Pulmonary rehabilitation referral and uptake from primary care for people living with COPD: a mixed-methods study

Abstract

Pulmonary rehabilitation (PR) for people with COPD leads to clinically significant improvements in quality of life and exercise capacity [1]. In England and Wales, UK, in 2013-2014, only 15% of eligible patients were referred (51% from primary care), of whom 31% did not attend assessment [2]. We aimed to generate a theory-informed understanding of enablers and barriers to PR referral and uptake from primary care.This mixed-methods study [3] used normalisation process theory (NPT) [4] to understand how PR referral becomes embedded in clinical practice via NPT constructs of coherence (how clinicians understand and value PR), cognitive participation (how PR referral is sustained in practice), collective action (how PR referral is operationalised) and reflexive monitoring (how clinicians judge whether PR referral is worthwhile). Burden of treatment theory (BoT) [5] informed understanding of the patient experience via parallel constructs relating to how patients make sense of their condition and treatment, how they organise self-care work, what taking up PR involves for patients and how patients judge if PR is worthwhile.Online surveys (dichotomous, multiple response, Likert scales and free-text items) were sent to all PR providers in the East of England (EoE), to other PR providers in England and Wales who contributed to the national COPD audit, and to all primary care practices in the EoE. Purposive sampling was used to recruit for semistructured interviews and focus groups, targeting all EoE PR providers and, in EoE areas with higher and lower PR utilisation rates, general practitioners (GPs), practice nurses, commissioners and patients (white British and South Asian) who had accepted a PR offer, declined PR or were not referred. Survey, interview and focus group questions were mapped to NPT constructs. Qualitative data and free-text survey responses were analysed following a framework approach [6] informed by NPT constructs. Qualitative data collection and concurrent analysis continued until saturation was achieved, i.e. deductive codes were adequately represented and no new codes identified [7]. Quantitative data were analysed descriptively. GP and nurse survey responses were compared using Chi-squared analysis. Research questions and interview/focus group guides were reviewed by the patient and participant involvement group.Informed consent was obtained from all participants. The study was approved by Cambridge Central Research Ethics Committee (ref. 17/EE/0136).EoE primary care practices (107 out of 415, 25.8%), EoE PR services (14 out of 20, 70%), and other England and Wales PR services (46 out of 179, 25.7%) completed the surveys. 32 clinicians, six commissioners and 42 COPD patients took part in interviews and focus groups. 28 patients had accepted a PR offer, seven had declined, seven were not referred and seven were of South Asian heritage (table 1).From the survey and qualitative research, we identified enablers and barriers across six domains (figure 1). @ERSpublications Healthcare service and patient ba...

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