Interventions to increase referral and uptake to pulmonary rehabilitation in people with COPD: a systematic review

Abstract

Pulmonary rehabilitation (PR) reduces the number and duration of hospital admissions and readmissions, and improves health-related quality of life in patients with COPD. Despite clinical guideline recommendations, under-referral and limited uptake to PR contribute to poor treatment access. We reviewed published literature on the effectiveness of interventions to improve referral to and uptake of PR in patients with COPD when compared to standard care, alternative interventions, or no intervention. The review followed recognized methods. Search terms included “pulmonary rehabilitation” AND “referral” OR “uptake” applied to MEDLINE, EMBASE, CINAHL, PsycINFO, ASSIA, BNI, Web of Science, and Cochrane Library up to January 2018. Titles, abstracts, and full papers were reviewed independently and quality appraised. The protocol was registered (PROSPERO # 2016:CRD42016043762). We screened 5,328 references. Fourteen papers met the inclusion criteria. Ten assessed referral and five assessed uptake (46,146 patients, 409 clinicians, 82 hospital departments, 122 general practices). One was a systematic review which assessed uptake. Designs, interventions, and scope of studies were diverse, often part of multifaceted evidence-based management of COPD. Examples included computer-based prompts at practice nurse review, patient information, clinician education, and financial incentives. Four studies reported statistically significant improvements in referral (range 3.5%–36%). Two studies reported statistically significant increases in uptake (range 18%–21.5%). Most studies had methodological and reporting limitations. Meta-analysis was not conducted due to heterogeneity of study designs. This review demonstrates the range of approaches aimed at increasing referral and uptake to PR but identifies limited evidence of effectiveness due to the heterogeneity and limitations of study designs. Research using robust methods with clear descriptions of intervention, setting, and target population is required to optimize access to PR across a range of settings.

Keywords:

• health services research
• service improvement
• access to healthcare
• evidence-based practice
• long-term condition
• supervised exercise

Supplementary material

MEDLINE search strategy

1. (((pulmonary rehabilitation.ti,ab.) or (((emphysema or copd or chronic obstructive pulmonary disease or chronic bronchitis or chronic asthma).ti,ab. or exp Pulmonary Disease, Chronic Obstructive/or exp Bronchitis, Chronic/or exp Asthma/or exp Emphysema/) and ((exercis* or rehab* or physiotherap* or “physical therap*”).ti,ab. or exp Exercise Therapy/or exp Exercise/or exp rehabilitation/or exp Physical Therapy Modalities/))) and ((refer* 1 or referring or referred or referral* or assess*).ti,ab. Or exp “Referral and Consultation”/) And ((rate* or number* or audit* or percentage or barrier* or facilitat* or frequen* or infrequent* or rare* or common* or uncommon or standard* or influenc* or reluctant* or barrier* or obstacle or (meet* adj3 criter*)).ti,ab. Or exp practice patterns, physicians/or exp guideline adherence or exp data collection/))

2. ((pulmonary rehabilitation.ti,ab.) or (((emphysema or copd or chronic obstructive pulmonary disease or chronic bronchitis).ti,ab. or exp Pulmonary Disease, Chronic Obstructive/or exp Bronchitis, Chronic/or exp Emphysema/) and ((exercis* or rehab* or physiotherap* or “physical therap*”).ti,ab. or exp Exercise Therapy/or exp Exercise/or exp rehabilitation/or exp Physical Therapy Modalities/))) and ((uptake or up-take or (up adj3 take*) or non-attend* or nonattend* or attend* or engag* or (treat* adj3 refus*) or decline* or concordan* or complian* or barrier* or obstacle* or adher* or accept*).ti,ab. Or exp treatment refusal/or exp patient compliance/or exp patient acceptance of healthcare/)

3. or 2

4. ((((Meta-Analysis as Topic/or Meta-Analysis/or exp Review Literature as Topic/) or ((meta analy$) or (metaanaly$) or ((systematic adj (review$1 or overview$1)))).tw. or (Cochrane or embase or psychlit or psyclit or psychinfo or psycinfo or cinahl or cinhal or (science citation index) or bids or cancerlit or reference list$ or bibliograph$ or hand-search$ or (relevant journals) or (manual search$)).ab. or ((selection criteria or data extraction).ab. and review/)) NOT (Comment/or Letter/or Editorial/)) Or (((Randomized Controlled Trials as Topic/or randomized controlled trial/or Random Allocation/or Double Blind Method/or Single Blind Method/or clinical trial/or exp Clinical Trials as topic/or PLACEBOS/) or ((clinical trial, phase i) or (clinical trial, phase ii) or (clinical trial, phase iii) or (clinical trial, phase iv) or (controlled clinical trial) or (randomized controlled trial) or (multicenter study) or (clinical trial)).pt or ((clinical adj trial$) or ((singl$ or doubl$ or treb$ or tripl$) adj (blind$3 or mask$3)) or (placebo$) or (randomly allocated) or (allocated adj2 random$)).tw) NOT (case report.tw or letter/or historical article/))) or (quantitative or (mix* adj method*)).mp.

5. 3 and 4

Acknowledgments

Delivery of this work was supported by the Cambridge Biomedical Research Centre.

Author contributions

JF, FE, IW, and CD conceived and designed the review. IK provided expert support and conducted the literature search. FE and IW reviewed the titles and abstracts, selected the papers, and extracted and analyzed the data. All authors were involved in drafting and revision of the manuscript for important intellectual content and approved the final version to be published. All authors agree to be accountable for aspects of the work. JF is the guarantor of the paper.

Disclosure

The authors report no conflicts of interest in this work.