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dc.contributor.advisorRisør, Mette Bech
dc.contributor.authorLaue, Johanna
dc.date.accessioned2017-04-20T12:23:21Z
dc.date.available2017-04-20T12:23:21Z
dc.date.issued2017-03-24
dc.description.abstractExacerbations of chronic obstructive pulmonary disease (COPD) compose a considerable burden for both patients and health care systems. Optimal management in primary care, including self-treatment of COPD exacerbations with antibiotics and oral corticosteroids, is considered to be one key for providing good care for patients at reasonable costs. This thesis aimed to explore treatment of COPD exacerbations with antibiotics and/or oral corticosteroids and hospitalization from different primary care perspectives, e.g. guidelines, general practitioners and patients. A systematic review of treatment criteria for antibiotics and oral corticosteroids in national and international COPD guidelines, and an assessment of the underlying evidence for these recommendations composed the first part of the project. The results showed that the recommended treatment criteria were mostly based on respiratory symptoms, and that the studies the recommendations are based on are often conducted with patients that are not representative for a primary care setting. The second study explored COPD patients’ perspective on self-treatment with antibiotics and oral corticosteroids through a thematic analysis of 12 semi-structured in-depths interviews. We found that concerns with the medications’ adverse effects play a key role in CODD patients’ decisions to initiate self-treatment with antibiotics and/or oral corticosteroids. The nature of the patient-physician relationship including the patients’ understanding of legitimacy to seek help is important to their help seeking behaviour when feeling insecure about the need for treatment or in case of treatment failure. The third study investigated GPs’ accounts of their decision-making regarding treatment with antibiotics and oral corticosteroids and hospitalization through a thematic analysis of seven focus group discussions. The results show that one main driver of GPs’ decision-making are worries about having overlooked a severe underlying illness. GPs consider at holistic understanding of illness and the patients’ own experiential knowledge important to make reasonable decisions for the individual patient under medical uncertainty. Moreover, GPs’ decisions depend on the availability and reliability of other formal and informal carers, and the healthcare systems’ organization and sociocultural ‘code of conduct’. Overall, the findings of this thesis support an integrative and collaborative approach to management of COPD exacerbations. The heterogeneous, versatile and often individualized nature of COPD exacerbations requires a flexible framework to decision-making that integrates both medical knowledge and other types of knowledge that are grounded in human experience and relationships. Such an integrative understanding of knowledge may guide future clinical research and guideline development in considering primary care evidence and expertise from primary care stakeholders and patients to a larger extent, and may also facilitate collaborative management of COPD exacerbations that allows for sharing expertise and responsibility between patients and the involved carers.en_US
dc.description.abstractForverringer av kronisk obstruktiv lungesykdom (KOLS) er en betydelig byrde for pasienter og helsesystemer. Optimal behandling av KOLS forverringer i primærhelsetjenesten, inkludert egenbehandling med antibiotika og orale kortikosteroider, ansees som meget viktig for å sikre god behandling og samtidig redusere den økonomiske byrden. Denne avhandlingen ønsker å øke kunnskapen om behandling av KOLS pasienter med eksaserbasjoner i primærhelsetjenesten ved å utforske tre forskjellige perspektiver (retningslinjer, pasienter og allmennleger) på dette fenomenet. Denne avhandlingen er basert på tre studier. Første studie er en systematisk review av behandlingskriterier for antibiotika og orale kortikosteroider i nasjonale og internasjonale KOLS retningslinjer og en kritisk evaluering av evidensen som anbefalingene er basert på. Resultatene viser at behandlingskritene er hovedsakelig basert på respiratoriske symptomer og at evidensen er i lite grad overførbar til en primærhelsetjenestekontekst. I den andre studien ble KOLS pasienters erfaringer med egenbehandling utforsket ved tematisk analyse av 12 semi-strukturerte dybde-intervjuer. Hovedfunnene viser at bekymringer for medisinenes bivirkninger spiller en viktig rolle i pasientens beslutninger angående behandlingsstart, og at lege-pasient forholdet inkludert pasientens forståelse av eget ansvar for behandlingen kan påvirke i stor grad om og når pasienter søker hjelp ved usikkerhet eller når behandlingen ikke virker. Målet for den tredje studien var å utforske allmennlegers beslutninger på behandling av KOLS eksaserbasjoner med antibiotika og orale kortikosteroider, og innleggelser, ved tematisk analyse av 7 fokusgruppeintervjuer fra forskjellige europeiske land og Hongkong. Hovedfunnene viser at usikkerhet og redsel for å ha oversett alvorlig sykdom er sterke pådrivere i allmennlegers beslutninger. Allmennlegene syntes at en holistisk forståelse av sykdommen og å involvere pasienters erfaringsbasert kunnskap i beslutningene er viktig for adekvat behandling av den enkelte pasienten. Samlet støtter resultatene av de tre studiene integrativ og samhandlingsbasert behandling av KOLS pasienter med eksaserbasjoner. De heterogene, komplekse og ofte individualiserte KOLS eksaserbasjoner krever en fleksibel ramme for beslutninger som integrerer både biomedisinsk kunnskap og andre typer kunnskap som er basert på menneskers erfaring og relasjoner. En slik integrativ forståelse av kunnskap vil kunne guide fremtidig klinisk forskning og utvikling av retningslinjer i å ta større hensyn til medisinsk kunnskap og ekspertise fra primærhelsetjenesten og pasienter, og vil også kunne fremme samhandling basert på deling av kunnskap og ansvar mellom pasienter og helsepersonell, og helsepersonell imellom.en_US
dc.description.doctoraltypeph.d.en_US
dc.description.popularabstractChronic obstructive pulmonary disease (COPD) is a chronic lung disease that affects many people worldwide. COPD patients experience repeatedly that their symptoms deteriorate for a short period (COPD exacerbation). These exacerbations of the illness affect the patients’ quality of life and are costly for the healthcare systems, especially when patients have to be treated in the hospital. It is therefore a main goal in COPD care to treat exacerbations early and optimally in primary care. Antibiotics and oral corticosteroids are typical treatment options, but it is not clear which patients that are treated in primary care actually benefit from these medications. This thesis aimed to investigate different perspectives on how COPD patients with exacerbations are managed in primary care, with a focus on decision-making regarding treatment with antibiotics and oral corticosteroids and hospitalization. Therefore, we evaluated national and international COPD guidelines, and interviewed COPD patients about self-treatment of COPD exacerbations and general practitioners (GPs) about how they manage COPD exacerbations. Our findings show that treatment criteria in COPD guidelines, such as breathlessness and purulent sputum, are of little use to decide whether antibiotics and/or oral corticosteroids are necessary. The interviews with COPD patients revealed that making treatment decisions for COPD exacerbations based on such medical uncertainty can result in hesitation to start self-treatment and eventually in more severe exacerbations. Fear of the consequences of wrong decisions was also a major challenge for GPs, and our findings from the GP interviews showed that GPs may therefore treat and hospitalize patients even if they do not know if it is necessary. Importantly, it seemed as if GPs’ knowledge about their patients, and the patients’ own experience from previous exacerbations can be helpful for GPs to interpret the often diffuse symptoms and to make reasonable treatment decisions for the individual patient. Overall, the findings of this thesis support a collaborative approach to management of COPD exacerbations that is grounded on a trustful patient-physician relationship. This may help to reduce uncertainty and related worries for both patients and GPs, and could make it easier for patients to contact their GPs when feeling uncertain with self-treatment. We argue that improvement of care for COPD patients in primary care requires healthcare systems that allow for the development of long-term patient-physician relationships, and more focus on communication and collaboration with patients in the education of future healthcare professionals.en_US
dc.description.sponsorshipThe Norwegian Research Council, The Norwegian Research Fund for General Practice, The General Practice Research Unit UiT The Arctic University of Norwayen_US
dc.descriptionThe paper II of this thesis is not available in Munin. <br> Paper II: Laue, J., Melbye, H., Risør, M. B.: “Self-treatment of acute exacerbations of chronic obstructive pulmonary disease requires more than symptom recognition – A qualitative study of COPD patients’ perspectives on self-treatment”. Published version available in <a href=http://dx.doi.org/10.1186/s12875-017-0582-8> BMC Fam Pract. 2017; 18: 8. </a>en_US
dc.identifier.urihttp://hdl.handle.net/10037/10949
dc.language.isoengen_US
dc.publisherUiT The Arctic University of Norwayen_US
dc.publisherUiT Norges arktiske universiteten_US
dc.rights.accessRightsopenAccessen_US
dc.subject.courseIDDOKTOR-003
dc.subjectVDP::Medical disciplines: 700::Clinical medical disciplines: 750::Family practice: 751en_US
dc.subjectVDP::Medisinske Fag: 700::Klinisk medisinske fag: 750::Allmennmedisin: 751en_US
dc.subjectVDP::Medical disciplines: 700::Clinical medical disciplines: 750::Lung diseases: 777en_US
dc.subjectVDP::Medisinske Fag: 700::Klinisk medisinske fag: 750::Lungesykdommer: 777en_US
dc.titleManaging exacerbations of chronic obstructive pulmonary disease - An investigation of treatment decisions from a primary care perspectiveen_US
dc.typeDoctoral thesisen_US
dc.typeDoktorgradsavhandlingen_US


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