Barriers to, and facilitators for, referral to pulmonary rehabilitation in COPD patients from the perspective of Australian general practitioners: a qualitative study.

BACKGROUND: Pulmonary rehabilitation (PR) is recommended in the management of people with chronic obstructive pulmonary disease (COPD), but referral to this service is low. AIMS: To identify barriers to, and facilitators for, referral to PR programmes from the perspective of Australian general practitioners. METHODS: Semi-structured interviews were conducted with general practitioners involved in the care of people with COPD. Interview questions were informed by a validated behavioural framework and asked about participants' experience of referring people with COPD for PR, and barriers to, or facilitators of, this behaviour. Interviews were audiotaped, transcribed verbatim, and analysed using content analysis. RESULTS: Twelve general practitioners participated in this study, 10 of whom had never referred a patient to a PR programme. Four major categories relating to barriers to referral were identified: low knowledge of PR for COPD; low knowledge of how to refer; actual or anticipated access difficulties for patients; and questioning the need to do more to promote exercise behaviour change. Awareness of benefit was the only current facilitator. Three major categories of potential facilitators were identified: making PR part of standard COPD care through financial incentive; improving information flow with regard to referrals and services; and informing patients and public. CONCLUSIONS: Significant barriers to referral exist, but opportunities to change the organisation of practice and information management were identified. Behaviour change strategies which directly target these barriers and incorporate facilitators should make up the key components of interventions to improve referral to PR by general practitioners who care for people with COPD.

Barriers and enablers to physical activity participation in patients with COPD: a systematic review.

PURPOSE: Physical activity (PA) has been shown to improve symptoms in people with chronic obstructive pulmonary disease (COPD). Despite the high health and financial costs, the uptake of management strategies, particularly participation in PA and pulmonary rehabilitation (PR), are low. The review objective here was to identify potential barriers and enablers, which people with COPD report being associated with their participation in PA programs, including PR. METHODS: A systematic search was undertaken to identify studies (published Jan 2000 to Aug 2011) reporting any barriers and enablers experienced by people with COPD regarding participation in PA and PR. Methodological quality of the studies was appraised using McMaster critical appraisal tools. A narrative summary of findings was undertaken reporting on individual study characteristics, country of origin, participants, and potential barriers and enablers. RESULTS: Eleven studies (8 qualitative and 3 quantitative) met the inclusion criteria for this systematic review. Several methodological issues (small sampling, poor description of data collection and analysis, issues with generalizability of the research findings) were common among included studies. Barriers identified included changing health status, personal issues, lack of support, external factors, ongoing smoking, and program-specific barriers. Enablers identified included social support, professional support, personal drivers, personal benefit, control of condition, specific goals, and program-specific enablers. CONCLUSION: The findings from this review may assist health professionals, patients, care givers and the wider community to develop effective strategies to promote participation in PA and PR among people with COPD.

A holistic client-centred program for vulnerable frequent hospital attenders: cost efficiencies and changed practices.

OBJECTIVE: A small percentage of Australians frequently attend hospital emergency departments (ED) with potentially avoidable health crises. These individuals are termed 'vulnerable' due to their complex health and social needs. When these needs are unmanaged, unnecessary ED and hospital-admission costs are incurred. A holistic community-based program was developed to engage a cohort of vulnerable individuals in strategies to improve their health and health behaviours, and health service use. METHODS: A purposive sample of frequent ED attendees was identified in one Australian metropolitan health region. Core program elements included working with clients within their environment, problem solving, empowerment, education, goal setting and mentoring. Evaluation data included services provided for, and time spent with, clients; hospital admission and emergency department attendances and related costs; client engagement data; mental health measures; client stories and participant interviews. RESULTS: Data was analysed from 37 clients. On average, staff spent 34 hours with each client, costing approximately $1,700 each. Significant improvements resulted in client health and health behaviours. Crisis emergency department and inpatient admissions decreased, and planned outpatient clinic use increased. CONCLUSION: Low-cost community-based intervention for frequent ED attendees has the potential for significant tertiary hospital savings.