Management of chronic breathlessness in primary care: what do GPs, non-GP specialists, and allied health professionals think?

Keywords: allied health, assessment, breathlessness, general practitioner, integrated care, management, multimorbidity, patient-centred care, primary care.

Breathlessness, associated with conditions such as asthma, other lung diseases, heart failure and obesity, is experienced by about one in 10 Australians (Poulos et al. 2021). Shortness of breath detrimentally impacts health outcomes (Abidov et al. 2005), social participation, and quality of life (Ho 2001; Nishimura et al. 2002). The Bettering the Evaluation and Care of Health (BEACH) Study, a prospective study of a random sample of 1000 Australian general practices between 2000 and 2009, reported that one percent of GP presentations were for breathlessness (Currow et al. 2013). Thus, streamlining the diagnosis and management of breathlessness in primary care may play an important role in reducing this burden on individuals and, ultimately, the health system.

Misdiagnosis of breathlessness is not uncommon in clinical practice. A study of primary care patients referred for breathlessness reported that <30% listed a referral diagnosis that was concordant with the final diagnosis (Huang et al. 2018). This finding was supported in another study where <40% of breathless patients referred to secondary care with heart failure were confirmed to actually suffer from heart failure (Nielsen et al. 2001). Misdiagnosis can be harmful because it may increase the risk of inappropriate or delayed testing or treatment and negatively affect patients’ clinical outcomes (Singh et al. 2017). Other causes of misdiagnosis identified in previous studies include: the multifactorial nature of breathlessness (Sunjaya et al. 2021a), the indistinct nature of diagnostic tests to ascertain a single cause (Decramer et al. 2013), and the variety of ways patients present and explain their breathlessness (Sunjaya et al. 2021b).

Improving the assessment and management of breathless patients at the primary care level may lead to more appropriate and fewer extraneous secondary care referrals, faster commencement of appropriate treatment, reduced morbidity, and reduced healthcare costs. The ‘breathless patient’ and how to manage breathlessness is currently more important than ever, with the negative effects of pollution in the biosphere, post-COVID-19 syndrome, and increasingly sedentary lifestyles. All these negatively impact cardiopulmonary health, thus potentially further increasing the burden of breathlessness in Australia and internationally.

Hence, this study aimed to explore the perspectives of GPs, multidisciplinary non-GP specialist physicians (hereafter referred to as ‘specialists’), and allied health professionals on the role of primary care in diagnosing and managing chronic breathlessness, the barriers faced, and the facilitators to optimise care of patients with chronic breathlessness.

During 2021, a convenience sample of GPs, non-GP specialists (cardiology, respiratory, palliative care, hereafter referred to as ‘specialists’), and allied health professionals (psychologists, physiotherapists, occupational therapists) were recruited through The George Institute for Global Health, UNSW Sydney networks, and health professional public database searches using an email invitation. Snowball sampling was also conducted with participants being requested to recommend other participants.

A semi-structured focus group guide was developed based on literature and building upon our previous exploratory focus group (Sunjaya et al. 2021a) to address the study aims. Topics explored included: (1) views on the role of primary care in diagnosing and managing chronic breathlessness; (2) barriers to optimal assessment in primary care; and (3) facilitators to further optimise the care of patients with chronic breathlessness.

Seven 90- to 120-min virtual focus groups (three with GPs, two with specialists, two with allied health), with participants ranging between three and 10 individuals per focus group, were conducted via teleconference and led by the investigators (AS or CJ), with another investigator recording the field notes (AM). The focus groups were recorded and transcribed verbatim.

Data were analysed using the qualitative analysis software, NVivo (QSR International), using thematic analysis (Terry et al. 2017). The codes developed were then discussed with the other investigators (CJ, AM, CA), and differences in opinions were solved via consensus. Direct remarks from the participants are presented between quotation marks. To ensure the rigour of our study, we aligned ourselves with the four criteria – credibility, dependability, confirmability, and transferability – established by Lincoln and Guba (1986) for trustworthiness in qualitative research. Details of how our approach relates to the criteria are available in Table 1 (Lincoln and Guba 1986; Forero et al. 2018).

Table 1.  Our qualitative approach, as compared to Lincoln and Guba’s four-dimensions criteria (Lincoln and Guba 1986; Forero et al. 2018).

Ethical approval for the research was granted by the University of New South Wales Human Research Ethics Committee (HC200534). Informed consent forms were sent to participants prior to the focus group and verbal consent was also sought during data collection.

Thirty-five health professionals (10 males, 25 females) accepted invitations and participated in seven focus groups; 18 were GPs, eight were specialists (four cardiology, two respiratory, two palliative care), and nine allied health professionals (five psychologists, two occupational therapists, two physiotherapists). Thirty-three were based in New South Wales and one each from South Australia and Queensland. Most (n = 31) were based in urban areas, with two from regional areas. Their years in practice ranged from 1 to 45 years.

Findings below are reported based on the eight key themes from the focus groups, which are: (1) divergent perspectives on the role of GPs; (2) lack of patient awareness and breathlessness metrics; (3) access constraints and knowledge gaps on use of common diagnostics; (4) too many guidelines that are not fit-for-purpose; (5) access and funding constraints to allied health; (6) sharing the load; (7) siloed medicine; and (8) collaborative continued care. For problems identified, possible solutions suggested by participants are summarised underneath each section. Combined the solutions suggest a need to break away from the siloed nature of medicine especially through greater primary and secondary care collaboration and continuity in care delivery to improve the quality of care for patients with breathlessness, as well as leveraging emerging technologies to bridge current gaps and constraints in the health system (Fig. 1).

Fig. 1.  Summary of key themes, solutions and selected quotes.

Most GPs expressed the view that that they can independently assess breathlessness and for most obvious causes, would classify patients accurately into the relevant care pathways even if further specialist support is needed. GPs also mentioned their role in working with nurse coordinators as the first point of contact for many patients in the community.

We’re not bad at sorting out the obvious ones for which path they should go down, even if they need specialist input ……. most of the time it’s relatively clear. (GP)

GPs are diagnosticians, it’s more [a case] of what tests do they organise themselves versus sending off to get done at a different centre under someone else’s diagnostic management. (GP)

Specialists viewed GPs as being ‘integral’ in the diagnosis and management of breathlessness; however, they reported that in many cases, referred patients were inadequately worked up or that no previous historical information was included in the referral letter to expedite the diagnostic process. Similarly, allied health professionals indicated that patients with breathlessness referred by GPs often had not been fully investigated, which hindered the support they could provide patients. One physiotherapist commented that they see GPs as ‘navigators’ to ‘help patients navigate through the health system’.

The majority [of referred patients] do not have a cardiac cause of breathlessness; I think they are inadequately worked up. Some even haven’t had basic blood tests to look at e.g. haemoglobin, iron studies. They have usually had a chest X-ray. But I think most of the time breathlessness by itself is generally not an isolated cardiac issue. (Cardiologist)

I think it’s good for them [GPs] to start with a few basic things to try and delineate where they’re heading, which may be specialist referral and further investigations from there. (Cardiologist)

GPs reported patients often do not bring it (their breathing difficulty) to the fore on their own as a barrier to recognition of the problem in primary care. If GPs do not trigger a discussion, breathlessness may be unrecognised, and assessment may be delayed.

Specialists also noted that unlike hypertension and diabetes, which have ‘nice metrics’ for management, breathlessness is a problem where ‘metrics’ are more difficult and hence GPs do not ask patients whether they are breathless as often. Most GPs reported being unfamiliar with any scale to assess the severity of breathlessness such as the modified Medical Research Council (mMRC) scale.

Some of the tests GPs report they commonly do for breathlessness, and tests specialists mentioned they would expect GPs to have performed depending on the patient, prior to referral include electrocardiograms (ECGs), spirometry, echocardiogram, arterial blood gas analysis, chest X-rays, full blood counts, iron studies, glucose profile, lipids, thyroid function tests and renal function (bicarbonate, creatinine, urea). There were mixed views on chest CT-scans, CT pulmonary angiogram (if pulmonary embolism is suspected), echocardiograms and B-type natriuretic peptide (BNP). Even so, some specialists noted that GPs might not be ‘confident’ in interpreting results of basic diagnostic tests for breathlessness such as spirometry, ECG and lung function tests.

We do have facility to accept referrals from GPs at least locally in the lung function lab here and I’m sure, a lot of the other labs will accept referrals from GPs as well, but I’m not sure the GP’s really feel confident referring for the lung function tests. They may know about spirometry (but) may not be confident about the other things that are all listed on the form. (Respiratory)

Some of the things that we might think would be useful, like spirometry I really don’t think GPs feel comfortable interpreting necessarily so. Potentially, further education on ECG reporting, spirometry, and some of those more technical tests, not that we’re expecting them to know all the detail, but some basic assessment. I think, it is beneficial, you know .. (to educate) .. what are the signs on an ECG that you’d be looking for in someone who’s breathless. (Cardiologist)

GPs also reported they were often limited by what they can access in primary care depending on their location and what is reimbursed by Medicare. Variable access to tests such as spirometry, lung function tests, ECG, echocardiography, and BNP, among others, was reported by the GPs and acknowledged by specialists.

Specialists acknowledged these accessibility and policy issues, including that relatively poor reimbursement for time invested maybe a barrier for GPs performing these ‘basic tests’ before referral. Some tests were also only reimbursed if referred by a specialist. This barrier also included costs to their patients when they are referred for such tests. Specialists also noted the ‘broad spectrum’ of practising GPs and, depending on their experience, that some are more independent than others in what they can do.

I tend to do as much diagnostic testing as I can but there’ll be a number of tests I’ll send to a specialist because I either can’t access them, or I might not have realised what’s needed because it’s something unusual. (GP)

I don’t see many GPs referring for spirometry and I think it’s an access issue, and/or possibly a cost issue. I think they may not know how to access the services, so I think that might be a big problem that needs to be addressed as well. It’s becoming harder for GPs to even do ECGs with the Medicare changes, as I think they’re no longer rebated for doing an ECG and reporting it so that’s compounding this issue. (Cardiologist)

I don’t think specialist investigation should be ordered [by GPs] like BNPs because they cost a huge amount of money for the patient, so I think those should not necessarily be the first line of tests that the GPs do. (Cardiologist)

In contrast, sending patients to specialists for diagnostics could potentially add to long waiting times in public hospitals, even ‘6 months to a year to get everything done’. Whereas ‘private’ referrals are sometimes not affordable for many patients.

Coronavirus disease 2019 (COVID-19) was also reported to be a barrier to conducting basic tests such as spirometry in practice. Several of the GPs worry that post-COVID-19, it would become a ‘de-skilled procedure’ and will further fall out of use despite its great utility for diagnostics in various diseases such as asthma and chronic obstructive pulmonary disease (COPD).

GPs want better access and a streamlined process to arrange essential diagnostic tests such as spirometry, lung function tests and echocardiography in practice. Specialists concurred that providing GPs greater support to access diagnostic tests is of importance, but noted that GPs could currently utilise more of the basic tests prior to referral. Specialists said GPs could assist them by obtaining detailed medical histories and undertaking physical examination (such as heart and lung sounds) to elicit and assess breathlessness in practice, and that education campaigns for patients may be needed.

GPs acknowledged that the main challenge in assessment and management of breathlessness is its multimorbid and multifactorial nature. Somewhat inconsistent with this, they felt a pressure to make a ‘single diagnosis’ in practice. A similar response was also reported among specialists. Allied health professionals also noted that it would not be possible and should not be expected that GPs would be a master of everything.

I think the biggest problem isn’t the diagnosis of the single cause, e.g. if they had heart disease or they’ve got a respiratory disease, but it’s a lot about challenging patients [who] have both or three things affecting them and working out how to approach each of those conditions, and also the whole picture, which is tricky. (GP)

I think perhaps we have entirely the wrong approach to breathlessness because we act (GPs and specialists included) in a disease/organ system-based way, and I think that’s the mistake to start with because we usually have multifactorial causes of breathlessness and we usually have lung disease and heart disease together in my experience. (Respiratory)

What’s the cause of the breathlessness and what’s the contribution of all of the multimorbidities (is important), not to try to ‘put it into a box’. (Psychologist)

Everything is sort of dumped on the GPs unfortunately, and quite overwhelming at times for them I’m sure, and they do a brilliant job, but they can’t be the master of everything, that’s why we have the respiratory physicians, cardiologists, palliative care specialists. (Occupational Therapist)

Regarding management of breathlessness, GPs shared the complexities and noted many factors of concern in a patient with breathlessness, which are not covered in any current guidelines, and most commented that there are too many guidelines for a GP to master. One example provided was for COPD where the Lung Foundation, Royal Australian College of General Practitioners (RACGP), and Health Pathways all have their own guidance documents. GPs also wanted guidance for patients for whom their breathless was due to contributors such as anxiety and depression.

Multi-disciplinary teams when the diagnoses go across multiple [diseases], it’s trying to get away from the organ-based sort of old-fashioned way…..breathlessness is one of those symptoms like pain that needs its own (integrated service). (GP)

GPs indicated that for several common diagnoses such as anxiety-related or fitness-related breathlessness, there are no guidelines available. Whereas for respiratory disease, they need to access current guidelines from various sources. A unified, streamlined process to access screening tools and algorithms suitable for primary care for the various types of breathlessness would be welcomed. Specialists concurred that guidelines and resources for GPs are frequently updated and awareness of changes to guidelines for diseases such as COPD etc. is important, but challenging.

Specialists and allied health acknowledged that GPs do not have ‘the luxury of time’ to take a comprehensive history. They suggested a ‘checklist’ for GPs or a ‘stepwise algorithm’ on an approach to a patient with an unknown cause of breathlessness with a focused history would be helpful. This should ‘refresh their memory’, but at the same time, not be ‘prescriptive’, as they believed the GPs do ‘know their patients and what they’re going through’, including the role of anxiety and other factors in their patient’s breathlessness.

Key additional tools and resources identified to help GPs included clinical clues to common diagnoses such as vocal cord dysfunction, dysfunctional breathing, interstitial lung diseases or breathlessness due to deconditioning, and assistance in interpreting basic technical tests. These could specifically focus on interpretation of tests with which GPs expressed discomfort, such as spirometry and ECGs.

When often they’re trying to see a list of patients with not much time, this is one where it might be good to have a checklist some of the things are very simple to check off the list things like metabolic disturbances … (Respiratory)

People come in with a diagnosis of asthma, possibly from the GP and then they’ve been to the specialist and it (asthma) was actually ruled out and it turns out that they had dysfunctional vocal cords, or they had breathing pattern disorder or something that was not respiratory. (Psychologists)

GPs reported barriers to referring patients to allied health. They advised that the Medicare reimbursement for only five visits per year quota for allied health visits is prohibitive to optimal care. Specialists and allied health professionals acknowledged the benefits of GP referrals for patients to disease-specific exercise programs such as pulmonary or cardiac rehabilitation.

Most of the patients with chronic breathlessness will tend to have other comorbidities and they soon use up their five allied health visits that they can get for all the different problems. (GP)

Five sessions for people with multiple chronic health conditions barely scratches the surface. (GP)

GPs want their patients to have increased access to ‘preventive health coaching’ and access to allied health services, which combine individualised assessment with group classes (including virtual sessions), ideally supported by a Medicare rebate.

Specialists commented that GPs have a role in establishing the severity of breathlessness, conduct mental health screening and offer smoking cessation support, where applicable. Although sometimes challenging in very breathless patients, they believe GPs could also play a greater role in encouraging patients with breathlessness to exercise.

I think they [GPs] need a little bit of guidance as to which patients they can push a little bit with exercise to try and gain endurance and fitness and which patients they absolutely shouldn’t do because they know they’re on the edge of a myocardial infarction or some sort of cardiac problem. (Respiratory)

Psychologists expressed support for GPs conducting a mental health assessment (if deemed appropriate) that would inform development of more focused mental healthcare plan in collaboration with allied health. At the same time, allied health participants noted the ‘burdens’ GPs already have and that any supporting system to assess breathlessness should not burden them or patients further.

I’m mindful of not overburdening GPs, but whatever assessments the patient can do prior to referral, the better. (Psychologist)

Keeping [breathlessness] assessment, simple and streamlined is really important. (Psychologist)

Allied health professionals also considered that GPs could provide useful basic non-pharmacologic symptom management such as using the ‘breathing, thinking and functioning’ model, ‘positioning’, ‘breathing techniques’ and the ‘handheld fan’.

Another role specialists advised could be beneficial for GPs was in assessing and ensuring maintenance of pharmacological and physical treatment regimens for chronic breathlessness. This included empowering GPs to perform therapeutic initiations; for example, for heart failure and COPD medications.

However, specialists and allied health also noted the importance of balancing the benefits and potential harms of GPs doing more, including in relation to the burden of primary care practice. Some allied health participants did raise concerns about GPs providing advice on breathing techniques when their patients did not have a definite diagnosis. Whereas although specialists noted more diagnostics can be done in primary care, these tests should not be a cause to delay referral.

…. just expanding on what [Psychologist] said – sometimes implementing strategies, such as mindfulness, or focusing on the breath when they’re not ready for it can actually be harmful. (Physiotherapist)

Beyond national guidelines, at the local health district or even hospital level, GPs reported disparate systems for referral. This meant patients often require multiple visits, despite the GP trying to align specialist consults as much as possible. Specialists acknowledged the often ‘siloed’ nature of their specialty may ‘frustrate’ referring GPs and result in months to complete a workup with all the varied specialties (e.g. cardiologists, respiratory specialists, and haematologists).

GPs want a fit-for-purpose referral system. Ideally, the referral system would provide an ‘honest feedback that the appointment will be in 2 months, and if you click that they need to be seen sooner this is who you contact [option to request a faster consult for the GP]’.

Rather than referring for an in-person consultation, GPs indicated a preference for rapid access to remote (virtual) expert support, not necessarily always by referring the patient, but as useful in guiding initial investigations. In contrast, one of the respiratory specialists providing such a service for GPs for COPD noted the low response rate despite promoting this service.

Not necessarily referral, but actually thinking I just need to talk this through with somebody who’s an expert in this disease area or this organ system. (GP)

…. what I get when we promote that number [specialist remote consultation phone number] is GP ringing about pulmonary nodules because they’re worried about them and I entirely understand why they do that, but they in general don’t call about spirometry, COPD, asthma or anything related to that. (Respiratory)

The various health professionals had differing views on the role of primary care, but all agreed that GPs and specialists working together in ‘collaborative care’ is key.

As part of the broader picture, GPs wanted to be ‘in the loop’ throughout a patient’s journey in visiting multiple specialists. They noted that when specialists communicate their course of action with GPs, GPs could help reduce patients’ anxieties regarding specialist recommended treatment, resulting in a more rapid and satisfactory assessment of the patient.

Specialists acknowledged that more can be done in providing GPs the information through letters and feedback that focus on all the interventions GPs can do. Specialists certainly believe that GPs ‘can do a lot more’ than they currently are doing in caring for patients with breathlessness. Allied health professionals also indicated that GPs could make a ‘big difference’ by ‘reinforcing the strategies’ post referral and optimising medication management, given they see patients far more frequently than specialists and allied health professionals.

I think liaising with general practitioners when you do make a diagnosis and making a chronic management plan [in consultation] with them is probably helpful and we probably don’t do that enough. (Cardiologist)

…. one crucial thing is very good communication with the GP and not just with medical specialists, but actually communication with the GP by the multidisciplinary team [to discuss] how the GP can support some intervention that we’ve initiated. (Psychologist)

Having the GP as the person to go back to can be really important to have that continuity of care. (Physiotherapist)

GPs have the rapport and relationship with patients and the ability to prepare them for referral onto other services like palliative care and allied health, so education is definitely needed. (Physiotherapist)

Importantly, owing to the multifactorial nature of breathlessness as discussed above, GPs suggested that an integrated service, similar to those for metabolic disease (Western Sydney Local Health District 2022), pain (Pain Australia 2022) and falls prevention (Southern Adelaide Local Health Network 2021), would be of great benefit. This idea was independently suggested by specialists and the allied health panel who had participated in similar clinics in the past.

Seeing the patient, at the same time [with other specialties] and coming up with a united plan about breathlessness – that was really good and really useful. (Respiratory)

Other models suggested by GPs included increasing ‘home monitoring’, ‘day-stay hospital models’ for diagnostic testing, and the use of virtual care for delivery of allied health classes.

This qualitative study explored the viewpoints of both early career and experienced GPs, various non-GP specialists, and allied health professionals from three Australian states. It raises important points on the role of GPs in assessing and managing chronic breathlessness to optimise patient care, and identifies current gaps in breathlessness care.

GPs view their role as ‘diagnosticians’; however, they have limited access to many diagnostic tests, even those as basic as spirometry, which they may not use even if available. This lack of access to diagnostics, along with the knowledge gap identified in the focus groups, may be one reason for the low concordance between the referral and final specialist diagnosis reported in previous studies in Australia (Huang et al. 2018). The results of the Burden of Obstructive Lung Disease (BOLD) study, which found 29% of people with a physician-made diagnosis of COPD, emphysema, or chronic bronchitis, had no evidence that airflow limitation does support the need for these tests, and for GPs to be able to either do them or access them in order to provide best care (Toelle et al. 2013).

The multifactorial and multimorbid nature of patients presenting with breathlessness was identified as a challenge for primary care. A previous study among primary care professionals in Scotland regarding diagnosing asthma also identified the overlapping nature of the disease with others such as COPD as a challenge in practice (Akindele et al. 2019). In that study, as in ours, educational programs to upskill GPs in their decision-making and access to diagnostics to clarify uncertainties were suggested as potential solutions.

All participants also agreed that current guidelines were often not suited for multimorbid patients, even those with common disease combinations such as anxiety, cardiac disease, and COPD. This issue is one that has also been identified by the World Health Organization in primary care, but remains unresolved, including in Australia (World Health Organization 2016; Harrison and Siriwardena 2018). The use of electronic clinical decision support systems that synthesise relevant diagnostic criteria and guidelines, including leveraging emerging technologies such as artificial intelligence, presents an opportunity to empower GPs to do more by providing them the support to navigate diagnostic uncertainties, as well as ensure their management aligns with best practice (Sunjaya 2022; Sunjaya et al. 2022b).

When patients are referred to non-GP specialists, GPs report lengthy waiting periods for their patients to be assessed; some as long as 6 months. A 2019 study in Australia had reported median waiting times to see a specialist in Victoria, South Australia, Tasmania, and Queensland as 56 days, 5.9 months, 234 days, and 180 days respectively (McIntyre and Chow 2020). Remote access to specialist advice where GPs can discuss their patients without referring them for a specialist consultation is one possible solution to bridge this gap. A 2021 pilot study on the use of remote access to specialists in Queensland showed that it is feasible in Australia and reduced the need for a face-to-face referral by about 85% (Job et al. 2021). A similar study in Ontario, Canada, during the COVID-19 pandemic suggested that telemedicine consults can prevent about 25% of what would otherwise be in-person specialist visits, thus freeing up space in the health system (Singh et al. 2022).

Furthermore, empowering GPs to do more was a theme supported by specialists in a recent study in the US. Real world data suggest that a substantial proportion of primary and secondary care physicians do not communicate with each other regarding the patients they jointly care for (Timmins et al. 2022). This was in line with comments from the participants in our focus group.

Allied health services such as rehabilitation and counselling form important adjuncts to breathlessness care. For example, in COPD patients. pulmonary rehabilitation has been reported to significantly improve dyspnoea score results and health-related quality of life (McCarthy et al. 2015). Thus, it is essential that GPs not be limited in their ability to refer patients to allied health when clinically indicated, especially for those with a functional cause of breathlessness and others likely to benefit from an integrated multidisciplinary approach. Capacity constraints for some of these services may be reduced through measures such as virtual group or home-based classes, which have been reported to compare favourably to face-to-face, centre-based programs in improving quality of life and reducing hospitalisations in patients with cardiovascular disease (Cox et al. 2021; Dalal et al. 2021).

An integrated point of rapid referral, which combines the expertise of main specialty groups related to breathlessness such as cardiology, respiratory, mental health, exercise physiologists, and geriatrics, where specialists and allied health would work together to holistically manage a patient with breathlessness would be a possible goal of the health system. A similar approach called the Breathlessness Intervention Service was trialled in a single centre in the United Kingdom with mixed results; it had a positive qualitative impact, but with a slight increase in costs (Farquhar et al. 2016). Further studies are underway to confirm these findings (Schunk et al. 2021).

Limitations of this study include the relatively low number of participants; however, we recruited a mixed group with varying clinical experiences, and common themes were raised across all the focus groups.

Primary care has a crucial role in assessing and managing chronic breathlessness. To improve the outcomes and assist with time/cost/anxiety concerns, GPs need access to relevant and user-friendly resources, including guidelines that focus on the multifactorial and multimorbid nature of chronic breathlessness. Furthermore, there remains great potential to improve linkage between GPs, specialist and allied health care, including new ways of referral and online consults. Finally, a need for integrated breathlessness clinics for GP referral was identified, analogous to those for pain and falls clinics, to ensure patients receive optimal care in the shortest possible time frame.

The data that support this study cannot be publicly shared due to ethical or privacy reasons and may be shared upon reasonable request to the corresponding author, if appropriate.

The authors declare no conflicts of interest.

This study was supported by a grant from the Sydney Partnership for Health, Education, Research and Enterprise (SPHERE) Seed Grant. AS is supported by a Scientia PhD scholarship from UNSW Sydney. The funders had no role in the study design, data collection, data analysis, data interpretation, or writing of the manuscript.