title: Working with primary care clinicians and patients to introduce strategies for increasing referrals for pulmonary rehabilitation.
abstract: BACKGROUND
  Pulmonary rehabilitation (PR), a programme of exercise, education and psycho-social support, is recommended for patients with chronic obstructive pulmonary disease but referral rates are relatively low compared with need.
  
  
  OBJECTIVE
  Working with primary care clinicians (GPs and practice nurses) from eight practices, this project developed strategies for influencing clinician and patient behaviours as a means of increasing referral rates for PR.
  
  
  METHODS
  A participatory action research design was employed. Semi-structured questionnaires captured clinicians' baseline knowledge of PR and their ideas for increasing referrals. Actionable changes were then recommended. Audits (at baseline, mid-point and end of project) were used to assess and initiate improvements in the quality of practice data about PR referrals. The impacts of these changes were explored via further clinician surveys (free text questionnaire). Semi-structured questionnaires, posted to patients eligible for PR, assessed their characteristics, and, where applicable, their views on PR referral processes and reasons for not wanting PR.
  
  
  RESULTS
  The baseline survey of clinicians (n=22) revealed inadequate knowledge about PR, particularly among GPs. Actionable changes recommended included in-house education sessions, changes to practice protocols, and 'pop-ups' and memory aids (mugs and coasters) to prompt clinician/patient discussions about PR. Audit findings resulted in changes to improve the quality and availability of coded information about patients eligible for PR. These changes, supported by clinicians (n=9) in the follow-up survey, aimed to facilitate and increase the quality of patient/clinician discussions about PR. Findings from the patient survey (n=126, response rate 25.7%) indicate that such changes will increase the uptake of PR as patients who accepted a referral for PR provided more positive feedback about their discussions with clinicians.
  
  
  CONCLUSIONS
  The strategies introduced were relatively easy to implement and the anticipated advantage is more patients accessing the health and quality of life benefits that PR offers.
authors.affiliation: 1Former Research Associate,Health Services Research,Health Service Research Unit,Keele University,Keele,Staffordshire,UK.
authors.forename: Faye
authors.initials: F
authors.lastname: Foster
authors.affiliation: 2Clinical GP Research Fellow,Research Institute of Primary Care and Health Sciences,Keele University,Keele,Staffordshire,UK.
authors.forename: Rosie
authors.initials: R
authors.lastname: Piggott
authors.affiliation: 3Research Associate,Biostatistics,Health Service Research Unit,Keele University,Keele,Staffordshire,UK.
authors.forename: Lucy
authors.initials: L
authors.lastname: Riley
authors.affiliation: 4Reader in Health Services Research,Research Institute of Primary Care and Health Sciences,Keele University,Keele,Staffordshire,UK.
authors.forename: Roger
authors.initials: R
authors.lastname: Beech
mesh_terms: D000328:Adult; D000368:Aged; D001291:Attitude of Health Personnel; D003657:Decision Making; D005260:Female; D058005:General Practitioners / Q000523:psychology*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009042:Motivation; D009741:Nursing Staff, Hospital / Q000523:psychology*; D010361:Patients / Q000523:psychology*; D011320:Primary Health Care / Q000458:organization & administration*; D029424:Pulmonary Disease, Chronic Obstructive / Q000534:rehabilitation*; D012017:Referral and Consultation; D011795:Surveys and Questionnaires
keywords: COPD; behaviour; delivery of health care; participatory research; pulmonary rehabilitation