[Why is pulmonary rehabilitation so underused? How can this situation be improved?]

[Pulmonary rehabilitation, a historical perspective from Hippocrates to tele-rehabilitation]

In ancient times Hippocrates described a disease, the 3rd phthisis, which seems to correspond to COPD and is mainly treated by walking, gradually increasing the number of steps until reaching 10,000 steps a day at the end of the initial period of treatment. The recent era began in the second half of the 20th century and ended in 2015, with an unusual Cochrane Library editorial in which it was stated that the accumulated evidence (statistically significant and clinically relevant improvements in clinical signs, tolerance to exercise, quality of life, days hospitalization…) on the effects of rehabilitation programs suffice to suspend research on the subject and to justify focus on new elements in the programs. It is essential, in fact, to establish uniform practical recommendations for the prescription of routine rehabilitation (number and duration of physical activity sessions, therapeutic education, re-training intensity…). In addition, studies should be carried out on new practices: community or home rehabilitation, long-term rehabilitation, tele-rehabilitation.

[Barriers to referral to pulmonary rehabilitation in COPD patients from the perspective of general practitioners]

INTRODUCTION

In spite of recommendations of the highest level of proof (rank A), the respiratory rehabilitation remains very widely sub-prescribed by general practitioners, who are nevertheless in the front line in the care and the follow-up of the patients affected by BPCO.

MATERIAL AND METHODS

Semi-qualitative study with the general practitioners installed in the city of Montauban (Tarn-et-Garonne).

RESULTS

The rate of answer was 57%. Eighty-six percent of the patients BPCO followed in general medicine have never participated in a respiratory rehabilitation program. Eighty percent of the questioned general practitioners declared not to know the last recommendations of the HAS. A total of 66.7% of the questioned general practitioners considered that prescription of respiratory rehabilitation comes within their remit. Eighty seven percent of the general practitioners declare not to know the existing respiratory programs of rehabilitation in their region.

CONCLUSION

The main barrier for prescription of respiratory rehabilitation for patients BPCO in general medicine could be the misunderstanding of the local existing programs. The distribution of existing tools such as the map of the programs of respiratory rehabilitation established by the group Alvéole of the Society of Pneumology of French language (SPLF) could so be a facilitating factor.

Major care gaps in asthma, sleep and chronic obstructive pulmonary disease: a road map for knowledge translation

Large gaps between best evidence-based care and actual clinical practice exist in respiratory medicine, and carry a significant health burden. The authors reviewed two key care gaps in each of asthma, chronic obstructive pulmonary disease and obstructive sleep apnea. Using the 'Knowledge-to-Action Framework', the nature of each gap, its magnitude, the barriers that cause and perpetuate it, and past and future strategies that might address the problem were considered. In asthma: disease control is ascertained inadequately, leading to a prevalence of poor asthma control of approximately 50%; and asthma action plans, a key component of asthma management, are provided by only 22% of physicians. In obstructive sleep apnea: disease is under-recognized, with sleep histories ascertained in only 10% of patients; and Canadian polysomnography wait times remain longer than recommended, leading to unnecessary morbidity and societal cost. In chronic obstructive pulmonary disease: a large proportion of patients seen in primary care remain undiagnosed, mainly due to underuse of spirometry; and <10% of patients are referred for pulmonary rehabilitation, despite strong evidence demonstrating its cost effectiveness. Given the prevalence of these chronic conditions and the size and nature of these gaps, the latter exact an important toll on patients, the health care system and society. In turn, complex barriers at the patient, provider and health care system levels contribute to each gap. There have been few previous attempts to bridge these gaps. Innovative and multifaceted implementation approaches are needed and have the potential to make a large impact on Canadian respiratory health.