Barriers Hinder Primary Care Providers From Referring Patients With COPD to Pulmonary Rehabilitation

A lack of relationships with pulmonary rehabilitation providers and provider perceptions about patient acceptance serve as limiting factors, new research shows.

For patients with chronic obstructive pulmonary disease (COPD), pulmonary rehabilitation (PR) can be a low-cost, highly effective treatment option, often resulting in improved exercise capacity, reduced symptoms, and a better prognosis. Yet, the therapy remains under-utilized, largely due to a lack of referrals from primary care providers.

In a new study in BMJ Open, corresponding author Rachel Elizabeth Jordan, MA, MPH, PhD, of the University of Birmingham in the United Kingdom, and colleagues reported on barriers to and enablers of PR referrals. Their results suggest there are more barriers than enablers, and the barriers are complex.

In previous research, Jordan and colleagues said they found that often, referrals were based on factors such as patient characteristics rather than patient need.

“In summary, referrers reported many barriers but few enablers, which collectively resulted in infrequent discussions about PR and associated referrals,” the authors said.

While that earlier research helped identify barriers and enablers, the investigators wanted to better understand the relative importance of those barriers and enablers, and how psychological and structural elements affected providers’ behaviors.

Jordan and colleagues enrolled 252 primary care providers, asking them to participate in 1 of 2 phases. The first phase consisted of semi-structured interviews among 19 providers. Next, 233 providers were asked to complete a 54-item questionnaire based on the Theoretical Domains Framework (TDF), which is designed to understand how to influence behaviors.

The results showed physicians who had specific respiratory qualifications, such as COPD or asthma diplomas, were nearly twice as likely to refer patients to PR than those without (59.1% vs 32.2%). Providers with more than a decade of experience were also slightly more likely to refer patients to PR.

When Jordan and colleagues looked at particular barriers, they found that a major problem was infrequent engagement between rehabilitation providers and referrers, as well as concern about whether patients would be able to handle PR or access it.

The investigators reported that primary care providers “collectively reported low confidence in patients’ and motivations to attend PR, a belief likely to be strengthened by reports of few patients requesting referral.”

The authors said that phenomenon may explain why referrals are more common when patients’ symptoms are getting worse; perhaps providers are more likely to suggest PR at those times since they assume patients might be more likely to accept such a referral.

They said providers who were networked with PR providers or other providers with an interest in respiratory were more likely to refer patients to PR. In addition, having a dedicated time to suggest referrals (such as an annual review), and offering on-screen referral prompts within practice software helped enable referrals.

Jordan and colleagues said most providers in the study did not believe financial incentives would affect their referral rates. That question was not assessed in the study, although the authors said a study of incentives for referrals to diabetes programs did not lead to a significant jump in referrals.

The investigators closed by noting that the COVID-19 pandemic caused many providers to temporarily cancel in-person PR. They said a resulting backlog of patients will complicate the issue and cause providers to need to consider how they will manage a potential surge of patients requiring the therapy.


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. Published online January 19, 2022. doi:10.1136/bmjopen-2020-046875

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