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

Figures & data

Figure 1 PRISMA.

Table 1 Characteristics of Included Studies

Author; Setting and Country	Study Design	Population/Setting	Intervention	Control	PR Pathway
					Referral	Uptake	Adherence
Zwar 2012^Citation61	Cluster RCT	44 General Practices in Australia N= 451 diagnosed COPD patients	Partnership model of care Home visits: COPD trained nurse; working with GP and other HCPS; implement evidence based individualized care plan agreed with patients	Usual care COPD guidelines provided to GPs practices.		X
Zwar 2016^Citation62	Cluster RCT	36 General Practices in Australia N= 254 newly diagnosed COPD patients	Evidence-based disease management plan implemented by nurse/GP teams including: practice staff education; computerized electronic care planning templates PLUS same case-finding/diagnosis training as control	8 hrs case finding/ spirometry training/ interpretation for practice nurses with computer-based toolkit + copy of COPD- national guidelines.		X
Aboumatar 2021^Citation41	RCT	Out-patient department in 2 hospitals in USA. N=292 diagnosed COPD patients	Peer support + self-management support from respiratory care practitioner Peer support via 1:1 and 8 group conversations + self-management support as control	Self-management support from respiratory care practitioner Written educational guide + 1-hour session and phone support		X
Barker 2020^Citation63	RCT	Secondary care; UK n=196 COPD patients with AECOPD	Patient co-designed education video as an adjunct to usual care	Usual care COPD discharge bundle including standardized verbal information about PR + information leaflet.	X	X	X
Pumar 2019^Citation53	RCT	Secondary care; Australia N=65 undertaking PR with diagnosed COPD (75%); ILD; asthma; bronchiectasis	CBT to treat anxiety and depression for patients attending PR 2 x face to face 1hr CBT + 4×45 min telephone sessions. 8 weeks of PR + booklet	Control 8 weeks PR + booklet on COPD 4 x sham telephone calls			X
Yao 2020^Citation60	RCT	Secondary Care; China N=128 COPD patients attending PR	Peer support to attend PR Patients supported to attend education lectures; community activities. Peer support by telephone/Wechat; undertook PR with patients during hospitalization. PR as described in control	Usual care PR including breathing exercises and 5–10 mins walking/jogging			X
Ringbaek 2016^Citation54	Quasi-randomized trial	Secondary Care outpatients Demark N=115 COPD patients attending PR	Tablet with instruction and training (electronic diary given to patients for home and PR use) - in addition to group PR	Usual group PR			X
Roberts 2015^Citation55	CCT	N=20 General Practices; England N=1350 Patients with COPD	Patient held COPD scorecard with 6 quality indicators; to discuss at COPD review. Helpline for queries.	Usual Care including a self- management plan; rescue pack distribution and instruction part of a regional QI intervention.	X
Harris 2009^Citation47	CCT	Secondary Care Australia N=249 patients with moderate to severe COPD	Patient held manual summarizing evidence about COPD and suggested questions to ask doctor	Usual care Simple; single sheet pamphlet containing information about COPD	X	X
Deprez 2009^Citation44	Pre-Post	Primary care; USA N=18 primary care practices: patients with COPD	Adoption of evidence-based and best practice clinical guidelines Expert support/meetings to practices; to review GOLD guidelines; plan evaluation with optional telephone; email; additional visit support	No control	X
Wardini 2013^Citation43	Intervention study with historic control	Secondary care; Canada Moderate to severe COPD admitted to 3–4 week PR program. N=32 (intervention); n=unclear controls	individualized virtual game system Wii workout 3 times x week in addition to standard 5 x inpatient PR.	5 x per week inpatient PR			X
Graves 2010^Citation46	Intervention study with historic control	Secondary Care; England N=400 Patients referred to PR	Pre-PR group opt-in face to face session: 90 minutes; 8–12 weeks after referral; attend mandatory session with physio and psychologist to discuss fears; expectations and PR content.	Usual care No pre-PR session		X	X
Ulrik 2010^Citation58	Intervention study with historic control	N=124 GPs; Denmark Diagnosed COPD Survey 1: Before n=1716 Survey 2: After N=1342	Education program for GP staff based on the GOLD guidelines designed by a group of Danish pulmonologists and GPs with a special interest in COPD. Individual; local; and regional meetings.	No control	X
Tottenborg 2013^Citation57	Retrospective cohort study	Secondary care; Denmark COPD Patients at any hospital outpatient clinic Year 1 (2008) n=12,111 Year 2 (2009) n=14,153 Year 3 (2010) n=15,164 Year 4 (2011) n=15,264	Initiation of national multidisciplinary quality improvement program in 2008 with implementation of evidence-based treatment and care.	No control	X
Foster 2016^Citation45	QI study	N=8 General Practices; UK N=9 GPs n=13 practice nurses N=126 patients eligible for PR	Range of practice-based strategies to increase referrals to PR In-house training run by PR service (30 mins). Screen prompts at COPD review. Practice protocol re: referrer role and when to refer Memory aids-logo on coasters/mugs Pop up alerts for eligible patients	No control	X
McCarron 2019^Citation52	QI study	Secondary care; UK Random selection of patients referred to PR who attended; attended and dropped out; did not attend. Pre n= 281; post n= 323	Patient information (both written and audio‐visual (AV)) and education of physicians on the importance of PR and how to make a referral	No control		X	X
Hopkinson 2012^Citation48	Service evaluation with historic control	Secondary care; UK Patients discharged from hospital respiratory ward following acute exacerbation Post-intervention: n=94 Pre-intervention n=22	COPD discharge bundle Patient education and telephone support post discharge Staff Education/support: Directions to notify respiratory nurse specialist; implement discharge bundle* and prize draw incentive.	Historic control	X
Lange 2007^Citation50	Pre-post	General Practice; Denmark Year 1: n=2549 mod/severe COPD patients from n=184 GPs Year 2: n=2394 mod/severe COPD patients from n=156 GPs	Educational program to GPs and staff; and attendance of national COPD forum to improve implementation of COPD guidelines	No control	X
Lange 2009^Citation51	Pre-post	Hospital outpatients; Denmark Patients attending COPD consultation Year 1 n=941 COPD patients Year 2 n=927 COPD patients	Staff educational program on COPD guidelines	No control	X
Angus 2012^Citation42	Uncontrolled feasibility study	N=16 General Practices; UK N=293 patients on the COPD register; n=18 nurses	45-minute consultation using computer guided software based on NICE COPD guidelines and including PR prompts.	No Control	X
White 2019^Citation59	Uncontrolled feasibility study	Community PR; England N=66 COPD patients newly referred to PR appointment	Lay Health Workers support (LHW) for COPD patients referred to PR LHW with previous experience of PR: 3 days of training; 3 phone sessions; 8 mentor meetings	No control		X	X
Sewell 2017^Citation56	Uncontrolled service evaluation	Secondary Care, England N=1170 COPD patients with suspected AECOPD	COPD discharge bundle delivered by specialist respiratory nurses (REDS) to inpatients pre-discharge- 5 quality outcomes plus SM manual and Breathe Easy patient group contacts.	No control	X
Hull 2014^Citation49	Longitudinal audit	N=36 GP practices in London. Spirometry confirmed COPD patients. Year 1 population: n 259,071 COPD year 1 (n): 2798 COPD year 2 (n): 3176 COPD year 3 (n): 3391	Locally-adapted COPD care package based on National COPD guidelines + financial incentives. Included regular patient review and care planning; structured templates; respiratory consultant support and education at MDT meetings; network co-ordinators focused on non-attenders.	Local and national comparators	X
Angus 2019^Citation70 Abstract only	Uncontrolled service evaluation	N=741 patients on COPD registers from 54 general practices in the UK.	Computer clinical support decision aids incorporating GOLD 2018 guidance to support patient reviews.	No control	X
Cox 2019^Citation66 Abstract only	Pilot study - single arm	Secondary care; Australia N=29 patients with stable COPD or ILD attending outpatients	Video patient testimonials about PR	No control	X
Cornwallis 2017^Citation65 Abstract only	Prospective cohort study	Primary /integrated care; UK COPD diagnosis and/or FEV1 >/=50% predicted and/or on high dose inhaled corticosteroids. Primary care (n=94) or integrated respiratory care service (n=67)	Virtual Clinic to recommend guideline-based interventions to optimize COPD care for primary care practices and integrated respiratory service.	No control	X
Avent 2015^Citation64 Abstract only	Prospective cohort study	Secondary Care; UK N=50 Patients admitted with AECOPD; controls NR	Inpatient physiotherapy-led exercise class twice weekly during hospital admission with AECOPD.	Usual Care	X
Nuguru 2019^Citation67 Abstract only	Quality improvement - Pre and post no control	Outpatient Secondary care; USA 6 physicians and 1 registered nurse in outpatient clinic. Review of 60 charts	Education on guidelines	No control	X
Tong 2017^Citation68 Abstract only	Single centered retrospective audit	Respiratory Ward; Secondary Care; Australia N=70 Patients admitted for AECOPD (n=33 pre/37 post)	Implementation of COPD pathway based on COPD guidelines. One-page check list	No control	X
Wexler 2019^Citation69 Abstract only	Pre-post	Secondary Care; USA COPD (Gold B and above) 1 admission for AECOPD in a year N=36/39 pre/post-intervention	Quality improvement initiative: flyers near workstations; educational conferences; faculty reinforcement	No control	X

Abbreviations: *RCT, randomized controlled trial; CCT, controlled clinical trial; QI, quality improvement; FEV_1, forced expiratory volume in 1 second; COPD, chronic obstructive pulmonary disease; AECOPD, acute exacerbation of COPD; ILD, interstitial lung disease; HCPs, health care professional; UK, United Kingdom; USA, United States of America; PR, pulmonary rehabilitation; GOLD, international disease classification; CBT, cognitive behavior therapy; GP, general practice; MDT, multidisciplinary team; NICE, National Institute for Health and Care Excellence.

Figure 2 Risk of bias assessment: randomized studies.

Figure 3 Risk of bias assessment: non-randomized studies.

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