Improving referral from primary care to pulmonary rehabilitation for patients with COPD

Watson, Jane Suzanne ORCID: 0000-0001-8637-7121 (2022). Improving referral from primary care to pulmonary rehabilitation for patients with COPD. University of Birmingham. Ph.D.

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Pulmonary Rehabilitation (PR) is an essential non-pharmacological intervention for patients with chronic obstructive pulmonary disease (COPD), yet rates of referral across the UK are persistently low. There is little research on the perspectives of health care referrers which could highlight avenues for interventions that could improve referral rates.


Drawing on the principles of implementation science and including psychological theory offered by the Theoretical Domains Framework (TDF) and the Capability Opportunity Motivation and Behaviour model (COM-B), a multiphase mixed methods approach has been used. This commenced with a systematic review to identify previously tested PR referral uptake and adherence enhancing interventions. Then an inductive qualitative research study was carried out, followed by a second deductive approach where the TDF was applied to the original qualitative findings. This supported the generation of belief statements which informed a survey for distribution amongst a wider primary health care professional population. This sought to test the generalisability of the qualitative findings and used a sequential exploratory mixed methods approach. The findings from all individual approaches were then integrated to highlight key practice based referral barriers and enablers and inform intervention development, which utilised COM-B and its associative Behaviour Change Wheel (BCW).


The systematic review showed there is a paucity of controlled studies that have evaluated referral, uptake and adherence interventions. Patient held COPD scorecards and training respiratory healthcare professionals in motivational interviewing alongside personalised care planning may be effective referral enhancing strategies.

The combined Primary Health Care Practitioners (PHCP) qualitative and quantitative investigations showed referral to PR is complex. There are multiple barriers and very few enablers, which relate to three populations: patients, PHCPs and PR providers, individually and collectively. Key findings highlight that PR knowledge and awareness is important, but intrinsic and extrinsic factors pertinent to patients, systems and providers affect subsequent referral behaviours, both positively and negatively. However, PHCPs with respiratory qualifications report having greater confidence in answering patient’s questions and to refer more frequently than those without.

Intervention design using COM-B and the BCW is time consuming and challenging. However, its use highlighted PHCPs ‘unconscious beliefs (termed ‘automatic motivation’) around a number of perceived patient factors affected referral behaviours. Nevertheless, PHCPs consider PR beneficial for patients with COPD and describe wanting to refer more patients.


PHCPs decisions to refer patients with COPD to PR are influenced by many factors before and during the physical PR referral process. Interventions need to consider how to enhance collaborative working across patients, PHCPs and PR providers in order to increase PR awareness, uptake and completion. It must also consider intervention fidelity. Adopting targeted strategies to increase PR awareness that address patients and PHCPs motivations and enhancing PR provider engagement are likely to help. Testing these interventions within a cluster RCT are recommended next steps.

Type of Work: Thesis (Doctorates > Ph.D.)
Award Type: Doctorates > Ph.D.
Licence: All rights reserved
College/Faculty: Colleges (2008 onwards) > College of Medical & Dental Sciences
School or Department: Institute of Applied Health Research
Funders: None/not applicable
Subjects: R Medicine > RA Public aspects of medicine
R Medicine > RA Public aspects of medicine > RA0421 Public health. Hygiene. Preventive Medicine


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