Adherence to a Pulmonary Rehabilitation Program: Start by understanding the patient

Pulmonary rehabilitation, a comprehensive, interdisciplinary, patient-centered intervention that includes exercise training and self-management education, is a crucial component of optimal care for patients with chronic obstructive pulmonary disease (COPD).(1) This intervention has proven benefits in exercise tolerance, dyspnea, and health-related quality of life. It also reduces health care utilization and number and severity of exacerbations.(2)

However, when pulmonary rehabilitation is offered to symptomatic patients with COPD, a considerable number of them choose not to participate, and a significant proportion of those that do choose to participate, fail to complete the program.(3) Understanding the reasons for these ″missed opportunities″ is imperative if we want to make a difference in the lives of our patients. Indeed, the consequences of poor adherence to effective therapies are substantial: poor health outcomes and increased health care costs. (4)

Adherence is defined by the World Health Organization as the extent to which a person's behavior corresponds with agreed recommendations by the health care provider. (5) Adherence to therapeutic interventions is an essential health behavior in the management of chronic disease. It is a complex, multidimensional phenomenon determined by the interplay of five sets of factors, termed "dimensions" (Figure 1). Data is limited on predictors of non-adherence, although it is clear that adherence is enhanced when the relationship between the patient and the health care provider is a partnership.

Figure 1. The Five Dimensions of Adherence. Adapted from the World Health Organization 2003

Previous studies have shown that major barriers to enrollment in pulmonary rehabilitation include disruption to the patient's routine, transportation problems, inconvenient timing of the program, influence of the patient's healthcare provider, and lack of perceived benefit. (6) Key factors for non-completion include intervening illness and co-morbidities, transportation, lack of perceived benefits, smoking, depressive symptoms and social isolation. (7) The articles by Selzler and colleagues (8) and Hogg and colleagues (9) in this issue of COPD: Journal of Chronic Obstructive Pulmonary Disease contribute to knowledge in this area by evaluating and defining predictors of program attendance, completion and success. Both studies had large sample sizes (>800 participants). Patients in the Selzler group attended a single out-patient pulmonary rehailitation program in a large urban hospital in Canada. The variables associated with program drop-out were younger age, smoking history, and health status. Interestingly, their findings indicate that patients’ perceived health status was more likely to influence program completion than actual pulmonary impairment. Gender was not found to be a predictor of response to treatment. Patients in the Hogg study attended pulmonary rehabilitation programs in 7 centers: two in-hospital facilites and five community settings. Patients were less likely to attend the program if they were under 55years or over 74 years of age, referred by hospital team or a COPD specialist. Factors associated with lower rates of completion included referral by a general practitioner, Medical Research Council (MRC) score greater than 4, lower baseline levels of exercise capacity and quality of life, and increased baseline scores for depression/anxiety.

So what can we do to improve adherence? It is vitally important that we engage the patient as a partner. Patients are more likely to adhere to treatment when they believe it will improve disease control, or anticipate serious consequences related to non-adherence. As healthcare providers, we play a critical role in helping patients understand the nature of their disease, the potential benefits of treatment, and most importantly, encouraging them to take ownership of their disease by utilizing effective self-management strategies. A recent study (11) evaluated the effectiveness of a group ''opt-in'' session prior to individualized assessment and entry into pulmonary rehabilitation. The intention was to improve adherence rates. During this ''opt-in'' session, potential enrollees listened to a description of the process and general concepts of pulmonary rehabilitation delivered by the rehabilitation staff. When compared to historical controls, a significantly higher proportion of individuals who participated in the group ''opt-in'' session and began rehabilitation graduated (88 versus 76%). Drop-out rates due to illness were similar in both groups, but drop-out rates not due to illness were significantly lower in the group that participated in the opt-in session (5 versus 15%).

While more information is needed on the reasons for and predictors of non-adherence and non-participation, we must put far greater efforts into developing effective strategies in this area. Increasing our ability to promote patient adherence is likely to have a far greater impact on the health of the population than any improvement in specific medical therapies. The potential rewards for both patients and society are great.