Implementation of co-designed strategies enhances referral to pulmonary rehabilitation for people with COPD in tertiary care: an interrupted time series study

Pulmonary rehabilitation programs (PRPs) are a core component of care for people with chronic obstructive pulmonary disease (COPD), yet referral is low. The aims of this study were to; (i) engage with people with COPD receiving care at a tertiary hospital and HCPs involved in the management of people with COPD, to co-design and implement strategies that sought to improve referrals to PRPs; (ii) evaluate the effect of implementing co-designed strategies on the rate of referral to PRPs across three tertiary hospitals; and (iii) understand the sustainability of co-designed strategies by estimating relative costs and number of potentially prevented hospitalisations to achieve cost neutrality.

This uncontrolled quasi-experimental study was informed by the behaviour change wheel and co-design framework. It included three distinct periods: (i) pre-implementation, (ii) co-design and implementation, and (iii) post-implementation. During pre- and post-implementation, people with COPD were sequentially recruited from three tertiary hospitals. Medical records were tracked to determine PRP referral. During the co-design and implementation period, four people with COPD and six HCPs developed and implemented strategies addressing known barriers to PRP referral. Referral rates in pre- and post-implementation periods were compared using segmented Poisson regression. Sustainability was estimated by modelling the number of hospitalisations that would need to be avoided annually to offset implementation costs. Program uptake, completion, and clinical outcomes were not assessed.

Co-designed strategies included PRP promotional products; off-loading parking expenses; deploying ‘case finders’ across the three tertiary hospitals whose primary role was to find people with COPD appropriate for a PRP and support them to engage; and visual prompts for HCPs to refer. Data were available on 590 people with COPD (age 69 ± 11 years, FEV₁ 49 ± 20% predicted, 56% males). Between pre- and post-implementation periods, the mean referral rate to PRP increased from 25% to 52%, respectively (incident rate ratio 2.1, 95% confidence interval 1.1 to 3.9). Co-designed strategies would be cost neutral if they prevented 14 major or 30 minor COPD-related hospitalisations annually.

Co-designed strategies that addressed known barriers to people with COPD being referred to a PRP produced a two-fold increase in rate of referrals. Given the evidence that PRPs reduce healthcare utilisation, long-term funding of these strategies may indicate cost neutrality.