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2019 HSR&D/QUERI National Conference Abstract

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1026 — "Not Until I Have To": Veteran Care Seeking and Delay of Care During COPD Exacerbations

Lead/Presenter: Vincent Fan,  COIN - Seattle/Denver
All Authors: Fan VS (VA Puget Sound, University of Washington), Young JP (VA Puget Sound), Simpson TL (VA Puget Sound, University of Washington) Battaglia C (VA Eastern Colorado, University of Colorado) Trivedi R (VA Palo Alto, Stanford University) Simons C (VA Puget Sound) Edelman JD (VA Puget Sound, University of Washington) Swenson ER (VA Puget Sound, University of Washington) Locke E (VA Puget Sound) Kramer CB (VA Puget Sound, University of Washington)

Objectives:
Chronic obstructive pulmonary disease (COPD) is the 3rd leading cause of death in the U.S. and is characterized by exacerbations often requiring hospitalization. Many exacerbations cannot be prevented, therefore early treatment is key in preventing COPD hospitalizations. Since many people fail to seek timely care during exacerbations, we sought to understand how Veterans perceived symptoms and what led them to seek or delay care.

Methods:
We conducted semi-structured interviews with Veterans with COPD who experienced a recent exacerbation to understand their care seeking. Participants were asked to describe the course of their recent and past exacerbations, including onset, coping, care seeking, and treatment. Interviews were audio-recorded, transcribed, and analyzed using content analysis.

Results:
A total of 45 Veterans (96% male; mean age 70; mean MRC dyspnea 2.6) completed interviews. Although all Veterans recognized the onset of new exacerbation symptoms, few reported consistently seeking timely treatment. Almost all described a desire to avoid seeking care for practical (time, cost, transportation, inconvenience) or psychosocial (not wanting to deal with it, stubbornness, not wanting to be a bother) reasons. Veterans presented a common approach to responding to symptoms: 1. Often evaluating symptoms as not urgent enough to necessitate care seeking; 2. "Waiting it out" in hopes that symptoms resolved; 3. Active symptom management ; 4. Seeking care only when self-management strategies were exhausted, symptoms became unbearable or "bad enough", episodes went on for longer than anticipated, or a caregiver encouraged them to seek treatment. Some Veterans described "waiting too long" which resulted in urgent care seeking, hospitalization, and delayed recovery. Negative consequences from previously delaying care, clinician reinforcement, and caregiver encouragement were described as contributing to earlier care seeking.

Implications:
Commonly held beliefs and behavior patterns may lead Veterans to delay care for exacerbations even when they recognize and are familiar with managing their symptoms. Past negative consequences, caregiver encouragement, and clinician reinforcement appear to reduce delaying care.

Impacts:
Clinicians can play an important role in encouraging early care seeking for COPD exacerbations. Addressing the practical and psychosocial factors associated with delaying care is critical to creating effective patient-centered COPD management plans.