Referral of patients with chronic obstructive pulmonary disease to pulmonary rehabilitation from primary care: A local survey of GPs and practice nurses

Introduction

Chronic obstructive pulmonary disease (COPD) is a progressive lung disease associated with breathlessness, inability to exercise, frequent infections and hospitalisation (Early et al. 2019). Pulmonary rehabilitation (PR) is a multidisciplinary programme involving exercise training, disease education and behavioural interventions shown to significantly improve symptoms of dyspnoea and exercise capacity in patients with COPD (Nici et al. 2006). Within Northern Ireland (NI), COPD is the second most common reason for emergency admission to hospital with about 30% of patients being readmitted within 3 months (NI COPD Audit 2017). PR reduces the number and duration of respiratory hospital admissions and readmissions experienced (Steiner et al. 2015). PR is also recommended within the National Institute for Health and Care Excellence (NICE) quality standards (2011) for patients with COPD exercise limitation due to breathlessness.

Despite the clear benefits, implementation of PR programmes in people with COPD is reported to be low, with only 3%–16% of eligible patients being referred, and as few as 1%–2% gaining ongoing access to such programmes (Johnston & Grimmer-Somers 2010). A recent study by Watson et al. (2020) found referral barriers included limited awareness of clinical benefits, little knowledge of local PR providers, consultation time constraints and presumed low patient motivation. A review by Milner et al. (2018) previously had reported that the most frequently identified enablers of PR referral were PR training, mentoring or experience in PR, with other enablers such as PR awareness events, reminders and a streamlined referral process. Early et al. (2019) also found that nurses felt more prepared than GPs to make referrals and reported a better understanding of PR. In addition, nurses felt they lacked support from GPs in reinforcing PR discussions with patients.

The rationale for the study was borne from the acknowledgement by the principal investigator (LG) that previous attempts to offer PR training and information sessions, as well as the provision of awareness events to local primary care services, had resulted in limited engagement. Retrospective analysis of PR referral numbers locally had also identified a 10% reduction over the preceding 3-year period. A large proportion of this reduction was attributed to a reduction in general practitioner (GP) referral numbers.

The aim of this article was to understand why referral rates of people with COPD to PR from primary care are low and then to identify referral barriers and ascertain facilitators for improving referral rates. It was envisaged that an understanding of referral may facilitate improved referral rates and ultimately patient outcomes. The study aims to also ascertain differences between GPs and practice nurses (PNs) with regards to exertional breathlessness questioning and PR education.

Methods

Study design

The study involved a cross-sectional survey focusing on the referral of patients with COPD by GPs and PNs to PR, knowledge of local PR services, referral barriers and strategies to improve referral rates.

Survey procedure

Recruitment took place through meeting the practice managers (PMs) of 19 prospective GP practices within a single locality of a local health and care trust and discussing the aims of the study. PMs who consented to assist with the study acted as a communication conduit between the research team and GPs/PNs. The PMs were advised to distribute the survey to all GPs within their practice and PNs involved in the management of patients with COPD. Those PMs who agreed for their practices to participate in the study distributed a participant information sheet and the survey in paper format, or directed them to an electronic version, to all those eligible for inclusion in the study. 1 month was given to complete the survey. After 2 weeks the principal investigator contacted the PMs within each practice to determine engagement and reinforce completion.

Survey format

There was no questionnaire available that met the aims of this study therefore the questionnaire was developed independently and piloted in 2 GP practices. Four participants completed the questionnaire in the pilot period and feedback highlighted no issues with question completion and therefore the questionnaire was distributed in its initial format. To encourage participation, the survey was in the form of a multiple-choice questionnaire (Appendix 1) with 13 closed checklist type questions, designed to take less than 20 minutes to complete, given the time constraints within primary care. To help improve response rate, the survey was available in either a digital format and was provided on the platform Survey Monkey, or a paper copy distributed by the PMs. A study by Taylor & Scott (2018) which reviewed physician’s preference with regards surveys recommended the use of mixed mode survey design to accommodate doctors with different mode preferences.

Data analysis

On completion of the 1-month data collection period electronic data was exported from Survey Monkey and from the paper copies to SPSS Version 25. The data was analysed using simple descriptive analysis including modal and percentage response rates. Inferential statistical analysis in the form of chi-square (χ2) was performed to compare GPs and PNs responses with regards exertional breathlessness exploration/determination of Modified Research Council (MRC) score and discussion of PR benefits, with the value of p <0.05 considered to be statistically significant.

Ethical issues

This research study was granted ethical approval by the Ulster University Research Governance Filter Committee in September 2019 (reference: RG3_2019-091). Ethical implications of the research were considered and identified as informed consent, anonymity of responses, independent recruitment and safe storage of data in line with Ulster University General Data Protection Regulations 2018. The study design ensured that all responses received either electronically or in paper copy form were anonymous.

Results

Figure 1 shows a flow chart depicting the recruitment process.

The combined completion rate for the survey was 34%.

Caseload

Regarding the estimated percentage of patients reviewed by respondents that have a diagnosis of COPD, 71% (n = 17) of respondents estimated this to be less than 25% of their total patient caseload. Other estimates included, 25% (n = 6) of between 25–50% of their caseloads, and 4% (n = 1) of between 50–75% of their caseloads. No respondents estimated that >75% of their caseload included patients with COPD.

Use of NICE quality statements and referral to PR

In terms of the knowledge of the NICE quality standards related to PR in COPD, 88% (n = 21) of respondents stated that that they were aware of the statements.

Regarding the questioning of patient’s around breathlessness on exertion and MRC score, 82% (n = 9) of PNs and 23% (n = 3) of GPs answered that they regularly explored this issue. A statistically significant relationship was found with regards to PNs being more likely than GPs to discuss breathlessness on exertion and MRC score, Χ2 = 8.2 (p <0.05). Regarding PR education, 91% (n = 10) of PNs and 43% (n = 6) of GPs stated that they discuss benefits with service users that meet referral criteria. The relationship was deemed to be statistically significant with Χ2 = 5.37 (p <0.05). Respondents estimated the percentage of patients COPD that they refer to PR. Overall, 83% (n = 20) of respondents estimated that they referred less than 50% of their patients to PR and 17% (n = 4) of respondents did not refer any patients to PR.

Knowledge of PR in local area and referral process

71% (n = 17) of respondents were aware of the location and structure of the classes within their local area and 92% (n = 22) were aware of the referral process.

Barriers to referral

The main barrier to PR identified by the respondents (Figure 2) was perceived patient unwillingness or refusal to accept a referral to a PR programme with 63% (n = 15) responses citing this as the main barrier.

Figure 2: Main barrier for referral to PR program.

Service user barriers

58% (n = 14) of respondents perceived the main barrier to service users in attending a PR programme was that they did not understand the potential benefits, whilst 25% (n = 6) felt patients had a fear of exercising (Figure 3).

Figure 3: Main barrier for patients attending a PR program.

Methods to improve referral rates

29% (n = 7) of respondents felt that information in the form of leaflets/posters for patients would be the best intervention to improve referral rates to PR (Figure 4).

Figure 4: Key intervention to improve patient referral rate.

As outlined in Figure 5, 88% (n = 21) of respondents indicated that they would like more information regarding PR, with a wide variety of responses observed in terms of specific information.

Figure 5: Beneficial information.

Discussion

The survey was carried out due to a pattern of reduced PR referrals to a local respiratory service from primary care in order to better understand the barriers and enablers for PR referral. The aim was to use the findings to implement methods to improve PR referral rates within the local area, since previous attempts to implement educational and information sessions had poor engagement levels.

In terms of PR referral barriers, the findings of this study demonstrate similarities to that of Watson et al. (2020). The main views of respondents on the perceived barriers of referral to PR were patient unwillingness/refusal to attend (63%) and time constraints within the consultation (17%), with clinicians reporting that another significant patient barrier to attending PR is a lack of understanding of the benefits (58%).

Patient refusal to attend PR is a common theme in the literature. Grant et al. (2012) reports that 45% of patients refuse a referral to PR following an exacerbation of COPD and a further 45% do not attend the initial assessment. Early et al. (2018) report that the influence of the referring doctor and lack of explanation of the benefits is a referral barrier. It is important to consider that clinicians may decide to make their own assumption as to whether a patient will attend PR, rather than definitively offering referral and explaining the benefits. This fact is supported by Rochester et al. (2018) who found that 2⁄5 of respondents reported that their health care provider had never told them about PR or the potential benefits. Clinicians should also strongly convey the benefits of PR in terms of reduced hospital admissions and improved quality of life to patients in order to improve uptake rates. Sohanpal et al. (2015) highlighted that reasons for attending included a trusted, enthusiastic doctor who explained the benefits, perceived increased severity of the condition, perceiving that PR would help increase control and independence and improve health, and perceived social benefits.

According to the survey responses PNs reported that they questioned patients around breathlessness and MRC score and the responses indicate the PNs were also more likely to promote PR than GPs, with a statistically significant difference evident. Watson et al. (2020) found that PNs had greater knowledge than GPs regarding PR and this finding is pertinent to consider in the context of referral rates within this survey. Despite this finding, it also needs to be considered that the nature of the consultations may also be different, in that PNs discuss breathlessness and MRC scores during annual review consultations versus GPs who are more likely to review patients for exacerbations of COPD.

Within the survey, 4 GPs cited time constraints within the consultation process as the main barrier to referring patients to PR. Given the fact that GP workload is estimated to have increased by 15% in the last 7 years (Fisher et al. 2017) this is particularly pertinent. There have been recommendations to extend appointment times to 15 minutes as this would allow GPs to spend more time on health promotion (Oxtoby 2010), which would be extremely cost effective for the National Health Service in the long run but given increasing appointment pressures this would be extremely difficult to implement. For the PNs carrying out annual COPD reviews, it may be that more time is available for these consultations where time to discuss self-management techniques is therefore possible.

This survey has several limitations with the small sample size used being the most evident. In addition, the GP response rate within the study was only 23%, although published response rates from medical practitioners is often below 30% (Bonevski et al. 2011). The low GP engagement within the study raises questions regarding response bias (Bjertnaes et al. 2008) as well as non-response bias. Within the survey every effort was made to reduce response bias and therefore improve reliability of responses by using well designed questions, keeping the survey short and maintaining respondent anonymity. With regards to non-response bias, the PMs were contacted 2 weeks after the survey was disseminated in order to encourage participation. Whilst an improved response rate would have been desirable in order to improve the external validity of the results, low response rates should not be cited as reasons to dismiss results as uninformative (Meterko et al. 2015).

PMs were used as a communication conduit in an attempt to reduce non-response and respondent bias but in hindsight may have introduced an element of sampling bias. PM feedback identified 14 PNs responsible for the management of patients with COPD and it is not possible to ascertain whether other PNs who reviewed patients with COPD were unavailable during the study period. Given PNs can have multiple roles within GP practices and may not review patients with COPD PMs were asked to distribute the survey to the appropriate PN, however this may have led to sampling bias. Of the 16 GP practices surveyed there were a total of 75 GPs registered as working at these sites, although the PMs distributed the survey to only 56 GPs. It is acknowledged that all GP staff working in a practice may not have been available during the 1-month survey period, however sampling bias cannot be ruled out given that 25% of GPs were not distributed a survey. In addition, the fact that a convenience sample was used limits the ability to control for confounding bias within the survey. Confounding factors not considered were clinician experience, previous PR training that respondents had attended and experience in dealing with patients with COPD, which may have influenced answers provided within the survey, particularly around MRC and PR promotion.

Another limitation with the study is the fact that clinicians provided perceived answers to some survey questions, rather than using actual raw data. However, on discussion with PMs, practices did not have the systems in place to capture this information. This may have affected the survey validity and it is therefore imperative to bear this in mind when considering the survey outcomes. Despite this, within the study it is evident that there is a clear need to improve referral rates to PR as 59% (n = 14) of respondents estimated referring less than 25% of patients who meet the referral criteria and 17% (n = 4) referring no patients at all. An important factor that potentially limits referral to PR is the fact that 71% of respondents estimated that less than 25% of their caseload was comprised of patients with a diagnosis of COPD, therefore some clinicians may not they have the necessary skills to promote PR. A survey by Rochester et al. (2018) confirmed the need for greater healthcare professionals’ knowledge and awareness of PR to foster patient referrals. Interestingly knowledge of local PR services in terms of location and class structure was reported at 71% within the local area but given this was self-reported this should be viewed with caution given the fact that 88% of respondents felt that they could benefit from more information regarding PR.

29% of respondents also felt that patient information leaflets/posters would assist in improving referral rates. This is a pertinent point given previous research recommends that professional societies and patient groups develop educational materials for people with chronic respiratory disease regarding PR (Rochester et al. 2018). 25% (n = 6) of respondents felt that computer-based prompts would assist in improving referral rates. A study by Angus et al. (2012) used a computer guided consultation and found that 24% of patients with confirmed COPD were referred to PR. A systematic review by Roshanov et al. (2011) also detailed the use of electronic decision support systems in the management of chronic disease and found that just over half of the systems improved patient health. Unfortunately, only 4 studies within the review investigated systems to support the management of patients with COPD and the evidence to support its use in this context is limited. Despite this the studies did not all incorporate key factors associated with effectiveness and further research in this area is warranted.

Conclusion

In this local survey, referral from primary care to PR in the COPD population appeared to be underutilised by clinicians. Within this survey it is apparent that referral rates remain low for a variety of reasons but primarily since clinicians perceive that patients are unwilling to accept a referral, as well as GPs citing time constraints within the consultation process. PNs reported that they question patients about their MRC scores and educate patients regarding PR more than their GP colleagues, although the context of the consultation needs to be considered alongside this. This study supports the need for further research around PR promotion and referral from primary care, particularly amongst GPs, in order to positively promote its benefits and improve service utilisation.

Key points

• Within this local survey, PR referral from primary care is underutilised with an ongoing need for promotion of the health benefits of PR programmes.

• A predominant barrier to PR referral identified by respondents is the patient willingness to attend, with respondents reporting that another barrier is a lack of understanding from the patient as to the benefits of PR.

• PNs reported that they question service-users around exertional breathlessness and educate around the benefits of PR was significantly higher than participating GPs (p <0.05).

Declaration of conflicting interest

The author(s) can confirm that there are no conflicts of interest.

Funding

The research received no grant from any funding agency in the public, commercial or not-for-profit sectors.

Acknowledgments

Sincere thanks to Dr Daniel Kerr (supervisor) for his assistance and guidance throughout the completion of this study.

Thanks to the practice managers who agreed to assist and distribute this survey to staff within their practices.

Thanks to the GPs and practice nurses who took the time to complete the survey.

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