AS we know, pulmonary rehabilitation (PR) is regarded by the recent British Thoracic Society (BTS) 2013 guidelines as a “fundamental treatment”’ for chronic obstructive pulmonary disease (COPD) as opposed to an “optional extra”.
This would suggest that medication and exercise/education (PR) shares equal importance as part of the management of COPD. Yet, my attendance to the BTS Winter 2014 conference suggested otherwise!
After Dr Neil Greening had completed his inspiring talk on PR after COPD exacerbation, the panel asked for a show of hands regarding post exacerbation referrals and access to PR. Only a dismal show of hands were raised in the Churchill auditorium that morning…
Furthermore, before a recent Clinical Commissioning Group (CCG) presentation, I asked the audience about their baseline understanding of PR, and to my disappointment very few people had awareness about what constitutes PR and its importance in the holistic management of COPD. This raised the question – as physiotherapists, are we failing our patients in both primary and secondary care settings with regards to access to PR and helping our patients understand its value?
Most recently there are examples of recent research that I feel highlights where we are going wrong.
The recent work of Fleming et al (2013) explored the patient acceptability post acute exacerbation of COPD (AECOPD) through face to face audio and video taped interviews. Despite the small sample size the patients responses began forming a recurring theme which was that they had a poor recall of information given to them whilst an inpatient. Fleming et al. emphasises that other themes that were prominent including improving PR accessibility and enhancing social aspects of PR.
Interestingly Greening et al (2014) looked at an early intervention to enhance recovery during hospital admission for an exacerbation of chronic respiratory disease using a randomised controlled trial. They found that for those patients that did attend, pulmonary rehabilitation was effective, but found that the vast majority did not attend for the duration of the course.
Consequently the question raised by Greening’s research was: should the focus for PR be on outpatients in a stable state and by identification of a person’s phenotype?
Drawing from these pieces of research, the overall problem is clear: poor educational awareness of healthcare professionals about the importance of PR and medication optimisation for COPD patients.
Reassuring, explaining the social, supportive and nurturing aspect of PR to people could be a key factor in helping with suitability for referral (identification of phenotypes) and attendance rates mentioned by Greening et al (2014).
Are we getting enough time with our patients to do this? Pressure on beds and high turnover would suggest that perhaps this is not a frequent occurrence in secondary care.
One answer may be to increase the pressure on more NHS Trusts to implement COPD related care bundles based on the successful examples from other Trusts. An example of when it works is my former trust (University Hospitals of Leicester NHS Trust) and the Respiratory Discharge Service (REDS) team who have delivered a discharge care bundle for patients with COPD admitted to Glenfield Hospital. Part of the care bundle process involves people being assessed for their suitability for PR.
Perhaps we should be pushing for respiratory departments to make an effort for more in-service programmes in improving awareness of PR amongst respiratory, acute medical unit or clinical decisions unit ward staff. Maybe there already is? If there is it should be more celebrated. Let’s not forget the role of our current outpatient PR teams.
The responsibly to underpin PR importance also falls to our current PR teams to help educate multidisciplinary teams across GP practices and clinics.
Again, if this is already happening we should be celebrating it and also exploring the impact on referrals from secondary care.
In conclusion, it appears that Twitter is bridging the previously distant gap between special interest groups and teams across the country, helping us learn from each other, share findings and research e.g. #Resp Ed, @, @.
If we know research supports PR, our overall goal as a multidisciplinary team dealing with COPD should be to prioritise better accessibility and patient understanding as opposed to satisfying audits and service statistics.
Steven Jackson is a physiotherapist practising in the UK with a special interest in respiratory care, specifically people suffering from chronic obstructive pulmonary disease
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