No abstract

BackgroundPulmonary rehabilitation (PR) is a cost-effective, internationally recommended intervention for patients with chronic obstructive pulmonary disease (COPD). Referral is predominately led by primary healthcare practitioners (PHCPs), but referral and patient uptake is poor.AimTo understand barriers and enablers for PHCPs when considering patient referral to PR, to explore the influence of patient characteristics, and to understand how referral rates may be increased.Design and settingPHCPs who care for and refer patients with COPD to PR were purposively selected from general practices across Cambridgeshire and Peterborough, and the West Midlands.MethodA qualitative study. Semi-structured interviews were undertaken to theme saturation, exploring PR referral. Images depicting patients with varying COPD severity were used to stimulate memory and associative recall. Interviews were recorded, transcribed verbatim, and analysed using rapid qualitative analysis.ResultsA total of 19 PHCPs were interviewed. Barriers to PR referral included limited awareness of the clinical benefits, little knowledge of local PR providers, consultation time constraints, and presumed low patient motivation. While practice nurses had the greatest knowledge, they still described difficulty in promoting PR. PHCPs frequently described assessing patient suitability based on presumed accessibility, social, and disease-specific characteristics rather than the clinical benefits of PR. Referrals were facilitated by financial incentives for the practice and positive feedback from patients and providers.ConclusionThere were more barriers to PR referral than enablers. Providers must engage better with PHCPs, patients with COPD, and carers, and actively promote PR. Increasing PHCPs’ awareness of the benefits of PR, financial incentives, and alternative referral pathways should be considered.

SUMMARY. Urinary excretion rates of transferrin, albumin. N-acetyl-8-Dglucosaminidase (NAG) and a-I-microglobulin (A1 M) were measured in type 2 (non-insulin-dependent) diabetic patients at diagnosis and after 6 and 12 weeks treatment. Initially 21 (53%) patients had elevated transferrin excretion rates. The proportion of patients with raised transferrin excrction rates fcll to 30% at 6 wccks and 20% at 12 wecks with treatment of diabetcs. At diagnosis I 1 (28%) paticnts had elevated albumin excretion rates and 10 of these had clevatcd transferrin excrction rates. After 6 weeks treatment only six ( 1 So/,) had elevatcd albumin excrction ratcs and by 12 wecks this number had fallen to four (IOYO). NAG and A I M lcvcls also fcll with treatment of diabetes. There were correlations betwccn the transfcrrin cxcrction rate and albumin excretion rate ( r = 0436. P < 0.OOOl). transfcrrin excrction ratc and NAG ( r = 0.46, P < O.OOOl), and transferrin excrction ratc and A I M ( r = 0.55, P < 0.00Ol) at each visit. Therc were weaker correlations between thc albumin excretion rate and A I M and NAG at each visit. The correlations between the transfcrrin excretion ratc and markers of tubular function (NAG and AIM) suggest that tubular dysfunction may play a part in rcnal loss of transfcrrin in diabetes mellitus. There were no differences in transferrin excretion rates between patients with and without evidence of complications. Additional key phrases: alhuminuria; alpha-I-mi~~ro,~lohulin~ N-acetyl-hero-Dglucosamin idase