INTRODUCTION

Chronic obstructive pulmonary disease (COPD), a leading cause of disability and death in the U.S., disproportionately affects rural residents.1 Rural counties experience more COPD-related exacerbations, hospitalizations, and deaths than urban counties.1,2 Furthermore, isolated rural veterans have a higher risk of mortality following hospitalization for an acute exacerbation compared to urban veterans.3 Rural–urban disparities in COPD outcomes are multifactorial in origin with contributions from factors such as occupational exposures, tobacco use, and socioeconomic status.4,5 Lack of access to resources required to deliver evidence-based COPD management, such as outpatient pulmonary rehabilitation, likely also affects rural disparities in COPD.6 To address this, we aimed to assess barriers to, facilitators of, and recommendations for improving evidence-based COPD management in rural clinics.

METHODS

We conducted a qualitative study of primary care providers (PCPs) who manage patients with COPD in rural clinics. A total of 101 PCPs from the Veterans Health Administration (VHA) Midwest Health Care Network were sent an email invitation to participate. A total of 12 PCPs were willing and able to participate in the interview. We performed 30 min semi-structured interviews over video conference with probes designed to elicit perceived factors that impact evidence-based COPD management for rural veterans. Interviews were audio-recorded and transcribed. Two investigators (AKB and TW) used NVivo (QSR, International, Burlington, MA, USA) to perform qualitative analysis; interviews were coded using an inductive approach and themes were organized into a hierarchical frame. This study was approved by institutional review boards at the Minneapolis VA Health Care System (VAM-20-00,583) and the University of Minnesota (STUDY00011069).

RESULTS

Twelve primary care providers whose clinics were located across four states (Iowa, Minnesota, Nebraska, South Dakota) in the VA Midwest Health Care Network were interviewed, including five physicians, six nurse practitioners, and one physician assistant. The mean age was 52 ± 12 years and the majority had  ≥20 years of clinical experience. Representative quotes are displayed in Table 1.

Table 1 Elucidative Quotes Describing Rural Primary Care Perspectives on the Challenges, Facilitators, and Recommendations to Improve Access to Evidence-Based COPD Management
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Table 2 provides a summary of the key barriers (limited clinic resources and challenges in coordinating care), facilitators (multidisciplinary clinic support and resources for tobacco cessation), and recommendations (improve access to pulmonary specialty care, develop clinical support tools, and establish COPD management program) to improve evidence-based COPD care.

Table 2 Summary of Key Barriers, Facilitators, and Recommendations to Improve Evidence-Based COPD Management in Rural Clinics
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DISCUSSION

Rural PCPs identified many barriers to, facilitators of, and recommendations toward improving evidence-based COPD management in rural VA clinics. Although PCPs face challenges in coordinating care and overcoming resource barriers, they also acknowledge that evidence-based COPD care is bolstered by multidisciplinary clinical support and tobacco cessation options.

Our findings provide a pathway forward to improve evidence-based COPD care for rural veterans. Actionable steps include increasing access to spirometry in rural clinics improve accuracy of COPD diagnosis and improving transportation services to and from VA health care facilities where services are available to reduce travel burden for rural veterans. Improving primary care clinic staffing and specialty care outreach to rural clinics may also improve provision of care within the VA system that can lead to reduced fragmentation of care and improved patient and PCP satisfaction.

Future research should build on our findings. Further research should include perspectives from other stakeholders, including patients and health system leadership to inform future delivery models. This will improve delivery of evidence-based COPD care, while also increasing access to care for rural COPD patients. For example, given consensus that a COPD management program would be beneficial, efforts could focus on leveraging multidisciplinary teams, including pharmacists, to improve COPD care by targeting rural patients with frequent exacerbations who are at highest risk for poor outcomes. Lastly, research on utilizing telehealth to provide access to evidence-based services, such as spirometry and pulmonary rehabilitation, would be beneficial.

This work has limitations: PCP perspectives from the Midwest region only; modest sample size, though we reached thematic saturation; potential for selection bias; and narrow focus on access to COPD care, which may not be applicable across other diseases or specialty care. Still, this study provides concrete steps forward to improve COPD care and outcomes for rural veterans.