A Systematic Review of the Effectiveness of Interventions to Promote Referral; Adherence; and Uptake of Pulmonary Rehabilitation for Patients with Chronic Obstructive Pulmonary Disease

Abstract

Background: Pulmonary rehabilitation (PR) is an effective treatment for patients with chronic obstructive pulmonary disease (COPD). However, referral, uptake, and adherence remain low. Objective: To determine effectiveness of interventions to increase patient referral, uptake, and adherence to PR programs for patients with COPD. Methods: Randomized controlled trials (RCTs), non-randomized controlled trials, pre-post studies, and uncontrolled studies were sought from 7 databases and 3 clinical trial registries, to end August 2021. Full articles/conference abstracts were included if a coordinated set of activities was targeted to healthcare professionals (HCPs) caring for COPD patients, adults with COPD or their carers, to increase referral, uptake or adherence to any type of PR program. Two review authors independently screened titles, abstracts and full texts, extracted data and critically appraised studies using standard risk of bias tools. Results: From 11,272 records, 30 studies (23 full-text; 7 abstracts) met inclusion criteria: study interventions and designs were varied and generally low quality, targeting patients (n=13), HCPs (n=14) or both (n=3 studies). A CCT of patient held evidence score cards increased referral by 7.3% compared to 1.3% for usual care (p-0.03). A cluster RCT involving COPD nurse home visits with individualized care plans increased uptake to 31% compared to 10% in usual care (p=0.002). For people with anxiety or depression, one RCT of cognitive behavioral therapy alongside PR increased adherence (mean sessions 14.0 (sd 1.7) compared to 12.4 (sd 2.6)). Conclusion: Although a small number of studies, the weight of evidence suggested that interventions incorporating partnership working between patients and HCPs appeared to increase referral, uptake, and adherence with greater effectiveness than those targeting single populations. Increasing knowledge and empowering HCPs and patients may be important strategies. Concerns about study design and risk of bias suggest clear need for well-designed trials of interventions to report full pathway outcomes.

Protected characteristics reported in pulmonary rehabilitation: a scoping review

“…To address this, the collection of data is vital [ 38 ]. Any results from collecting the data can be used to promote health equity by proposing where evidence-based changes are required in practices, policies and programmes [ 109 ], for example in adapting pulmonary rehabilitation to improve uptake and adherence in those least likely to attend [ 39 ]. As data on these characteristics have not been commonly collected, then any health inequalities among these characteristics cannot be identified or monitored and improvements cannot be made [ 104 , 109 – 111 ].…”

“…Collecting and reporting an individual's characteristics in pulmonary rehabilitation studies and audits consistently allows for the monitoring of potential health inequalities and may provide information on differences in the access, completion and outcomes of pulmonary rehabilitation across individuals [ 35 , 36 ]. This information can be used to establish whether services are equitable, fair and accessible for all [ 37 , 38 ] and challenge health inequalities by adapting and improving services [ 38 ], including pulmonary rehabilitation [ 39 ]. Reporting guidelines such as Consolidated Standards of Reporting Trials, Strengthening the Reporting of Observational Studies in Epidemiology and Consolidated Criteria for Reporting Qualitative Research recommend the reporting of “important” characteristics of study participants; however, no specific characteristics are stated [ 40 – 42 ].…”

Effectiveness of a home-based pulmonary rehabilitation maintenance programme: the Rehab2Life study protocol

“…Traditional patient education programmes often assume that simply providing information will lead to behaviour change. However, this program recognises a critical limitation that education alone is insufficient [ 35 ] and does not improve exercise performance [ 14 ]. This program explicitly addresses this gap and prioritises fostering awareness and willingness to change alongside knowledge acquisition.…”

“…This program explicitly addresses this gap and prioritises fostering awareness and willingness to change alongside knowledge acquisition. Nonetheless, patient education is a crucial component of PR programmes, as it empowers patients with the knowledge and skills to manage their condition effectively and improve their HRQoL [ 35 , 36 ]. .…”

A systems approach to developing user requirements for increased pulmonary rehabilitation uptake by COPD patients

“…In England, around 31% of referred COPD patients do not take up their PR appointment, more so from deprived communities 9 , 10 . Systematic reviews have found insufficient high-quality evidence to make clear recommendations for effective interventions to increase uptake 11 , 12 . In a previous study, we identified barriers and enablers to PR uptake at several stages on the PR pathway within and between primary care, PR providers and patients.…”