Title:	PR Toolkit – Development of an intervention to increase utilisation of Pulmonary Rehabilitation (PR) in primary care
Background:	In the UK approximately 1.2 million people live with chronic obstructive pulmonary disease (COPD), a progressive lung disease in which people experience breathlessness, exercise incapacity and are vulnerable to exacerbations, frequently requiring hospitalisation. COPD costs the NHS £800m pa, mostly relating to hospital admissions. NICE recommends that pulmonary rehabilitation (PR), providing supervised exercise and education, is offered to patients functionally disabled by COPD. PR leads to improvements in exercise capacity and quality of life and fewer repeat exacerbations requiring hospitalisation, thus contributing to NHS savings. However, although there are some promising interventions which may improve referral and uptake, PR is underutilised in England and Wales. In 2013/14 referrals accounted for only 15% of normative need and those who attended assessment accounted for 10% of normative need. 51% of referrals are from primary care. This project will develop an evidence-based, affordable toolkit to increase primary care referrals to PR and the number of patients who take up an offer. It will interface with working practices/systems and incorporate resources, informed by research, to overcome barriers to referral and uptake and support facilitating factors.
Methodology description:	Mixed methods will include survey and qualitative research to develop a theory-based toolkit informed by three closely aligned theories. Normalisation Process Theory (NPT) will be used to understand how healthcare professionals (HCPs) routinise management of COPD, including PR referral. Patient experience will be understood through Burden of Treatment Theory, a structural model of the relationship between treatment burden and patients’/carers’ capacity to undertake work required to manage their condition. Health service responses to reduce this burden will be understood through the Minimally Disruptive Medicine Care Model, a patient-centred approach in which patients and professionals work together to advance patient goals whilst imposing the smallest possible treatment burden. We will survey all GP practices in East of England to identify how barriers to PR referral and uptake can be overcome and identify existing resources for possible inclusion in the toolkit. Survey data will be mapped to referral and uptake data from PR services in East of England to explore relationships between referral processes and geographical variation in referral and uptake. Semi-structured interviews and focus groups will be held with patients and accompanying carers, practice nurses, GPs, physiotherapists delivering PR and commissioners, sampling from CCG areas that have low and high utilisation of commissioned places. Qualitative data will be analysed following a framework analysis approach. NPT and burden of treatment constructs will inform a deductive coding structure supplemented by inductive coding to allow unexpected findings to emerge.
Sample group description:	The study team will develop the toolkit with a toolkit user group (HCPs and patients/carers) using an iterative design process from concept to development, including acceptability and usability testing. Built on a WordPress platform, it will be created in the live location immediately. We will then evaluate it with practice nurses in five primary care practices over four weeks to assess real life performance and exploratory efficacy testing. Toolkit content will be defined from the research but could include existing educational materials such as DVDs or novel electronic prompts/templates, links to guidelines/decision-support tools with options for printing. Simple, practical and flexible, it will provide key information about what makes a difference to PR referral and uptake. An online platform will enable ongoing development/updating.The research will explore patient and professional ideas to increase referral and uptake and use this understanding to develop a practical and flexible toolkit of resources for integration into clinical workflows. The toolkit will address needs of HCPs and patients in decision-making about PR so that greater numbers of patients can access its benefits.
Funder:	NIHR Research for Patient Benefit (RfPB)
Collaborators:	Dr. Jonathan Fuld (PI), CUH, Dr. Frances Early, CUH, Dr. Ian Wellwood, PCU, Professor Sally Singh, Professor Patricia Wilson, Ms Lianne Jongepier, Ms Ruth Barlow
Project organisation
Start date:	1st April 2017
End date:	31st August 2018
Contact person:	Professor Christi Deaton
Contact Details:	Telephone: 01223 330335 E-mail: cd531@medschl.cam.ac.uk
Further Information, References and Publications