Abstract
ABSTRACTObjective To assess clinicians’ knowledge about pulmonary rehabilitation, and identify the barriers faced when referring patients with health insurance to pulmonary rehabilitation.Methods This was a survey-based cross-sectional study conducted in 2019, at a private reference hospital in São Paulo, Brazil. Eligible participants were physicians registered with the following specialties: internal medicine, geriatrics, cardiology, pulmonology or thoracic surgery.Results We collected 72 responses, and 99% of participants recognized chronic obstructive pulmonary disease as a potential indication for pulmonary rehabilitation; less often (75%), they listed interstitial lung disease, bronchiectasis and pulmonary hypertension. Most participants (67%) incorrectly associated pulmonary rehabilitation with lung function improvement, while 28% of cardiologists and 35% of internists/geriatricians failed to recognize benefits on mood disorders. Notably, 18% of participants recommended pulmonary rehabilitation only to patients on supplemental oxygen and 14% prescribed only home physical therapy, patterns more commonly seen among non-respiratory physicians. The three most perceived barriers to referral and adherence were health insurance coverage (79%), transportation to pulmonary rehabilitation center (63%) and lack of social support (29%).Conclusion Financial, logistic and social constraints pose challenges to pulmonary rehabilitation enrollment, even for patients with premium healthcare insurance. Moreover, physician knowledge gaps may be an additional barrier to pulmonary rehabilitation referral and adherence. Providing continued medical education, incorporating automatic reminders in electronic medical records, and using telerehabilitation tools may improve pulmonary rehabilitation referral, adherence, and ultimately, patient care.
Highlights
Pulmonary rehabilitation (PR) is a complex and individualized intervention that involves a multidisciplinary team of physicians, physical therapists, dietitians and psychologists
An American study, for instance, showed that only 3.7% of chronic obstructive pulmonary disease (COPD) patients treated by Medicare, in 2012, were in rehabilitation programs,(10) which is consistent with similar international surveys.[11,12] The multiple reasons for this scenario can usually be grouped into one of the following three categories: availability of PR centers, physician awareness, and patient issues impacting on attendance and adherence
In 2017, Brazil had more than 150 cardiopulmonary rehabilitation centers, which seems a lot when compared to other Latin American countries, such as Argentina [32], Colombia [12], Mexico [3] or Uruguay [2].(13) given the prevalence of COPD in the Brazilian population aged over 40 years is estimated to be 15%,(14) and that patients with various other chronic lung diseases would benefit from participation in PR programs, the number of existing centers is still insufficient
Summary
Pulmonary rehabilitation (PR) is a complex and individualized intervention that involves a multidisciplinary team of physicians, physical therapists, dietitians and psychologists. Rehabilitation programs benefit patients with bronchiectasis, pulmonary hypertension, interstitial lung disease and patients pre- and postoperatively after lung resection and lung transplant surgery.[4,5] Proven effects of PR include improvement in quality of life, exercise capacity and anxiety and reduction in depression, frequency of exacerbations and hospitalization rates.[2,3,6] More recently, PR was shown to significantly reduce 1-year mortality following exacerbation of COPD.[7] In this context, it is generally agreed that PR is a highly cost-effective strategy.[8,9] PR remains largely underutilized worldwide. Since most of these programs are based at reference hospitals in large cities, they are inaccessible to a considerable proportion of patients and significantly contribute to underutilization of programs.[10,12,15]
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