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.

Keywords:

• pulmonary rehabilitation
• chronic obstructive pulmonary disease
• intervention
• referral
• uptake
• adherence

Acknowledgments

This systematic review formed part of Watson’s PhD thesis which examined improving referral from primary care to PR for patients with COPD.⁸¹ It was also presented at the Primary Care Respiratory Society (PCRS) conference in England in 2022.⁸²

Disclosure

Dr Jane S Watson reports personal fees from Astra-Zeneca; outside the submitted work. Professor Rachel E Jordan reports personal fees from Boehringer Ingelheim; outside the submitted work. Professor Peymane Adab reports Research grants from NIHR (NIHR132630; 16/137/95; 17/128/04; 17/92/39; 17/42/42; NIHR129593; NIHR135211; NIHR131396); MRC; Yong Ning Pharmaceuticals Ltd Co.; COLT Foundation; Chair of NIHR Public Health Research Funding Committee; Deputy Director of NIHR School for Public Health Research; Member of Wellcome Trust Early Career Advisory Group in Population and Public Health; Output assessor for Panel A; subpanel 2 (Public Health; Health Services and Primary Care) in 2021 Research Excellence Framework; Member of Obesity Health Alliance Independent Obesity Strategy Working Group; 2019–2021. The authors report no other conflicts of interest in this work.