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. 2021 Oct 25:19:eAO6115.
doi: 10.31744/einstein_journal/2021AO6115. eCollection 2021.

Barriers to enrollment in pulmonary rehabilitation: medical knowledge analysis

[Article in English, Portuguese]
Fernanda Gushken  1 , Luiza Helena Degani-Costa  2 , Thaíz Carolina Pimentel Colognese  2 , Maíra Thomazini Rodrigues  2 , Mayra Zanetti  2 , José Luiz Bonamigo-Filho  2 , Luciana Diniz Nagem Janot de Matos  2
Affiliations

Barriers to enrollment in pulmonary rehabilitation: medical knowledge analysis

[Article in English, Portuguese]
Fernanda Gushken et al. Einstein (Sao Paulo). .

Abstract
in English, Portuguese

Objective: 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.

Objetivo: Avaliar o conhecimento dos médicos sobre reabilitação pulmonar e identificar as barreiras que eles encontram ao encaminhar pacientes com seguro saúde para reabilitação pulmonar.

Métodos: Trata-se de estudo transversal com uso de questionário, realizado em 2019, em um hospital privado de referência em São Paulo. Os participantes elegíveis eram médicos registrados nas seguintes especialidades: clínica médica, geriatria, cardiologia, pneumologia ou cirurgia torácica.

Resultados: Foram coletadas 72 respostas, e 99% dos participantes reconheceram doença pulmonar obstrutiva crônica como possível indicação para reabilitação pulmonar; com menor frequência (75%), listaram doença pulmonar intersticial, bronquiectasia e hipertensão pulmonar. A maioria dos participantes (67%) associou incorretamente a reabilitação pulmonar à melhora da função pulmonar, ao passo que 28% dos cardiologistas e 35% dos clínicos/geriatras deixaram de reconhecer os benefícios nos transtornos de humor. Notavelmente, 18% dos participantes somente recomendaram reabilitação pulmonar para pacientes em uso de oxigênio suplementar, e 14% prescreveram apenas fisioterapia domiciliar, padrão mais comumente visto entre médicos que não são especialistas em transtornos respiratórios. As três barreiras mais percebidas para encaminhamento e adesão foram cobertura de seguro saúde (79%), transporte para centro de reabilitação pulmonar (63%) e falta de apoio social (29%).

Conclusão: Restrições financeiras, logísticas e sociais representam desafios para a inclusão na reabilitação pulmonar, mesmo para pacientes com planos de seguro de saúde da categoria premium. Além disso, as lacunas de conhecimento dos médicos podem ser uma barreira adicional para o encaminhamento e a aceitação da reabilitação pulmonar. Educação médica continuada, lembretes automáticos nos prontuários eletrônicos e ferramentas de telerreabilitação podem melhorar o encaminhamento para reabilitação pulmonar, a adesão e, por fim, o atendimento ao paciente.

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Conflict of interest statement

Conflict of interest: none.

Figures

Figure 1
Figure 1. Knowledge about pulmonary rehabilitation, according to medical specialty. A) Knowledge about the indications of pulmonary rehabilitation; B) Knowledge about the benefits of pulmonary rehabilitation
Figure 2
Figure 2. Patterns of referral to pulmonary rehabilitation according to medical specialty. A) Frequency of referral; B) Type of referral
Figure 3
Figure 3. Barriers to referring patients to the pulmonary rehabilitation center at the organization
Figure 4
Figure 4. Strategies to increase adherence to pulmonary rehabilitation
Figura 1
Figura 1. Conhecimento sobre reabilitação pulmonar, segundo especialidade médica. A) Conhecimento das indicações de reabilitação pulmonar; B) Conhecimento dos benefícios da reabilitação pulmonar
Figura 2
Figura 2. Padrões de encaminhamento para reabilitação pulmonar, segundo especialidade médica. A) Frequência de encaminhamento; B) Tipo de encaminhamento
Figura 3
Figura 3. Barreiras para o encaminhamento de pacientes para o centro de reabilitação pulmonar institucional
Figura 4
Figura 4. Estratégias para aumentar a adesão à reabilitação pulmonar
See this image and copyright information in PMC

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