FRESH AIR implementation studies
Anastasaki, Marilena & Trigoni, Maria & Pantouvaki, Anna & Trouli, Marianna & Mavrogianni, Maria & Chavannes, Niels & Pooler, Jillian & van Kampen, Sanne & Jones, Rupert & Lionis, Christos & Tsiligianni, Ioanna. (2019). Establishing a pulmonary rehabilitation programme in primary care in Greece: A FRESH AIR implementation study. Chronic Respiratory Disease. 16. 147997311988293. 10.1177/1479973119882939.
For more on FRESH AIR go to www.ipcrg.org/FRESHAIR
2018 WHO paper identifies lack of GP referral to pulmonary rehabilitation as a problem
"Scoping review WHO conducted a scoping review on rehabilitation and PHC using the PubMed database. The search string rehabilitation [Title/Abstract] AND “primary health care” OR “primary care” [Title/Abstract] was used, including studies published in English between 2008 and 2018. Of the 530 abstracts that were examined, 246 were excluded. A further 78 were excluded following full text review, resulting in 212 included in the final analysis. Key findings Most of the literature reviewed (89%) came from high-income settings. Thematically, 64% of analysed studies mentioned referral to rehabilitation by the primary care workforce, while others referenced rehabilitation carried out in a primary care setting (25%), or explored the idea of rehabilitation in the primary care context (11%). One key issue repeatedly mentioned in the literature was under-referral to rehabilitation by the primary care workforce. For example, several studies focused on the under-utilization of pulmonary rehabilitation for COPD, despite overwhelming evidence of its benefits for all symptomatic COPD patients (31, 38– 41). A systematic review of surveys and audits found that only 3–16% of eligible COPD patients were referred to pulmonary rehabilitation (42). Reasons for underreferral include lack of knowledge about pulmonary rehabilitation, particularly among GPs, and insufficient resources (3, 43)"
See paper: Access to rehabilitation in primary health care: an ongoing challenge. Working Draft. 2018. Technical Series on Primary Health Care
Read our desktop helper on how to refer
Unfortunately Pulmonary rehab is not specified in a 2019 WHO Factsheet but we will continue to make the case for raising its profile.
There are some general toolkits:
Assessment tools (general)
Assessing quality of life and disease control
Exercise guidelines and exercise prescription
Idea for the aerobic component of the FITT principle exercises:
Barriers to adherence
"In a large national dataset, we have shown that patients living in more deprived areas are less likely to complete PR. However, deprivation was not associated with clinical outcomes in patients who complete therapy. Interventions targeted at enhancing referral, uptake and completion of PR among patients living in deprived areas could reduce morbidity and healthcare costs in such hard-to-reach populations."
Note: there is now a published Cochrane protocol Young J et al 2017 Interventions to promote referral, uptake and adherence to pulmonary rehabilitation for people with chronic obstructive pulmonary disease (COPD)
Role of psychology and psychologists
The diverse and evolving role of a psychologist within a respiratory multidisciplinary team (MDT) is described, providing a working model for service provision. The rationale for appointing a psychologist within a respiratory MDT is presented first, citing relevant policy and research and outlining the wider psychosocial impact of respiratory disease. This is followed by an insight into the psychologist’s role by highlighting important areas, including key therapy themes and the challenge of patient engagement. The way in which the psychologist supports the collective aims and aspirations of respiratory colleagues to provide a more holistic package of care is illustrated throughout.
Treating tobacco dependence
The simplest is a visual analogue scale from 0-10 that you can make. Other tools are available but subject to copyright. These include
Self management plans
References regarding PR and cost effectiveness
Mosleh SM, Bond CM, Lee AJ, Kiger A, Campbell NC. Effectiveness of theory-based invitations to improve attendance at cardiac rehabilitation: A randomized controlled trial. Eur J Cardiovasc Nurs [Internet]. 2014;13(3):201–10. Available from: https://doi.org/10.1177/1474515113491348
References from our desktop helper and position paper
Pulmonary rehabilitation reduced hospital admissions and mortality compared with usual community care (no rehabilitation). Quality of life was also improved and the effect was substantially larger than the minimal important difference. Pulmonary rehabilitation appears to be a highly effective and safe intervention in COPD patients after suffering an exacerbation.
Overall, evidence of high quality shows moderate to large effects of rehabilitation on health-related quality of life and exercise capacity in patients with COPD after an exacerbation. Some recent studies showed no benefit of rehabilitation on hospital readmissions and mortality and introduced heterogeneity as compared with the last update of this review. Such heterogeneity of effects on hospital readmissions and mortality may be explained to some extent by the extensiveness of rehabilitation programmes and by the methodological quality of the included studies. Future researchers must investigate how the extent of rehabilitation programmes in terms of exercise sessions, self-management education and other components affects the outcomes, and how the organisation of such programmes within specific healthcare systems determines their effects after COPD exacerbations on hospital readmissions and mortality.
Although results from RCTs suggested that PR reduces subsequent exacerbations, pooled results from the cohort studies did not favour PR, likely reflecting the heterogeneous nature of individuals included in observational research and the varying standards of PR programmes.
Cost-effectiveness and affordability - the business case
This home-based pulmonary rehabilitation model, delivered with minimal resources, produced short-term clinical outcomes that were equivalent to centre-based pulmonary rehabilitation.
Note that the shortcut to these resource pages on pulmonary rehabilitation is www.ipcrg.org/PR