What motivates primary healthcare practitioners to refer patients with Chronic Obstructive Pulmonary Disease (COPD) to Pulmonary Rehabilitation? A survey using the Theoretical Domains Framework

Background: Pulmonary rehabilitation (PR) is a highly effective intervention for patients with COPD but primary care referral rates are persistently low. The Theoretical Domains Framework (TDF) provides a structure for identifying motivators for behaviour change. Aim: Using the TDF to identify & classify the key barriers and enablers for UK primary healthcare practitioners (PHPs) when referring patients with COPD to PR. Methodology: A 54-item questionnaire, derived from our previous qualitative study and guided by the TDF, was distributed to UK based PHPs. Participants were recruited by e-mail (Primary Care Respiratory Society members), social media or direct targeting of participants at PHP conferences. Descriptive statistics were used to analyse responses. Results: Of 211 respondents, 103 (49%) report referring to PR < monthly or not at all. Identified enablers aligned with TDF domains on knowledge and skills. Most PHPs believed referral is easy (129; 61.1%) and (160; 75.9%) agreed to knowing PR programme content. Major barriers related to optimism (only 49 (23.6%) consider patients motivated) and (93; 44.1% believed patients in work are unable to attend). Barriers were also evident in domains social influences (44; 21.1%), report providers rarely engage & goals, (40; 18.9%) PHPs report in-practice measures to improve referral rates are rare. Conclusion: PR referral is infrequent. Knowledge and skills are evident, but interventions to overcome barriers; PHP perceptions of patient, provider engagement and improve goal focus are needed.