The PRIMAIR study: The challenge of improving general practitioners’ management of COPD in Sweden

Introduction: Continuing medical education (CME) to general practitioners (GPs) is a necessary step in implementing optimal COPD care. Subsequently, GPs should transfer this step into practice, including teaching self-management skills to patients. We aimed to assess the effects of two CME methods for GPs (case methods and traditional lectures), studying GP-related learning outcomes about COPD and patient-related clinical outcomes (health status, symptoms, exacerbations, comorbidities, health care visits, smoking, and subjective information needs). Methods: A pragmatic cluster-randomized controlled trial at primary healthcare centers (n=22) in Stockholm, Sweden was conducted 2014–2017 (The PRIMAIR study). A 2x2-hour CME about COPD was given to GPs (n=255). The GP learning outcomes were measured using a knowledge test prior to and 12 months after the CME. The subsequent clinical outcomes were assessed with validated questionnaires (CCQ, CAT, mMRC, and LINQ), and complementary clinical questions to patients (n=425), prior to and 18 months after the CME. Results: Both CME methods led to modest, but equally significant learning improvements in GPs. As for transferring theory into practice, use of pulmonary rehabilitation increased (13.2%–17.8%, P=0.04), and prevalence of smoking decreased (28.9%–25.1%, P=0.003). However, patients’ health status deteriorated (CCQ; 1.87–1.97, P=0.03, CAT; 15.1–16.3, P<0.001), and hospitalizations increased (5.4%–8.6%, P=0.047). Comorbid anxiety/depression, obstructive sleep apnea, and chronic pain, but not cardiovascular disease, were related to higher CCQ/CAT already at baseline. Patients’ subjective needs for information and support remained generally great in those with stable and/or mild-moderate COPD, particularly concerning diet, exercise and self-management. Discussion: Short educational interventions, commonly attended by busy GPs, are not enough to improve patient health. To provide sustained improvements in COPD management and thus long-term positive changes in patient health, it is important to recognize the need of regular and repeated COPD education, in the light of multimorbidity, to both professionals and patients.