstract: OBJECTIVE
  To explore the decision-making of general practitioners (GPs) concerning treatment with antibiotics and/or oral corticosteroids and hospitalization for COPD patients with exacerbations.
  
  
  METHODS
  Thematic analysis of seven focus groups with 53 GPs from urban and rural areas in Norway, Germany, Wales, Poland, Russia, the Netherlands, and Hong Kong.
  
  
  RESULTS
  Four main themes were identified. 1) Dealing with medical uncertainty: the GPs aimed to make clear medical decisions and avoid unnecessary prescriptions and hospitalizations, yet this was challenged by uncertainty regarding the severity of the exacerbations and concerns about overlooking comorbidities. 2) Knowing the patient: contextual knowledge about the individual patient provided a supplementary framework to biomedical knowledge, allowing for more differentiated decision-making. 3) Balancing the patients' perspective: the GPs considered patients' experiential knowledge about their own body and illness as valuable in assisting their decision-making, yet felt that dealing with disagreements between their own and their patients' perceptions concerning the need for treatment or hospitalization could be difficult. 4) Outpatient support and collaboration: both formal and informal caregivers and organizational aspects of the health systems influenced the decision-making, particularly in terms of mitigating potentially severe consequences of "wrong decisions" and concerning the negotiation of responsibilities.
  
  
  CONCLUSIONS
  Fear of overlooking severe comorbidity and of further deteriorating symptoms emerged as a main driver of GPs' management decisions. GPs consider a holistic understanding of illness and the patients' own judgment crucial to making reasonable decisions under medical uncertainty. Moreover, GPs' decisions depend on the availability and reliability of other formal and informal carers, and the health care systems' organizational and cultural code of conduct. Strengthening the collaboration between GPs, other outpatient care facilities and the patients' social network can ensure ongoing monitoring and prompt intervention if necessary and may help to improve primary care for COPD patients with exacerbations.
authors.affiliation: Department of Community Medicine, General Practice Research Unit, University of Tromsø - The Arctic University of Norway, Tromsø, Norway.
authors.forename: Johanna
authors.initials: J
authors.lastname: Laue
authors.affiliation: Department of Community Medicine, General Practice Research Unit, University of Tromsø - The Arctic University of Norway, Tromsø, Norway.
authors.forename: Hasse
authors.initials: H
authors.lastname: Melbye
authors.affiliation: Department of Community Medicine, General Practice Research Unit, University of Tromsø - The Arctic University of Norway, Tromsø, Norway.
authors.forename: Peder A
authors.initials: PA
authors.lastname: Halvorsen
authors.affiliation: Department of Family Medicine, Northern State Medical University, Arkhangelsk, Russia.
authors.forename: Elena A
authors.initials: EA
authors.lastname: Andreeva
authors.affiliation: Department of Family and Community Medicine, Medical University of Lodz, Lodz, Poland.
authors.forename: Maciek
authors.initials: M
authors.lastname: Godycki-Cwirko
authors.affiliation: Institute of General Practice, University Medical Center Rostock, Rostock, Germany.
authors.forename: Anja
authors.initials: A
authors.lastname: Wollny
authors.affiliation: Cochrane Institute of Primary Care and Public Health, School of Medicine, Cardiff University, Cardiff, UK.
authors.forename: Nick A
authors.initials: NA
authors.lastname: Francis
authors.affiliation: CAPHRI School for Public Health and Primary Care, Maastricht University, Maastricht, the Netherlands.
authors.forename: Mark
authors.initials: M
authors.lastname: Spigt
authors.affiliation: The Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong.
authors.forename: Kenny
authors.initials: K
authors.lastname: Kung
authors.affiliation: Department of Community Medicine, General Practice Research Unit, University of Tromsø - The Arctic University of Norway, Tromsø, Norway.
authors.forename: Mette Bech
authors.initials: MB
authors.lastname: Risør
mesh_terms: D000284:Administration, Oral; D000305:Adrenal Cortex Hormones / Q000008:administration & dosage* / Q000009:adverse effects; D000553:Ambulatory Care; D000900:Anti-Bacterial Agents / Q000008:administration & dosage* / Q000009:adverse effects; D001291:Attitude of Health Personnel; D000066491:Clinical Decision-Making; D003299:Cooperative Behavior; D003431:Cross-Cultural Comparison; D019033:Delivery of Health Care, Integrated; D018450:Disease Progression; D005060:Europe; D017144:Focus Groups; D058005:General Practitioners / Q000523:psychology*; D019538:Health Care Surveys; D007722:Health Knowledge, Attitudes, Practice; D006723:Hong Kong; D006760:Hospitalization; D006801:Humans; D007391:International Cooperation; D008168:Lung / Q000187:drug effects* / Q000503:physiopathology; D010358:Patient Participation; D010818:Practice Patterns, Physicians'; D029424:Pulmonary Disease, Chronic Obstructive / Q000175:diagnosis / Q000503:physiopathology / Q000628:therapy*; D012423:Rural Health; D012720:Severity of Illness Index; D035501:Uncertainty; D019564:Unnecessary Procedures; D014504:Urban Health
chemical_list: D000305:Adrenal Cortex Hormones; D000900:Anti-Bacterial Agents
keywords: COPD exacerbation; antibiotics; decision-making; hospitalization; oral corticosteroids; primary care