Access to pulmonary rehabilitation in real-world territorial care: the APTA friendly network as a structural and organizational model

BACKGROUND: Pulmonary rehabilitation represents a cornerstone of chronic respiratory disease management, supported by robust evidence demonstrating improvements in functional capacity, symptoms and health-related quality of life. Nevertheless, its implementation in real-world territorial respiratory care remains limited and highly heterogeneous, suggesting the presence of systemic and organizational barriers beyond clinical efficacy. METHODS: This mixed-methods, expert-based study combined structured expert discussion and targeted survey data collection among pulmonologists actively involved in community-based respiratory care within the regional healthcare system of Campania, Italy. The initiative was conducted within the framework of the Associazione Pneumologi Territoriali Ambulatoriali (APTA), a professional network representing territorial and outpatient pulmonologists, with the aim of capturing real-world implementation challenges in pulmonary rehabilitation delivery. Qualitative and quantitative findings were integrated through thematic triangulation to inform an implementation-oriented analytical framework. RESULTS: Organizational barriers to pulmonary rehabilitation were consistently reported across districts in the Campania Region. Approximately two thirds of respondents identified long waiting times and limited short-term availability as major obstacles to access, while around half reported administrative and bureaucratic constraints as key determinants of delayed rehabilitation activation. Marked inter-district heterogeneity in access pathways emerged independently of clinical need, and domiciliary rehabilitation was frequently perceived as suboptimal because of limited respiratory-specific expertise and lack of outcome monitoring. More than half of respondents expressed skepticism toward telemedicine-supported rehabilitation when implemented outside structured care pathways. CONCLUSIONS: These findings should be read as implementation-informed insights rather than definitive evidence of system performance. Within these limits, the observed barriers appear predominantly organizational, pointing to the need for integrated care networks and standardized access pathways. Although derived from a specific professional and regional context, the proposed framework may be applicable to other healthcare systems facing similar challenges in translating evidence-based pulmonary rehabilitation into routine practice.