The origin of pulmonary rehabilitation dates back 1942 wherein the American Medical Association Council on Rehabilitation defined rehabilitation as 'the restoration of the individual to the fullest medical, mental, emotional, social and vocational potential of which the person is capable' (Miller WF 2000). Following, in 1974, The American College of Chest Physicians, defined pulmonary rehabilitation as an art of medical practice wherein an individually tailored, multidisciplinary programme is formulated, which through accurate diagnosis, therapy, emotional support and education, stabilises or reverses both physio pathological and psychopathological manifestations of pulmonary diseases and attempts to return the patient to the highest possible functional capacity allowed by his disability and overall life situation (Petty TL 1975).
PR is a renowned programme that has been accredited by ATS/ERS (Nici L et al 2006) as high value intervention for patients with respiratory conditions including COPD, Asthma, Interstitial Lung Disease, Bronchiectasis, Pulmonary Artery Hypertension and Non-Small Cell Carcinoma with a Grade A evidence in improvements in exercise capacity and quality of life. For the past two decades, pulmonary rehabilitation (PR) has been unanimously endorsed as "Gold Standard Rehabilitation Science" and an integral component of respiratory medicine in the management of COPD to address the physical, psychological and social disorders in patients with chronic respiratory disease and promote long term health enhancing behaviour (Spruit et al. 2013).
What is current explicit status of Pulmonary Rehab (PR)?
Surprisingly, although the high value of PR is unprecedented by any other alternative therapies, it is still underutilized in primary, community and secondary care worldwide. In European countries, most referrals to PR are undertaken by healthcare practitioners from primary, community, secondary, and tertiary care settings, whilst in North America, self‐referral is relatively common (Spruit 2014). McNaughton (2016) reported that in New Zealand only 2% of the expected COPD population was referred to PR, whilst in England and Wales, 68,000 (15.2%) of 446,000 eligible patients were referred (Steiner 2015). Major reasons given for low patient referral by healthcare practitioners included a lack of knowledge about programme content and benefits of PR, challenging or uncertain referral process (or both), time pressures for the prospective referrer, uncertainty of whose role it was to refer, lack of training for early diagnosis in primary care, anticipated access difficulties for patients and uptake and completion of PR programmes by eligible patients (Foster 2016, Harris 2008a, Johnston 2013).
The current PR care model focuses on "What's the matter". Patient Autonomy (PA) is a “Forgotten Word” due to insufficient resources and knowledge around PR. In our current acute care model for respiratory disease there is little communication among specialists between secondary care and primary care providers, virtually no interdisciplinary decision making, no inclusion of social network or psychological services and little promotion of collaborative self-management strategies. There is no clear consensus of any standard content /format of self-management. Wider gaps persist in early identification and accurate diagnosis, non- adherence to long term management, value for money, interventions focused beyond breathing, lack of use of monitoring vital signs as a parameter to identify early physical inactivity and rewards system to promote healthy behaviour change for long-term benefit.
What would be a pragmatic solution?
Management of CRD should be based on individual treatable traits and should be summarized into three groups: pulmonary, extrapulmonary and behavioural treatable traits. Addressing a treatable trait must be based on understanding of both social and personal barriers and enablers of individual with COPD. This calls into action an Integrated Disease management model (IDM) (Chavannes NH et al 2009).
Future vision on PR should be reverted to "What matters to the patients" to encourage long-term health enhancing behaviour change. Successful behaviour change strategies take many forms. Theory and research suggest that the most effective behaviour change interventions are those that use multiple strategies and aim to achieve multiple goals of awareness, information transmission, skill development, and supportive environments and policies. Behavioural interventions should be sensitive to audience and contextual factors, and recognize that most behaviour change is incremental and that maintenance of change usually requires continued and focused efforts. Intervention strategies targeting the individual level should draw attention on social cognitive theory for goal setting, behavioural contracting, and tailored health communication between patient, primary and secondary care settings.
Wider perspective in health behaviour change interventions should underpin the theories of social practice, social networks and interactionism (Cited from Holman D and Borgstron E 2016). Goal-setting and monitoring are important elements of many successful interventions. The emergence of information technology tools such as the internet, wireless technology, and personal digital assistants have expanded the range of theory-based strategies available for effective behaviour change in health care and community settings. A suggestive model of digitally enabled hybrid (technology & human resources) integrated care model is proposed to deliver a right care, at right time to the right people with chronic respiratory disease. For this, an invigorating partnership between primary care, secondary care and social prescribing network should be established for an effective strategic and operational delivery of integrated disease management model closer to patient’s home.
SD Perumal, Cardiff University, Wales, UK.
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