J.E. Jacobs

Validity of spirometric testing in a general practice population of patients with chronic obstructive pulmonary disease (COPD)

Objective: To investigate the validity of spirometric tests performed in general practice. Method: A repeated within subject comparison of spirometric tests with a “gold standard” (spirometric tests performed in a pulmonary function laboratory) was performed in 388 subjects with chronic obstructive pulmonary disease (COPD) from 61 general practices and four laboratories. General practitioners and practice assistants undertook a spirometry training programme. Within subject differences in forced expiratory volume in 1 second and forced vital capacity (ΔFEV1 and ΔFVC) between laboratory and general practice tests were measured (practice minus laboratory value). The proportion of tests with FEV1 reproducibility <5% or <200 ml served as a quality marker. Results: Mean ΔFEV1 was 0.069 l (95% CI 0.054 to 0.084) and ΔFVC 0.081 l (95% CI 0.053 to 0.109) in the first year evaluation, indicating consistently higher values for general practice measurements. Second year results were similar. Laboratory and general practice FEV1 values differed by up to 0.5 l, FVC values by up to 1.0 l. The proportion of non-reproducible tests was 16% for laboratory tests and 18% for general practice tests (p=0.302) in the first year, and 18% for both in the second year evaluation (p=1.000). Conclusions: Relevant spirometric indices measured by trained general practice staff were marginally but statistically significantly higher than those measured in pulmonary function laboratories. Because of the limited agreement between laboratory and general practice values, use of these measurements interchangeably should probably be avoided. With sufficient training of practice staff the current practice of performing spirometric tests in the primary care setting seems justifiable.

How to promote healthy behaviours in patients? An overview of evidence for behaviour change techniques

To identify the evidence for the effectiveness of behaviour change techniques, when used by health-care professionals, in accomplishing health-promoting behaviours in patients. Reviews were used to extract data at a study level. A taxonomy was used to classify behaviour change techniques. We included 23 systematic reviews: 14 on smoking cessation, 6 on physical exercise, and 2 on healthy diets and 1 on both exercise and diets. None of the behaviour change techniques demonstrated clear effects in a convincing majority of the studies in which they were evaluated. Techniques targeting knowledge (n = 210 studies) and facilitation of behaviour (n = 172) were evaluated most frequently. However, self-monitoring of behaviour (positive effects in 56% of the studies), risk communication (52%) and use of social support (50%) were most often identified as effective. Insufficient insight into appropriateness of technique choice and quality of technique delivery hinder precise conclusions. Relatively, however, self-monitoring of behaviour, risk communication and use of social support are most effective. Health professionals should avoid thinking that providing knowledge, materials and professional support will be sufficient for patients to accomplish change and consider alternative strategies which may be more effective.

Effect of an integrated primary care model on the management of middle-aged and old patients with obstructive lung diseases.

Objective. To investigate the effect of a primary care model for COPD on process of care and patient outcome. Design. Controlled study with delayed intervention in control group. Setting. The GP delegates tasks to a COPD support service (CSS) and a practice nurse. The CSS offers logistic support to the practice through a patient register and recall system for annual history-taking and lung function measurement. It also forms the link with the chest physician for diagnostic and therapeutic advice. The practice nurses most important tasks are education and counselling. Subjects. A total of 44 practices (n =22 for intervention and n =22 for control group) and 260 of their patients ≥40 years with obstructive lung diseases. Results. Within the intervention group planned visits increased from 16% to 44% and from 19% to 25% in the control condition (difference between groups p =0.014). Annual lung function measurement rose from 17% to 67% in the intervention and from 11% to 18% in the control group (difference between groups p =0.001). Compared with control, more but not statistically significant smokers received periodic advice to quit smoking (p =0.16). At baseline 41% of the intervention group were using their inhalers correctly and this increased to 54% after two years; it decreased in the control group from 47 to 29% (difference between groups p =0.002). The percentage of patients without exacerbation did not change significantly compared with the control condition. The percentage of the intervention group not needing emergency medication rose from 79% to 84% but decreased in the controls from 81 to 76% (difference between groups p =0.08). Conclusion. Combining different disciplines in one model has a positive effect on compliance with recommendations for monitoring patients, and improves the care process and some patient outcomes.

What determines the provision of smoking cessation advice and counselling by dental care teams

Objective To investigate determinants of the provision of smoking cessation advice and counselling by various dental professionals in the dental team (dentists, dental hygienists and prevention auxiliaries). Design Cross-sectional design. Setting Sixty-two general dental practices in the Netherlands. Methods Multivariate logistic analyses of self-reported counselling behaviour collected from questionnaires for dentists (n = 72), dental hygienists (n = 31) and prevention auxiliaries (n = 50) in general dental practices. Main outcome measures Stimuli and barriers for smoking cessation counselling and advice behaviour to patients with or without oral health problems. Results Dental hygienists provided more general cessation advice and counselling than dentists. However, when patients had oral complaints, dentists counselled more often compared to prevention auxiliaries. The support from experienced colleagues positively influenced the provision of advice and counselling as well as the perceived self-efficacy for all kinds of dental professionals. Conclusions The provision of general smoking cessation advice to patients with no acute oral complaints can be improved by more involvement of the dentist and/or task delegation to prevention auxiliaries and dental hygienists. Social support is important in encouraging more smoking cessation advice and counselling. Implementation strategies for support of smoking cessation in dental care should focus on creating a positive advice culture among colleagues.

Validation of smoking cessation self-reported by patients with chronic obstructive pulmonary disease

Purpose The present study reports on the biochemical validation of the self-reported smoking status of patients with chronic obstructive pulmonary disease (COPD). The objective is to establish the proportion of overestimation of self-reported success rates. Methods A cross-sectional smoking-status validation study including 60 patients with COPD who reported that they had stopped smoking. In the analysis of urine samples, a cut-off point of 50 ng/mL of cotinine was used. Results At the time of biochemical validation, 55 patients reported that they had quit smoking while five patients resumed smoking. Smoking status was biochemically confirmed for 43 patients (78%) and 12 patients (22%) were classified as smokers. The sensitivity of the self- report of smoking was 29% and the specificity was 100%. Conclusion Many primary care patients with COPD do not provide valid information on their smoking status, which hamper adequate therapeutic interventions. Integration of biochemical validation in daily care could overcome this problem, but may harm the doctor–patient relationship.

Experienced barriers and facilitators for integrating smoking cessation advice and support into daily dental practice. A short report

In a controlled study, primary care dental professionals in the intervention group were encouraged to provide smoking cessation advice and support for all smoking patients with the help of a stage-based motivational protocol. The barriers and facilitators reported by the dental professionals on two occasions for their efforts to incorporate smoking cessation advice and counselling into daily patient care are summarised here. Lack of practice time and anticipated resistance on the part of the patient were cited as barriers by over 50% of the dental professionals in the first interviews. Periodontal treatment and the presence of smoking-related diseases were mentioned as the most important stimuli. The experience-based interviews revealed key points for the implementation of smoking cessation advice and support in daily dental care. Education on the associations between smoking and oral health, vocational training on motivational interviewing and the offering of structured advice protocols were identified as promising components for an implementation strategy to promote the involvement of dental professionals in the primary and secondary prevention of tobacco addiction.

General practice counseling for patients with chronic obstructive pulmonary disease to quit smoking: impact after 1 year of two complex interventions.

OBJECTIVE To evaluate two counseling programs in general practice to help smokers with chronic obstructive pulmonary disease (COPD) to quit smoking. METHODS Cluster randomized controlled trial including 68 general practices (667 patients) using a randomly assigned intervention program with counseling and advice about nicotine replacement therapy (and additional bupropion-SR in one of the programs) or usual care. Usual care consisted of periodic regular check-ups and COPD information. The main outcome measure was biochemically verified point prevalence at 12 months. RESULTS The two intervention groups were treated as one in the analysis because they were equally effective. The intervention resulted in a significantly self-reported higher success rate (14.5%) compared to usual care (7.4%); odds ratio=2.1, 95% confidence interval=1.1-4.1. Biochemically verified quit rates were 7.5% (intervention) and 3.4% (usual care); odds ratio=2.3, 95% confidence interval=0.9-6.0. CONCLUSION The program doubled the cessation rates (statistically nonsignificant). Too few participants used the additional bupropion-SR to prove its effectiveness. PRACTICE IMPLICATIONS The protocols can be used for COPD patients in general practice, but expectations should be modest. If quitting is unsuccessful, a stepped care approach should be considered.

Quality of Life of patients with asthma/COPD in general practice; impairments and correlations with clinical condition

Objectives: To investigate impairments in Quality of Life (QoL), and their determinants, in patients with mild to moderate asthma and chronic obstructive pul-monary disease (COPD) under treatment in general practice.Methods: In a cross-sectional study, 340 adult patients with asthma and COPD completed a self-administered questionnaire containing a generic (COOP-WONCA charts) and a disease-specific (QOL-RIQ) instrument, both especially developed for measuring QoL in primary care. Symptoms, exacerbations, medication use, FEV1, and comorbidity were also measured.Results: For both COOP-WONCA charts and QOL-RIQ: two-thirds of the patients reported some impairment; about 10% of these patients reported moderate to severe impairment. For the five COOP-WONCA charts the relationships between QoL scores and clinical characteristics ranged from r2=0.24 (physical fitness) to r2=0.12 (social activities). For the total QOL-RIQ score the variance (r2=0.31) was mostly explained by disease-related characteristics, especial...

Are oral health complaints related to smoking cessation intentions

OBJECTIVE Smoking influences oral health in several ways (such as the occurrence of periodontitis, teeth discolouration and oral cancer); therefore, smoking behaviour should be addressed in dental care. Dentists can play a role in primary and secondary prevention of tobacco dependence. They see their patients repeatedly over time. This study investigates whether oral health complaints can be seized as an opportunity to start smoking cessation counselling. METHODS A structured patient questionnaire in a sample of 1101 smokers (52.1% women, mean age 40.4 years) in a convenience sample of 87 primary care dental practices. The I-change model was used to describe factors influencing behavioural change. Dependent factors such as intention to quit smoking and related factors (attitude, social support and self-efficacy) were analysed in relation to independent factors such as oral health complaints (gingiva problems, gingiva inflammation, oral cancer and discoloured teeth) using a general linear model (univariate analysis), multinomial logistic regression analysis and multiple linear regression analysis. RESULTS A total of 56.3% had discoloured teeth, 27% of the smokers had a problem with their gums and 15.7% had gingiva inflammation. We found no direct relation between oral health complaints and the intention to quit smoking. However, teeth discolouration was positively related to attitudes towards smoking cessation [β, Confidential interval (95%); 1.92 (1.45-2.40 for advantages and -0.86(-1.18 to -0.53) for disadvantages] and negatively to self-efficacy regarding quitting [-2.69 (-3.49 to 1.88)]. CONCLUSIONS We found no direct relation between oral health complaints and the intention to quit smoking, but oral health complaints and especially teeth discolouration were related to factors influencing the quit intention. Patients with discoloured teeth are more likely to have a positive attitude towards smoking cessation but are uncertain to persist smoking cessation. It is suggested that teeth discolouration can be a good entrance for addressing smoking cessation in daily dental practice.

Smoking cessation counselling in general practice for COPD smokers: determinants for general practitioners' compliance with a treatment protocol

For chronic obstructive pulmonary disease (COPD), smoking cessation is the main treatment goal. We examined compliance with a smoking cessation treatment protocol for COPD smokers by 47 general practitioners (GPs). Baseline and evaluation questionnaires were completed, and 34 of the GPs then took part in a semi-structured telephone interview. The main outcome measure was restarting of the protocol when a patient had relapsed during a quit attempt. Attitudes, social influences and perceived self-efficacy were assessed to understand compliance or non-compliance with the treatment protocol. The rates of self-reported compliance with seven out of nine aspects of the protocol were high (76% on average). Fifty-three per cent of the GPs restarted the treatment protocol following patients relapse. A substantial percentage of the GPs reported being seriously disappointed by the effectiveness of the treatment protocol. A change of practice personnel or having unmotivated personnel hindered compliance with the treatment protocol. The majority of the GPs planned to continue using the protocol. Given that negative attitudes, a perceived lack of social support and lack of counselling self-confidence were associated with lower protocol compliance, less confident GPs and GPs who have negative attitudes towards the provision of smoking cessation support should delegate the counselling or refer their patients. It is also concluded that GPs should be given more realistic expectations about smoking cessation and, rather than drop support efforts when they experience a lack of time or lack of confidence for counselling smoking cessation, delegate these tasks to practice assistants or other personnel.