Response rates.
Table 1 shows paper survey distribution (>1100 across 6 events) and return rates for phase 2. 154 questionnaires were returned and 134 (83%) had completed the survey sufficiently and were included. Online, it is unknown how many potential practitioners read the survey invitation, therefore participation rates could not be calculated. 123 participants started the online survey, but only 99 (80.5%) completed it and were included in the analysis.
Table 1 Paper survey distribution
Description of participants
Table 2 presents the socio-demographic characteristics for all participants in the phase 1 qualitative (n=19) and phase 2 quantitative (n=233) studies.
Table 2 Baseline demographics of all participants
Referral to PR by type of healthcare professional
Overall, 109 (49.1%) reported being frequent referrers to PR, with GPs being less likely to refer and other professions including emergency care practitioners and nurse practitioners and ANPs more likely to refer. Referral was also higher among those with one or more continuous practice development (CPD) respiratory qualifications. However, this may be partly related to such qualification being higher among ANPs (82.5% (47/57)) and other grouped professions (58.8% (10/17)) than among GPs (17.9% (5/28)). More than 10 years spent in general practice appeared to marginally increase referral frequency (60.7%; 51.8%).
Table 3 PHCP referral practice*
40/233 (17.2%) responding PHCPs reported never referring to PR, with the largest group being practice nurses (29/40; 72.5%). 33 of 40 PHCPs offered a variety of reasons for non-referral including; not considering it to be part of their role, not seeing COPD patients or not knowing they could refer (12/33; 36.4%). Others reported it was undertaken by other
respiratory specialist/interested health care professionals across primary and secondary care settings (12/33; 36.4%). Further reported reasons were unsure how to and/or a lack of training (5/33; 15.1%), uncertainty about local service provision (3/33; 9.1%) and 1/33 (3.0%) reported belief that patients were not interested.
Phase 1 Results: TDF analysis of the qualitative interviews
Table 4 shows the referral behaviour of PHCPs mapped to all 14 TDF domains. The most frequently mapped domain was social and professional role (n=287 times) whilst the least mapped was behavioural regulation (n=4).
Table 4: Phase 1 Mapping of barriers and enablers for referral to TDF domain
Phase 2. Questionnaire results: Referral practice beliefs.
Table 5 presents the number and proportion of PHCPs that agreed or strongly agreed with each belief statement by frequency of referral.
Table 5: Phase 2 Results of TDF belief statements by referral frequency
In general, most PHCPs had some PR knowledge (especially the frequent referrers) and understood the beneficial consequences of PR. However, resources, social influences (such as relationship with PR providers) and pessimism about patient motivations were perceived barriers by a high proportion of PHCPs, irrespective of their referral practice.
There were however, differences in domains between frequent and infrequent PR referrers.
The greatest differences were within the ‘Knowledge’ domain. Frequent referrers most commonly reported agreement with all 7 statements, when compared to the infrequent referrers. For example, 97.3% reported knowing when to refer to PR and 80.7% being able to answer patients’ questions versus 65.5% and 53.3% of infrequent referrers.
Further group differences were demonstrated in the ‘Skills’ domain and ‘Beliefs about (PHCP) capabilities’, which showed that infrequent referrers were less confident in encouraging unmotivated patients to attend PR (67.6% versus 83.5% of frequent referrers). Reduced confidence amongst infrequent referrers was further reflected within the ‘Optimism’ domain and belief statement ‘I am confident my local provider offers a good service’ (46% against 74.3% of frequent referrers). However, over half (56.9%) of frequent referrers felt that patients in work were not able to attend PR, compared to less than a third (31%) of those who referred infrequently.
The remaining belief statements demonstrated greater group similarities than differences.
Environment, Social and Professional role: Most respondents felt that there was enough time in practice to refer (84.7%) and believed in encouraging PR attendance (96.4%). Yet promotional information on PR was rarely available in practices (29%). There was no clearly identified PR referrer; less than half (48.6%) felt it was the practice nurse’s role and (51.8%) reported other practice staff refer.
Social influences: Frequent referrers were slightly more likely to agree with 3 of the 4 domain belief statements than infrequent referrers. Although, collectively the groups reported both PR provider engagement and referral outcome reporting as low at only 22.6% and 29% respectively. PHCPs also reported patients rarely request referral to PR (5%).
Belief about consequences and Optimism: Most PHCPs agreed that PR offers physical health benefits, including improving breathlessness and reducing hospital admissions (91.9%, 89.6%) respectively. Yet far fewer PHCPs believed patients would attend and complete PR (46.2%), with fewer still agreeing that patients are PR motivated (24.2%).
Memory (decision-making): Only a small number of PHCPs reported forgetting to refer patients to PR (11.7%). COPD annual review templates were reported as helpful referral reminders (63.8%) and 25.8% reported the best time to discuss referral with patients was during COPD stability. Patient characteristics such as disease stability and smoking status do not appear to impede PHCP referral decisions as 98.2% reported referring smokers.
Goals, Reinforcement and Intention: in-practice review of eligible patients was not commonly reported (41%) and only (19.8%) reported in-practice targets to improve referral rates. Practice financial reward for referral (pre April 2019) was rarely reported (5%); indeed the implementation of financial reward via national QoF incentives (post April 2019) was considered unlikely to greatly improve referral behaviours, with less than a third (32.6%) stating they would refer more. However, there was general agreement that this incentive would increase practice awareness of PR (70.1%).
Phase 2. Questionnaire: Open questions.
A third of PHCPs (33.8%) responded to the open question at the end of the survey including 5/11 PHCPs who reported referral, but did not specify frequency, (answer length 3-167 words, mean 35). Non-frequent referrers reported more open comments (43/113 38.1%) than frequent referrers (33/109 30.3%)
This gave an additional 94 comments that related directly to PR referral. These were content mapped to all 12 relevant TDF domains. The comments predominately cited referral barriers.
Belief about capabilities had the highest number of comments 36/94 (38.3%) with many encompassing concerns about PR accessibility, particularly transport challenges for patients. For example, ‘Location of PR too far for patients to travel and too much commitment. Patients tend to be older adults on generally low incomes. A number of my patients would attend if it was close by with no expense’. A small number of PHCPs (3.2%) considered a patient’s inability to complete pre-PR spirometry as a referral barrier, and 10.6% of comments related to referral processes, which were reported to be lengthy and as such ‘easier simpler’ processes were requested.
Connected results
In order to identify the key factors that inhibit and/or enable PHCP referral to PR, Phase 1 and phase 2 results were merged to allow for data contrast and meta-inference (18) (Table 6).
Most PHCPs believed in PR and encouraging patients to attend. Referral is most likely to be considered at annual review (indeed referral is rarely offered to patients outside of this consultation). On-screen prompts are helpful reminders, but in practice material promoting PR is rare. PHCP PR knowledge is largely gained from networking with other respiratory interested health professionals and/or CPD education. PHCPs report patients have little motivation for PR, rarely ask for referral to PR and view that patients in work are unlikely to be able to attend.
Some findings of the qualitative study were not clearly replicated in the survey results. For example, phase one qualitative data highlighted that some GPs and ANPs felt the practice nurse was best placed to undertake PR referral at the time of annual review, yet respiratory interested GPs and those undertaking annual review did not share this view. The phase two survey data supported the latter position, where 29/129 (22.5%) of practice nurses reported never referring. Therefore responsibility of PR referral is not based on profession, but is undertaken by PHCPs who are respiratory interested and/or conducting the patient’s annual review.
Qualitative generalisable findings were limited in a number of areas meaning clear conclusion cannot be drawn, these included; time available to undertake referral, ease of referral process, perceptions of quality of PR programme, referral of patients when COPD symptom burden is increasing and non-referral in order to protect patient relationship.
Where generalisability is clear, a summary of the key behavioural barriers and enablers by TDF domain are shown in figure 2, demonstrating a greater number of barriers than enablers to referral. However, it is also important to report that barriers and enablers most commonly co-exist within the same domains.
Table 6 Integrated results matrix
Figure 2 Key barriers and enablers by TDF domain.