The effects of an innovative GP-physiotherapist partnership in improving COPD management in primary care

Abstract

Background Evidence suggests that management of people with Chronic Obstructive Pulmonary Disease (COPD) in primary care has been suboptimal, in particular, with low referral rates to pulmonary rehabilitation (PR). The aim of this study was to evaluate the effectiveness of a GP-physiotherapist partnership in optimising management of COPD in primary care. Methods A pragmatic, pilot, before and after study was conducted in four general practices in Australia. A senior cardiorespiratory physiotherapist was partnered with each general practice. Adults with a history of smoking and/or COPD, aged ≥ 40 years with ≥ 2 practice visits in the previous year were recruited following spirometric confirmation of COPD. Intervention was provided by the physiotherapist at the general practice and included PR referral, physical activity and smoking cessation advice, provision of a pedometer and review of inhaler technique. Intervention occurred at baseline, one month and three months. Main outcomes included PR referral and attendance. Secondary clinical outcomes included changes in COPD Assessment Test (CAT) score, dyspnoea, health activation and pedometer step count. Process outcomes included count of initiation of smoking cessation interventions and review of inhaler technique. Results A total of 148 participants attended a baseline appointment where pre/post bronchodilator spirometry was performed. 31 participants with airflow obstruction on post-bronchodilator spirometry (mean age 75yrs (SD 9.3), mean FEV1% pred = 75% (SD 18.6), 61% female) received the intervention. At three months, 78% (21/27) were referred to PR and 38% (8/21) had attended PR. No significant improvements were seen in CAT scores, dyspnoea or health activation. There was no significant change in average daily step count at three months compared to baseline (mean difference (95% CI) -266 steps (-956 to 423), p = 0.43). Where indicated, all participants had smoking cessation interventions initiated and inhaler technique reviewed. Conclusion The results of this study suggest that this model was able to increase referrals to PR from primary care and was successful in implementing some aspects of COPD management, however, was insufficient to improve symptom scores and physical activity levels in people with COPD. Trial registration ANZCTR, ACTRN12619001127190. Registered 12 August 2019 – Retrospectively registered, http://www.ANZCTR.org.au/ACTRN12619001127190.aspx.

Combined Lifestyle Interventions in the Prevention and Management of Asthma and COPD: A Systematic Review

“…Only two (4%) studies reported on eating behaviour and both found improvements, described as a decrease in total energy intake and increase in protein intake [86] and an increase in eating a balanced diet [76] (Figure 3A). Nine (19%) studies reported on PA levels, of which five found an increase in PA level [64,67,70,76,96] and four found no effect [63,65,69,95]. Out of 10 (21%) studies reporting an outcome on smoking cessation, only one found a decrease in the number of current smokers [66], while the other nine studies did not find any effect [35,59,63,70,71,76,89,90,95].…”

“…Nine (19%) studies reported on PA levels, of which five found an increase in PA level [64,67,70,76,96] and four found no effect [63,65,69,95]. Out of 10 (21%) studies reporting an outcome on smoking cessation, only one found a decrease in the number of current smokers [66], while the other nine studies did not find any effect [35,59,63,70,71,76,89,90,95]. No studies measured the effects on alcohol consumption or sleeping behaviour and only one study reported a decrease in stress level [94].…”

“…A total of 47 studies were included, of which 26 were RCTs [33,35,, 3 were nonrandomised controlled trials [76][77][78], and 18 were single group pre-post studies [34,[79][80][81][82][83][84][85][86][87][88][89][90][91][92][93][94][95]. The methodological quality of the studies ranged from strong to weak, with the majority being moderate and strong (Figure S1, quality assessment table available on https://osf.io/2jcm7).…”

“…Based on the mean levels of forced expiratory volume in 1 s (FEV1) reported across the studies, the majority of the patients had moderate COPD according to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) [6]. The majority of the studies reported on interventions with a duration of 8-12 weeks [52,53,56,57,60,69,72,73,[77][78][79][80][81][82][83][84][86][87][88]90,91,[93][94][95], but also very short-term (3-6 weeks [54,62]) and longer term (i.e., 4 months to 1 year [34,35,55,59,61,64,65,67,70,71,74,75,85,89] and extending beyond 1 year [58,63,66]) interventions were included. Sixteen studies (34%) investigated a pulmonary rehabilitation programme that targeted more than one lifestyle factor [52,54,…”

“…2) [35,52,55,[57][58][59]62,63,69,[73][74][75][76][77][78][79][83][84][85]87,88,[90][91][92]. Furthermore, there were 15 (32%) CLIs focusing on a combination of two lifestyle targets [33,34,53,60,64,66,68,[70][71][72]80,81,86,93,95], five (11%) focusing on a combination of four lifestyle targets [54,65,67,82,94], and three (6%) focusing on a combination of five lifestyle targets [56,61,89]. The highest number of CLIs targeted the combination of diet + PA + smoking (n = 14, 30%), followed by the combination of PA + smoking (n = 8, 17%; Figure…”