The study found an increase in pulmonary rehabilitation referrals, but no ‘statistically significant’ differences in clinical outcomes.
Chronic obstructive pulmonary disease (COPD) may be more effectively treated in a GP-physiotherapist based model of care, a study has found.
Published in BMC Primary Care, the small study was conducted across four general practices in the Northern Sydney LHD over a period of three months. The results indicate that the inclusion of a physiotherapist in a primary care team increased referrals to pulmonary rehabilitation, but clinical outcomes showed “no statistically significant” differences.
More broadly, the authors believe the study highlights the benefits of multidisciplinary models of care.
“In the current climate, where a key focus of the Strengthening Medicare Taskforce centres around access to multidisciplinary team care, we think these findings are useful in showing us different multidisciplinary models and new ways of working in primary care that have positive impacts for patient health outcomes,” lead author Dr Lisa Pagano told ARR.
COPD was the fourth leading cause of disease burden in Australia in 2022, and is associated with worse health outcomes and higher mortality rates – but disease progression can be slowed, resulting in better health outcomes.
“Strategies aimed at optimising disease management and increasing uptake of interventions such as pulmonary rehabilitation (PR) are essential to reducing the burden of COPD on healthcare systems,” the study authors stated.
Looking at ways to improve PR referrals and attendance is a key priority for policymakers. PR is regarded as “the cornerstone of non-pharmacological management”, and is essentially a program encapsulating supervised exercise training, education, and behaviour reform. Guidelines state that all patients of COPD – regardless of severity – will benefit from PR. But referral rates to PR remain low, with 0-11% of stable patients being referred to PR, with most referrals happening at later stages.
While the study found that the GP-physiotherapist model of care resulted in a greater number of PR referrals, PR attendance remained “suboptimal” at the three-month mark.
At three months, 78% of patients in the study were referred to PR, but only 38% attended. The authors indicate that lower attendance rates could be attributed to factors beyond the clinical GP setting. For example, patients were more likely to attend PR if they believed their lung disease was severe enough to warrant extra attention. As the participants in this study were diagnosed with COPD of a lower severity, “it is likely they may not have felt the need to participate in PR”.
However, attendance rates were higher than the general population, where it is estimated that only 5-10% of Australians with moderate to severe COPD have accessed a PR program.
Overall, the results of the study showed significant improvements from the treatment of COPD in practice.
Moreover, the increase in uptake in PR referrals was largely due to the experience of the physiotherapists in the study, who had “extensive experience in PR programs”. Therefore, if this model is implemented in practice, physiotherapists who are less experienced may not have the same levels of success.
The implementation of experienced physiotherapists alleviated issues that GPs face in managing treatment of COPD – with the report citing time constraints and a “lack of confidence managing COPD, and low efficacy in discussions surrounding PR, physical activity and complex behaviour change”.
Dr Pagano said clinicians who participated in the study believed “the GP’s and physiotherapist’s skills really complemented one another, especially in areas such as physical activity prescription”.
However, the results fell short on clinical outcomes, such as patient-reported symptoms, physical activity levels and health status scores, which showed no statistically significant improvements. But the study suggested that a smaller improvement may still be clinically relevant, due to the more “light touch” interventions used in the study. This would be consistent with other studies that looked into multidisciplinary approaches into early intervention of COPD.
Despite a lack of statistically significant improvements, the authors stressed that uptake of the intervention was “significantly better, with 78% completing the three-month follow-up assessment”.
The lack of change attributed to these factors may also be explained by the fact that most participants were classified as having new diagnoses of COPD, with the majority classified as GOLD stage I or II. Symptoms attributed to milder cases were identified as being “difficult to significantly improve over a short intervention period”.
Further, over the three months patients only received two follow-up appointments – which may be “insufficient to evoke long-term change in physical activity levels”. This highlights that “more frequent intervention, such as attending a PR program, may be necessary to encourage change in physical activity”. Additionally, the minimal change in physical activity levels may be attributed to the fact that most participants already had high physical activity levels and had “little room for further improvement”.
Researchers also found that the GP-physiotherapist model of care improved “key management components” such as increased rates of pneumococcal vaccination, initiation or review of action plans and smoking cessation interventions.
“Our findings are encouraging and may reflect the benefit of utilising physiotherapists whose scope of practice in chronic disease management includes the delivery of multiple interventions”, the authors wrote.
