Objectives To evaluate usefulness of limited community based care for patients with chronic obstructive pulmonary disease after discharge from hospital. Design Randomised controlled trial.

Objective: To evaluate a partnership model of care for patients with a diagnosis of chronic obstructive pulmonary disease (COPD). Design, setting and participants: Cluster randomised controlled trial with blinded outcome assessment of 44 general practices in south-western Sydney comprising 451 people with a diagnosis of COPD, conducted between 2006 and 2009. Intervention: Participants from intervention group practices were visited at their home by a registered nurse with specific training in COPD care who worked with the general practitioner, the patient and other health professionals to develop and implement an individualised care plan based on best-practice guidelines. Participants from control group practices received usual care. Main outcome measures: The primary outcome was disease-related quality of life measured using the St George's Respiratory Questionnaire (SGRQ) at 12-month follow-up. Other outcomes were overall quality of life, lung function, smoking status, immunisation status, patient knowledge of COPD, and health service use. Results: Of the 451 participants, 257 (57.8%) were confirmed as having COPD on postbronchodilator spirometry. Follow-up was completed for 330 patients (73.2%). At 12 months, there was no statistically significant difference in the mean SGRQ scores between intervention and control groups (38.7 v 37.6; difference, 1.1; 95% CI, -1.53-3.74; P =0.41) or in measures of quality of life, lung function and smoking status. Compared with the control group, in the intervention group, attendance at pulmonary rehabilitation was more frequent (31.1% v 9.6%; OR, 5.16; 95% CI, 2.40-11.10; P =0.002) and the mean COPD knowledge score was higher (10.5 v 9.8; difference, 0.70; CI, 0.10-1.21; P=0.02). Conclusion: The nurse-GP partnership intervention did not have an impact on disease-related quality of life at 12-month follow-up. However, there was evidence of improved quality of care, in particular, in attendance at pulmonary rehabilitation and patient knowledge of COPD. 1 Guidelines for care of COPD provide recommendations for slowing disease progression and optimising function in people with COPD.2,3 The key interventions are smoking cessation, pulmonary rehabilitation, influenza vaccination, optimising medicines, patient education and effective management of exacerbations.There is a need for effective approaches to implementation of evidence-based treatment in primary care, where many patients with COPD are managed. Nurses, either within the practice or visiting to provide specialised care, could have a role in improving management of COPD, including by helping to implement planned care.A review of nine randomised trials of nurse-led chronic disease management for COPD concluded that there was no evidence of improvements in patients' healthrelated quality of life, psychological wellbeing, disability or pulmonary function.4 A more recent Cochrane review of nine trials of outreach programs involving nurse home visits to COPD patients concluded that providing support and education, monito...

Background Advance care planning (ACP) can offer benefits to patients and their families, especially when delivered in outpatient settings, but uptake remains low. Common barriers for health professionals include a perceived lack of time and adequate training, experience, and confidence in conducting ACP. Patient-reported barriers include a lack of awareness of ACP or discomfort initiating or engaging in discussions about end-of-life. Methods We aimed to explore patients’ perspectives of an ACP intervention designed to address common barriers to uptake in the general practice setting. We provided training and support to doctors and general practice nurses (GPNs) to initiate and lead ACP discussions at their respective practices (2014 to 2015). Following the intervention, we conducted interviews with patients to explore their experience of engaging in ACP in the general practice setting. Thematic analysis was used to inductively code transcripts and identify key themes from semi-structured interviews with patients. Results Six major themes relating to patient experiences of GPN-facilitated ACP were identified: working through ideas, therapeutic relationship with nurses, significance of making wishes known, protecting family from burden, autonomy in decision-making, and challenges of family communication. The patients valued the opportunity to speak about issues that are important to them with the GPN who they found to be compassionate and caring. The patients felt that ACP would lead to significant benefits not only to themselves but also for their family. Despite encouragement to involve other family members, most patients attended the ACP discussions alone or as a couple; many did not see the relevance of their family being involved in the discussions. Some patients felt uncomfortable or reluctant in communicating the results of their discussion with their family. Conclusions With adequate training and support, GPNs are able to initiate and facilitate ACP conversations with patients. Their involvement in ACP can have significant benefits for patients. Psychosocial and relational elements of care are critical to patient satisfaction. Our findings show that some patients may feel uncomfortable or reluctant to communicate the results of their ACP discussions with their family. A future larger study is required to verify the findings of this pilot study.

Intervention uptake was low and had no additional beneficial effect, over usual care, on participants' health-related QoL.

Objectives: To compare the clinical diagnosis of chronic obstructive pulmonary disease (COPD) with results of post‐bronchodilator spirometry in general practice, and examine practitioner, practice and patient characteristics associated with agreement between clinical and spirometric diagnoses. Design, setting and participants: General practitioners from practices in Sydney identified eligible patients aged 40–80 years seen in the past year and prescribed respiratory medications whom they regarded as having COPD. Between November 2006 and April 2008, we collected information on the GPs and their practices, and demographic information, smoking status, comorbidities, respiratory medicines use, vaccination status, quality of life and spirometry results for participating patients. Main outcome measures: Frequency of COPD diagnosis on spirometry; odds ratios for characteristics associated with agreement between clinical and spirometric diagnoses. Results: 56 GPs from 44 practices participated in the study. Of 1144 eligible patients, 445 were recruited (mean age, 65 years; 49% male). Of these, 257 (57.8%) had post‐bronchodilator spirometry consistent with COPD ± asthma, 16 (3.6%) had asthma only, 82 (18.4%) had normal spirometry, and 90 (20.2%) had other spirometric diagnoses. Having a spirometer in the practice was not predictive of agreement between clinical and spirometric diagnoses. Older patient age was significantly associated with correct diagnosis, while higher numbers of comorbidities were associated with misdiagnosis. Conclusions: A substantial proportion of patients clinically identified as having COPD in general practice do not have the condition according to spirometric criteria, with inaccurate diagnosis more common in patients with comorbidities. Policy and practice change is needed to support the use of spirometry in primary care.