The study shows that hospitalisation of patients with serious asthma or COPD often takes place after a telephone consultation with a doctor, or by the patient going directly to the hospital. In our material, only 59 of the admissions (59 %) were based on a recent clinical examination. Patients who had previously been hospitalised with COPD or asthma exacerbation were more often admitted following a telephone consultation than patients who had not previously been hospitalised with these diagnoses (data not shown). This may indicate that those who have previously been hospitalised for exacerbation are more often convinced from their own experience that hospitalisation is called for. The high frequency of telephone consultations may also be an indication that clinical examination and the tests available to the primary doctor are not attributed much weight in the decision to hospitalise. It is likely that both patient and doctor feel that examination at a doctor's office or A&E will not contribute substantially or constructively and only lead to detrimental delay of the hospitalisation.
Admission to hospital following a telephone consultation was more common in Helgeland than in Tromsø. This may be due to variable availability at the municipal A&E units and different procedures with respect to requiring that the primary doctor verify hospitalisations. It may also be due to large variations in distance to doctor’s office and hospital. The likelihood of patients being hospitalised after a telephone conversation rose with increasing age. The doctors’ decisions were doubtless well founded when the patient was well known or clearly seriously ill. But when this happens as frequently as this study indicates, one may wonder whether some patients might be served equally well by an option of treatment outside hospital.
Telephone contact can also be a source of good advice. A survey from the UK has shown that ready access to telephone consultations for COPD patients may contribute to reducing the number of hospitalisations (8).
One may wonder how representative our findings are. There were about 200 admissions to Helgeland Hospital and the University Hospital of North Norway that could be considered for inclusion in the study. If we exclude those who died and those who were too sick or too mentally incapacitated to answer the questionnaire, there were probably not many more than the 122 to whom the questionnaire was distributed who could have been included. Since responses from 100 (82 %) of these could be analysed, we can assume that the results are relatively representative for the hospitals that participated.
The age and gender composition of the material corresponds to the national figures. However, there may be differences from one part of Norway to another with respect to how the doorkeeper function of the primary doctors is practised for this kind of patient. The completion of the questionnaire survey may also represent sources of error. Although patients were asked about events in the recent past, some may have responded incorrectly nonetheless because they do not remember details of the course of events or because questions were misinterpreted.
In this study we see reality from the perspective of a hospital. The picture would have been different if we had taken all patients with asthma or COPD exacerbation as our starting point and investigated how many contact doctors and what treatment is given. We would probably then have had a patient material where a minority would have been hospitalised.
In this material, those who initially contacted their primary doctor had to wait longer on average for hospitalisation than those who contacted A&E (data not shown). This may reflect the fact that those who contact A&E are sicker than those who contact their primary doctor. Primary doctors may also be more confident about treating the patient outside hospital than A&E doctors, as it is easier for them to provide close follow-up.
Doctors in the primary health-care service do not have unambiguous guidelines to follow in connection with asthma and COPD exacerbations. Spirometry can reveal whether the patient's respiration has become more obstructive; CRP measurement can provide information about the severity of the exacerbation and the probability of bacterial infection (9, 10), and pulsoximetry that shows reduced SpO2 can also say something about severity and indicate whether oxygen treatment should be given. However, the usefulness of these tests has not been evaluated to any great extent in connection with asthma and COPD exacerbations in general practice, and pulsoximetry is the only one that is recommended in international guidelines (1, 11, 12).
Doctors are in need of tools of this kind when deciding on treatment of exacerbations, as well as a sound knowledge of the severity of the disease, previous exacerbations and any comorbidity the patient may have. A clinical examination remains important for determining how ill the patient is and whether anxiety is contributing to their breathing problems. In many cases, primary doctors, with their knowledge of the patient, will be in a better position to make a good clinical assessment than the A&E doctor.
Primary doctors have two main options today when it comes to asthma and COPD exacerbation: hospital treatment and treatment at home. If it were also possible to admit the patient to an infirmary with access to blood gas measurement, X-rays and non-invasive respiratory support, primary doctors would have to expand their basis for decision-making and a thorough prehospital examination would be even more relevant. In other Western countries there has been fruitful testing of treatment at home, by hospital personnel, of patients with COPD exacerbation who had first been examined in Reception with a view to admission. This treatment has been regarded as suitable for about a quarter of the patients (13).
Recent COPD research indicates that it will be appropriate to divide COPD into sub-groups that are to receive different treatments (4, 14). This will also have a bearing on handling of exacerbations. It will entail a need for continuing professional development, also for GPs, and development of routines that instil confidence in both primary doctors and patients.