Background Chronic cough is a common symptom in primary care. There appears to be significant variation in investigation and empirical treatment prior to referral on to secondary care. We looked at; a) Investigation/treatment undertaken prior to referral to secondary care and b) a survey of how GPs manage cough.
Method The study consisted of; a) Retrospective review of referrals (January 2012-January 2013) to a secondary care cough clinic and b) an online questionnaire on cough distributed to colleagues in primary care.
Results Of the primary care referrals, 47/58 casenotes were available (mean age was 59(27–84), 63% female). Only 4/47(8.7%) were current smokers. Median duration of symptoms at referral was 7 months (2–420), 35/47(74.5%) had a chest X-Ray prior to referral, 18/47(39.1%) spirometry, 3/47 had used ACE inhibitors. Most investigations performed prior to referral were normal. Empirical treatment attempted included; antireflux therapy 23/47(50%), inhaled corticosteroids 12/47(26.1%) and nasal steroids 9/47(19.6%). Various other treatments were used (including cough suppressants, antihistamines, leukotriene receptor antagonists and antibiotics) in 22/47(46%).
Only 16/51(31%) of questionnaire respondents were aware of published cough guidelines. Most respondents were aware of the definition of chronic cough (37/51(72.5%)). When asked to list the 3 commonest causes of chronic cough, asthma was identified by 33 (64.7%), GORD by 38 (74.5%) and rhinitis/post-nasal drip by 20 (39.2%). Treatments most commonly initiated included acid suppression (PPI’s) 33/51(64.7%), nasal spray 18/51(35.3%) and inhaled steroids 4/51(7.8%). The majority of patients do not get referred on to secondary care; 34/51(66.6%) of respondents estimate they refer less than 10% of cases. Referral was usually triggered by the following factors - unclear diagnosis, failed treatment, patient concern or abnormal tests.
Conclusions Many patients are referred on to secondary care without basic investigations and appropriate trials of recommended therapy. Knowledge of chronic cough in primary care is limited and most GPs are unaware of published guidelines. Increased education and awareness of cough guidelines could improve management of cough in the community. This is a topic that requires further systematic study as there is very little research in this area.
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