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Kotejoshyer R, Eve J, Priya A, Mazor K, Spitzer KA, Pekow PS, Pack QR, Lindenauer PK. Strategies to Improve Enrollment and Participation in Pulmonary Rehabilitation Following a Hospitalization for COPD: RESULTS OF A NATIONAL SURVEY. J Cardiopulm Rehabil Prev 2023; 43:192-197. [PMID: 36137210 PMCID: PMC10148891 DOI: 10.1097/hcr.0000000000000735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE Pulmonary rehabilitation (PR) improves outcomes for patients with chronic obstructive pulmonary disease (COPD); however, very few patients attend. We sought to describe strategies used to promote participation in PR after a hospitalization for COPD. METHODS A random sample of 323 United States based PR programs was surveyed. Using a positive deviance approach, a 39-item survey was developed based on interviews with clinicians at hospitals demonstrating high rates of participation in PR. Items focused on strategies used to promote participation as well as relevant contextual factors. RESULTS Responses were received from 209 programs (65%), of which 88% (n = 184) were hospital-based outpatient facilities. Most (91%, n = 190) programs described enrolling patients continuously, and 80% (n = 167) reported a wait time from referral to the initial PR visit of <4 wk. Organization-level strategies to increase referral to PR included active surveillance (48%, n = 100) and COPD-focused staff (49%, n = 102). Provider-level strategies included clinician education (45%, n = 94), provider outreach (43%, n = 89), order sets (45%, n = 93), and automated referrals (23%, n = 48). Patient-level strategies included bedside education (53%, n = 111), flyers (49%, n = 103), motivational interviewing (33%, n = 69), financial counseling (64%, n = 134), and transportation assistance (35%, n = 73). Fewer than one-quarter (18%, n = 38) of PR programs reported using both bedside education and automatic referral, and 42% (n = 88) programs did not use either strategy. CONCLUSIONS This study describes current practices in the United States, and highlights opportunities for improvement at the organization, provider, and patient level. Future research needs to demonstrate the effectiveness of these strategies, alone or in combination.
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Affiliation(s)
- Rajashree Kotejoshyer
- Department of Healthcare Delivery and Population Sciences, University of Massachusetts Chan Medical School-Baystate, Springfield (Drs Kotejoshyer, Eve, Spitzer, Pekow, Pack, and Lindenauer and Ms Priya); University of Massachusetts Chan Medical School, Worcester (Dr Mazor); and UMass Donahue Institute, Amherst, Massachusetts (Dr Spitzer)
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Watson JS, Jordan RE, Adab P, Vlaev I, Enocson A, Greenfield S. Investigating primary healthcare practitioners' barriers and enablers to referral of patients with COPD to pulmonary rehabilitation: a mixed-methods study using the Theoretical Domains Framework. BMJ Open 2022; 12:e046875. [PMID: 35045995 PMCID: PMC8772414 DOI: 10.1136/bmjopen-2020-046875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVES Pulmonary rehabilitation (PR) is a highly effective, recommended intervention for patients with chronic obstructive pulmonary disease (COPD). Using behavioural theory within mixed-methods research to understand why referral remains low enables the development of targeted interventions in order to improve future PR referral. DESIGN A multiphase sequential mixed-methods study. SETTING United Kingdom (UK). PARTICIPANTS 252 multiprofessional primary healthcare practitioners (PHCPs). MEASURES Phase 1: semistructured interviews. Phase 2: a 54-item paper and online questionnaire, based on the Theoretical Domains Framework (TDF). Content and descriptive analysis utilised. Data mixed at two points: instrument design and interpretation. RESULTS 19 PHCPs took part in interviews and 233 responded to the survey. Integrated results revealed that PHCPs with a post qualifying respiratory qualification (154/241; 63.9%) referred more frequently (91/154; 59.1%) than those without (28/87; 32.2%). There were more barriers than enablers for referral in all 13 TDF domains. Key barriers included: infrequent engagement from PR provider to referrer, concern around patient's physical ability and access to PR (particularly for those in work), assumed poor patient motivation, no clear practice referrer and few referral opportunities. These mapped to domains: belief about capabilities, social influences, environment, optimism, skills and social and professional role. Enablers to referral were observed in knowledge, social influences memory and environment domains. Many PHCPs believed in the physical and psychological value of PR. Helpful enablers were out-of-practice support from respiratory interested colleagues, dedicated referral time (annual review) and on-screen referral prompts. CONCLUSIONS Referral to PR is complex. Barriers outweighed enablers. Aligning these findings to behaviour change techniques will identify interventions to overcome barriers and strengthen enablers, thereby increasing referral of patients with COPD to PR.
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Affiliation(s)
- Jane Suzanne Watson
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | | | - Peymane Adab
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Ivo Vlaev
- Warwick Business School, University of Warwick, Coventry, UK
| | - Alexandra Enocson
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Sheila Greenfield
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
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Bickton FM, Shannon H. Barriers and Enablers to Pulmonary Rehabilitation in Low- and Middle-Income Countries: A Qualitative Study of Healthcare Professionals. Int J Chron Obstruct Pulmon Dis 2022; 17:141-153. [PMID: 35046649 PMCID: PMC8763198 DOI: 10.2147/copd.s348663] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 12/24/2021] [Indexed: 01/17/2023] Open
Abstract
Introduction Low- and middle-income countries bear a disproportionately high burden of global morbidity and mortality caused by chronic respiratory diseases. Pulmonary rehabilitation is recommended as a core intervention in the management of people with chronic respiratory diseases. However, the intervention remains poorly accessed/utilised globally, especially in low- and middle-income countries. Aim This qualitative study explored barriers and enablers to pulmonary rehabilitation in low- and middle-income countries from the perspective of healthcare professionals with pulmonary rehabilitation experience in these settings. Methods Online-based semi-structured in-depth interviews with healthcare professionals were undertaken to data saturation, exploring lived barriers and enablers to pulmonary rehabilitation in their low- or middle-income country. Anonymised interviews were audio-recorded, transcribed verbatim, and analysed using thematic analysis. Results A total of seven healthcare professionals from seven low- and middle-income countries representing Africa, Asia, and South America were interviewed. They included five physiotherapists (four females), one family physician (male), and one pulmonologist (female). Themes for barriers to pulmonary rehabilitation included limited resources, low awareness, coronavirus disease 2019, and patient access-related costs. Themes for enablers included local adaptation, motivated patients, coronavirus disease 2019 (which spanned both enablers and barriers), better awareness/recognition, provision of PR training, and resource support. Conclusion Barriers to pulmonary rehabilitation in low- and middle-income countries include limited resources, low awareness, coronavirus disease 2019, and patient access-related costs. Enablers include local adaptation, motivated patients, coronavirus disease 2019 (which spanned both enablers and barriers), better awareness/recognition, provision of PR training, and resource support. Successful implementation of these enablers will require engagement with multiple stakeholders. The findings of this study are a necessary step towards developing strategies that can overcome the existing pulmonary rehabilitation evidence-practice gap in low- and middle-income countries and alleviating the burden of chronic respiratory diseases in these countries.
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Affiliation(s)
- Fanuel Meckson Bickton
- UCL Great Ormond Street Institute of Child Health, London, UK
- Lung Health Research Group, Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Harriet Shannon
- UCL Great Ormond Street Institute of Child Health, London, UK
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Chan SC, Sekhon JK, Engkasan JP, Nathan JJ, Mirza FT, Liew SM, Hussein N, Suhaimi A, Hanafi NS, Pang YK, Yatim SM, Jackson T, Fernandes G, Habib GMM, Pinnock H, Khoo EM. Barriers and challenges of implementing pulmonary rehabilitation in Malaysia: Stakeholders' perspectives. J Glob Health 2021; 11:02003. [PMID: 34737852 PMCID: PMC8564882 DOI: 10.7189/jogh.11.02003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
- Soo Chin Chan
- Department of Rehabilitation Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Jaspreet Kaur Sekhon
- Department of Primary Care Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Julia Patrick Engkasan
- Department of Rehabilitation Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | | | - Fatim Tahirah Mirza
- Faculty of Health Sciences, Universiti Teknologi MARA, Shah Alam, Selangor, Malaysia
| | - Su May Liew
- Department of Primary Care Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Norita Hussein
- Department of Primary Care Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Anwar Suhaimi
- Department of Rehabilitation Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Nik Sherina Hanafi
- Department of Primary Care Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Yong Kek Pang
- Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | | | - Tracy Jackson
- NIHR Global Health Research Unit on Respiratory Health (RESPIRE), Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Genevie Fernandes
- NIHR Global Health Research Unit on Respiratory Health (RESPIRE), Usher Institute, University of Edinburgh, Edinburgh, UK
| | - G M Monsur Habib
- NIHR Global Health Research Unit on Respiratory Health (RESPIRE), Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Hilary Pinnock
- NIHR Global Health Research Unit on Respiratory Health (RESPIRE), Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Ee Ming Khoo
- Department of Primary Care Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
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van 't Hul AJ, Koolen EH, Antons JC, de Man M, Djamin RS, In 't Veen JCCM, Simons SO, van den Heuvel M, van den Borst B, Spruit MA. Treatable traits qualifying for nonpharmacological interventions in COPD patients upon first referral to a pulmonologist: the COPD sTRAITosphere. ERJ Open Res 2020; 6:00438-2020. [PMID: 33263050 PMCID: PMC7682701 DOI: 10.1183/23120541.00438-2020] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 08/26/2020] [Indexed: 12/28/2022] Open
Abstract
Introduction The present study assessed the prevalence of nine treatable traits (TTs) pinpointing nonpharmacological interventions in patients with COPD upon first referral to a pulmonologist, how these TTs co-occurred and whether and to what extent the TTs increased the odds having a severely impaired health status. Methods Data were collected from a sample of 402 COPD patients. A second sample of 381 patients with COPD was used for validation. Nine TTs were assessed: current smoking status, activity-related dyspnoea, frequent exacerbations <12 months, severe fatigue, depressed mood, poor physical capacity, low physical activity, poor nutritional status and a low level of self-management activation. For each TT the odds ratio (OR) of having a severe health status impairment was calculated. Furthermore, a graphic representation was created, the COPD sTRAITosphere, to visualise TTs prevalence and OR. Results On average 3.9±2.0 TTs per patient were observed. These TTs occurred relatively independently of each other and coexisted in 151 unique combinations. A significant positive correlation was found between the number of TTs and Clinical COPD Questionnaire total score (r=0.58; p<0.001). Patients with severe fatigue (OR: 8.8), severe activity-related dyspnoea (OR: 5.8) or depressed mood (OR: 4.2) had the highest likelihood of having a severely impaired health status. The validation sample corroborated these findings. Conclusions Upon first referral to a pulmonologist, COPD patients show multiple TTs indicating them to several nonpharmacological interventions. These TTs coexist in many different combinations, are relatively independent and increase the likelihood of having a severely impaired health status.
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Affiliation(s)
- Alex J van 't Hul
- Radboud University Medical Center, Radboud Institute for Health Sciences, Dept of Respiratory Diseases, Nijmegen, The Netherlands
| | - Eleonore H Koolen
- Radboud University Medical Center, Radboud Institute for Health Sciences, Dept of Respiratory Diseases, Nijmegen, The Netherlands
| | - Jeanine C Antons
- Radboud University Medical Center, Radboud Institute for Health Sciences, Dept of Respiratory Diseases, Nijmegen, The Netherlands
| | - Marianne de Man
- Bernhoven, Dept of Respiratory Diseases, Uden, The Netherlands
| | - Remco S Djamin
- Dept of Respiratory Diseases, Amphia Hospital, Breda, The Netherlands
| | - Johannes C C M In 't Veen
- Dept of Respiratory Diseases, STZ Centre of Excellence for Asthma & COPD, Franciscus Gasthuis & Vlietland Hospital, Rotterdam, The Netherlands
| | - Sami O Simons
- Dept of Respiratory Medicine, Maastricht University Medical Centre, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht, The Netherlands
| | - Michel van den Heuvel
- Radboud University Medical Center, Radboud Institute for Health Sciences, Dept of Respiratory Diseases, Nijmegen, The Netherlands
| | - Bram van den Borst
- Radboud University Medical Center, Radboud Institute for Health Sciences, Dept of Respiratory Diseases, Nijmegen, The Netherlands
| | - Martijn A Spruit
- Dept of Respiratory Medicine, Maastricht University Medical Centre, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht, The Netherlands.,Dept of Research and Development, CIRO+, Horn, The Netherlands.,REVAL-Rehabilitation Research Center, BIOMED-Biomedical Research Institute, Faculty of Rehabilitation Sciences, Hasselt University, Diepenbeek, Belgium
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Koolen EH, van den Borst B, de Man M, Antons JC, Robberts B, Dekhuijzen PNR, Vercoulen JH, van den Heuvel M, Spruit MA, van der Wees PJ, van 't Hul AJ. The clinical effectiveness of the COPDnet integrated care model. Respir Med 2020; 172:106152. [PMID: 32956973 DOI: 10.1016/j.rmed.2020.106152] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 08/14/2020] [Accepted: 09/09/2020] [Indexed: 12/28/2022]
Abstract
RATIONALE Integrated care models have the potential to improve outcomes for patients with COPD. We therefore designed the COPDnet integrated care model and implemented it in two hospitals and affiliated primary care regions in the Netherlands. The COPDnet model consists of a comprehensive diagnostic trajectory ran in secondary care followed by a non-pharmacological intervention program of both monodisciplinary and multidisciplinary components. OBJECTIVE To assess the clinical effectiveness of the COPDnet integrated care model on health status change in patients with COPD. METHODS A total of 402 patients with COPD were offered care according to the COPDnet model. At baseline and between 7- and 9-months later health status was measured with the Clinical COPD Questionnaire (CCQ). Primary analysis was carried out for the sample at large. In addition, subgroup analyses were performed after stratification for the type of non-pharmacological intervention where patients had been referred to. RESULTS The CCQ total score improved statistically significantly from 1.94 ± 1.04 to 1.73 ± 0.96 (P < 0.01) in the 154 patients with valid follow-up measurements. Subgroup analyses revealed significant improvements in the patients receiving pulmonary rehabilitation only. No change in health status was found in patients receiving pharmacotherapy only, carried out self-treatment or who participated in mono-disciplinary primary care offered by allied healthcare professionals. CONCLUSIONS An improved health status was found in patients with COPD who received care according to the COPDnet integrated care model. Subgroups participating in an interdisciplinary pulmonary rehabilitation program predominantly accounted for this effect.
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Affiliation(s)
- E H Koolen
- Radboud University Medical Center, Radboud Institute for Health Sciences, Department of Respiratory Diseases, 6525 GA, Nijmegen, the Netherlands
| | - B van den Borst
- Radboud University Medical Center, Radboud Institute for Health Sciences, Department of Respiratory Diseases, 6525 GA, Nijmegen, the Netherlands
| | - M de Man
- Bernhoven, Department of Pulmonary Diseases, 5406 PT, Uden, the Netherlands
| | - J C Antons
- Radboud University Medical Center, Radboud Institute for Health Sciences, Department of Respiratory Diseases, 6525 GA, Nijmegen, the Netherlands
| | - B Robberts
- Radboud University Medical Center, Radboud Institute for Health Sciences, Department of Respiratory Diseases, 6525 GA, Nijmegen, the Netherlands
| | - P N R Dekhuijzen
- Radboud University Medical Center, Radboud Institute for Health Sciences, Department of Respiratory Diseases, 6525 GA, Nijmegen, the Netherlands
| | - J H Vercoulen
- Radboud University Medical Center, Radboud Institute for Health Sciences, Department of Medical Psychology, 6525 GA, Nijmegen, the Netherlands
| | - M van den Heuvel
- Radboud University Medical Center, Radboud Institute for Health Sciences, Department of Respiratory Diseases, 6525 GA, Nijmegen, the Netherlands
| | - M A Spruit
- Department of Respiratory Medicine, Maastricht University Medical Centre, NUTRIM School of Nutrition and Translational Research in Metabolism, 6229 HX, Maastricht, the Netherlands; Department of Research and Development, CIRO+, 6085 NM, Horn, the Netherlands; REVAL-Rehabilitation Research Center, BIOMED-Biomedical Research Institute, Faculty of Rehabilitation Sciences, Hasselt University, 3590 BE, Diepenbeek, Belgium
| | - P J van der Wees
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ Healthcare, Department of Rehabilitation, 6525 GA, Nijmegen, the Netherlands
| | - A J van 't Hul
- Radboud University Medical Center, Radboud Institute for Health Sciences, Department of Respiratory Diseases, 6525 GA, Nijmegen, the Netherlands.
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Informal carers and peer support in pulmonary rehabilitation: an underutilized resource? Curr Opin Support Palliat Care 2020; 14:213-218. [PMID: 32740276 DOI: 10.1097/spc.0000000000000517] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW The aim of this review is to discuss the recent literature relating to the involvement of informal carers and peer support in pulmonary rehabilitation. RECENT FINDINGS Informal carers and peer support have been identified by both patients and healthcare workers as a crucial component in the care of those with chronic respiratory disease at home. Pulmonary rehabilitation, a cornerstone in the management of patients with breathlessness, is limited in its clinical effectiveness by poor referral, uptake and completion rates. Engagement of informal carers and support from peers may help maximize the utilization of pulmonary rehabilitation. SUMMARY This review highlights the need for more good-quality randomized controlled trials in identifying suitable interventions that may increase uptake and completion of pulmonary rehabilitation programmes. Qualitative studies have highlighted the potential for informal carers and peer support to play a key role in the design of research programmes, and in the delivery of pulmonary rehabilitation. This needs to be addressed in future research.
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