Pulmonary rehabilitation programs (PRPs) are important for people with symptomatic chronic obstructive pulmonary disease (COPD), but program attrition is common. Among people with COPD who appeared appropriate for a PRP, we prospectively mapped the rehabilitation journey, captured attrition and explored factors influencing attendance to pre-program assessment. 391 participants consented, of which 123 (31% [95% confidence interval {CI}] 27 to 36) were referred to a PRP (mean±SD or frequency[%]: age 68±10yr, 62 males[50%], BMI 27±8kg/m2, FEV1 45±19%predicted). Of those referred, 94 (76% [69 to 84]) attended a pre-program assessment. Ex-smokers (odds ratio [95%CI]; 2.6 [1.1 to 6.1]) and those who had a healthcare professional explain they would be referred (4.7 [1.9 to 11.7]) were more likely to attend a pre-program assessment. Of those who attended, 63 (67% [58 to 77]) commenced and 35 (56% [43 to 68]) completed a PRP. Substantial attrition occurs throughout the PRP journey. Understanding how HCPs can best contextualise PRPs to encourage uptake is an important area for further work.
Short Report
Quantifying uptake and completion of pulmonary rehabilitation programs in people with COPD known to tertiary care
https://doi.org/10.21203/rs.3.rs-3111624/v1
This work is licensed under a CC BY 4.0 License
Version 1
posted
You are reading this latest preprint version
Pulmonary rehabilitation
uptake
attendance
adherence
completion
maintenance
attrition.
Although the benefits of pulmonary rehabilitation programs (PRPs) for people with symptomatic chronic obstructive pulmonary disease (COPD) are well-documented [1, 2], these programs are underutilised globally [3]. A retrospective study demonstrated among those referred (n = 90), 76% attended the pre-program assessment, 88% commenced, and 72% completed the program [4]. Retrospective audits of the patient journey through PRPs give limited insight to the reasons for program attrition, and whether these reasons are modifiable. We recently completed a prospective observational study to capture the rehabilitation journey among people with COPD known to tertiary care in Perth, Australia. Data reporting on referral behaviours to PRPs was published last year [5]. Our study found that referral to PRPs within two weeks of hospital discharge for an exacerbation or two weeks following an out-patient respiratory medicine clinic appointment were suboptimal among participants who appeared suitable for a referral [5]. Our analyses also demonstrated that among those who were suitable for referral to a PRP, the only factor that predicted whether or not a person was referred was their level of interest in the program. That is, those not referred expressed less interest in participating in a PRP, with introverted personality traits and feelings of unworthiness contributing to their reduced interest [5]. This study was of sufficient interest to be accompanied by an editorial [6].
As part of this observational study, we followed all people who were referred to a PRP, irrespective of their suitability for the program, to understand uptake and attrition. In this report, among the people who were referred to a PRP during our 5-month recruitment period, we report the proportion who went on to attend a pre-program assessment, commence and complete a PRP. We also explore factors which influenced attendance to pre-program assessment. Quantifying reasons for suboptimal uptake of PRPs can assist in the development of strategies to mitigate the implementation gap so that more people can obtain the benefits associated with these programs.
Data reported in this prospective observational study were collected as part of a larger mixed-methods study [7]. Approvals from the relevant Human Research Ethics Committees were obtained prior to study commencement, and informed written consent was obtained from each participant. As described elsewhere [5], people with COPD were sequentially recruited from the Respiratory in-patient and out-patients areas of three tertiary hospitals in Perth, Western Australia (WA) between August 2020 and January 2021. Inclusion criteria targeted people who appeared broadly appropriate for a physiotherapist-led PRP, in either a hospital out-patient department or community centre. That is, participants were required to have a diagnosis of COPD, be English speaking, be independently ambulant and have a life expectancy of more than six months. Potential participants were excluded if they were living in supported residential aged care or had a cognitive impairment. Those recruited as out-patients were excluded if they had participated in either a PRP within the previous 12 months, or a ‘maintenance’ PRP within the previous 8 weeks. In our previous study which reported referral behaviours [5], we grouped participants according to their suitability for a referral to a PRP (based on symptoms limiting physical activity and no comorbidities precluding safety during exercise). Grouping according to suitability for a referral to a PRP enabled us to understand which participant referrals had been missed (which is the implementation gap) and which participants were appropriately not referred. However, because referral rates were suboptimal, in this current study, we have removed the suitability grouping. Therefore, for every participant who was referred to a PRP during the recruitment period, regardless of their suitability for the program, we prospectively recorded the number who (i) attended a pre-program assessment, (ii) commenced a PRP, (iii) completed a PRP and, (iv) received a strategy to maintain training-related gains. Variables collected included age, gender, body mass index (BMI), forced expiratory volume in 1 second (FEV1), smoking status, social support, recruitment setting (i.e. in-patient or out-patient), the interaction with the referring healthcare professional (HCP), who contacted the participant regarding the referral, and whether the participant was asked to attend their pre-program assessment at a location that differed from where they were referred. These variables were selected as they are easily measured by clinicians, and if found to differ between groups, could be used to modify clinical practice and potentially improve PRP engagement. These variables were compared between participants who were referred and attended the pre-program assessment versus those who were referred but did not attend the pre-program assessment using independent t-tests or chi-square (\(\chi\)2) tests. Variables which differed between groups were included in a logistic regression model to identify what influenced the odds of attendance to pre-program assessment. Although we would have liked to undertake similar analyses to explore factors influencing commencement and completion of PRPs, attrition limited our capacity to do so. Statistical analyses were completed in Stata 17 (StataCorp. 2021. College Station, TX: StataCorp LLC).
Figure 1 presents the flow of participants. Of the 391 participants who consented and were eligible for the study, 123 (31%; 95% confidence interval [CI], 27 to 36) were referred to a PRP (mean±SD or frequency [%]: age 68±10yr, 62 males [50%], BMI 27±8kg/m2, FEV1 45±19%predicted).
Of the 123 participants referred, 94 (76% [69 to 84]) attended their pre-program assessment and the between group analyses are presented in Table 1.
Table 1. Between-group differences in characteristics among those were referred to a PRP and did versus did not attend their pre-program assessment.
Data expressed as mean ± SD, median [IQR] or n (%). Boldface indicates a significant difference between groups. #indicates missing observations.
Abbreviations: Admin – administration staff, Ax – assessment, CI – confidence interval, HCP – healthcare professional, MD – mean difference, OR – unadjusted odds ratio, Site change – whether the pre-program assessment took place at a different site from where the referral was initiated, PRP – pulmonary rehabilitation program, PT- Physiotherapist, VAS – Visual Analogue Scale, Y – yes, χ2 – chi squared test statistic.
The odds of attending a pre-program assessment were greater in ex-smokers (compared with smokers; odds ratio [95%CI], 2.6 [1.1 to 6.1]) and in those who had a healthcare professional (HCP) explain that they would be referred (compared with those who did not; 4.7 [1.9 to 11.7]). Of the 94 participants who attended a pre-program assessment, 63 (67% [58 to 77]) went on to commence a PRP, with 46 (73% [62 to 84]) offered classes twice a week for at least eight weeks. The median[IQR] attendance was 9[4 to 15] classes. Of the 63 participants who commenced, 35 (56% [43 to 68]) completed a PRP, with all provided at least one maintenance strategy. Common reasons for attrition were participants declining, social barriers (such as work/carer commitments, reluctance to attend hospitals or social phobia of groups) and illness (such as an exacerbation of their disease).
We found that attrition was problematic throughout the entire rehabilitation journey. As described elsewhere [5], non-referral is the primary hurdle. Approximately 24% of those referred did not attend a pre-program assessment, despite majority of these ‘non-attenders’ appearing suitable for the program based on our criteria [5]. Similar to earlier work showing smoking status as a strong predictor of PRP attendance [8, 9], ex-smokers were 2.6 times more likely to attend the pre-program assessment, perhaps reflecting that they were ready to make behaviour changes to optimise health outcomes [10]. Participants who had the referral explained by a HCP were 4.7 times more likely to attend their pre-program assessment. That is, the odds of the referral being accepted by the person was substantially greater when there was an interaction with a HCP about the referral to a PRP. This highlights the importance of fostering a therapeutic alliance to change health behaviours and suggests that HCPs should help people with COPD to contextualise the evidence underpinning PRPs to individual circumstance [11]. But how do HCPs encourage referral acceptance? Perhaps HCPs, who are ‘credible sources’, use behaviour change techniques such as ‘problem solving’ to overcome individual barriers, or ‘verbal persuasion about capability’ to convert ambivalence or intention to participate into action [12, 13]. Our earlier publication demonstrated that among people with COPD, low interest in participating in a PRP may stem from underlying feelings of unworthiness [5]. Therefore, in people who appear ‘unmotivated or disinterested’ in a PRP, the HCP should consider carefully probing feelings of fear and shame that may lead them to feel unworthy of healthcare [14, 15].
Once assessed, 33% did not follow through and commence a PRP. Reasons for attrition included participants declining, illness or social barriers. Similarly, illness and social barriers were common reasons for attrition among the 44% who did not complete a PRP. Some of these barriers may be overcome by HCPs offering people with COPD a choice of alternative methods of PRP delivery such as home-based rehabilitation or telerehabilitation [3, 16, 17].
Strengths of this study include sequential recruitment of participants, with prospective follow-up via discussion with the physiotherapist or participant which provided insights to the reasons for attrition. Due to the attrition, we did not have an adequate sample to explore differences among those who did versus did not commence or complete a PRP.
Our study demonstrates that attrition from PRPs occurs across the rehabilitation journey. Smoking cessation and the HCP explaining the referral to a PRP to the patient increased the odds of attendance at the pre-program assessment. Understanding how HCPs can best contextualise PRPs to change health behaviours and encourage referral acceptance and uptake is an important area for further work. People who appear ‘unmotivated or disinterested’ in PRP may be masking a belief that they are unworthy of healthcare. Targeting this unhelpful belief may represent a pathway to optimise uptake.
BMI – body mass index, CI – confidence interval, COPD – chronic obstructive pulmonary disease, FEV1 - forced expiratory volume in 1 second, HCP – healthcare professional, PRP – pulmonary rehabilitation program.
Funding: This study is supported by the Department of Health, Government of Western Australia (RES-HEA-SOP-CL-61482-1). Author SH is supported by the Research Translation Project Scholarship.
Competing interests: The authors have no relevant financial or non-financial interests to disclose.
Author contributions: All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Sarah Hug and Kylie Hill. The first draft of the manuscript was written by Sarah Hug and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.
Ethics approval: This study has been approved by the South Metropolitan Health Service Human Research Ethics Committee (RGS0000003704) with reciprocal approval from Royal Perth Hospital, Sir Charles Gairdner Hospital and Curtin University (HRE2020-0095).
Consent to participate: Each individual participant gave written informed consent to participate in our study prior to data collection.
Notation of prior abstract publication/presentation: Hug S, Cavalheri V, Gucciardi D.F, Hill K. Illness and social factors influence attrition in pulmonary rehabilitation. Poster presentation at the TSANZSRS Virtual Annual Scientific Meeting March 31 – April 2, 2022. Respirology 2022; 27 (Suppl. 1): T065. https://doi.org/10.1111/resp.14226
Other acknowledgements: We would like to acknowledge the Department of Health, Western Australia (Research Translation Projects – 2019; Round 13) for support in the form of a research grant. We would also like to acknowledge our steering committee (Carol Watson, Nola Cecins, Peta Winship, Jade Larsson, Tamara Hatton and Tenae Cowie) and research assistants (Brooke Loxton, Emma Koenig, Hollie Lawson-Smith, Jo Cockram, Pip Windsor and Tamara Hatton).
Data Availability Statement: The data that support the findings of this study are available from the corresponding author upon reasonable request and approval from the Human Research Ethics Committee.
- McCarthy B, Casey D, Devane D, Murphy K, Murphy E, & Lacasse Y (2015). Pulmonary rehabilitation for chronic obstructive pulmonary disease. Cochrane Database Syst Rev(2), Cd003793. https://doi.org/10.1002/14651858.CD003793.pub3
- Alison JA, McKeough ZJ, Johnston K, McNamara RJ, Spencer LM, Jenkins, SC, Hill CJ, McDonald VM, Frith P, Cafarella P, Brooke M, Cameron-Tucker HL, Candy S, Cecins N, Chan AS, Dale MT, Dowman LM, Granger C, Halloran S, Jung P, Lee AL, Leung R, Matulick T, Osadnik C, Roberts M, Walsh J, Wootton S, Holland AE, Lung Foundation Australia, the Thoracic Society of Australia & New Zealand (2017). Australian and New Zealand Pulmonary Rehabilitation Guidelines. Respirology, 22(4), 800-819. https://doi.org/10.1111/resp.13025
- Holland AE, Cox NS, Houchen-Wolloff L, Rochester CL, Garvey C, ZuWallack R, Nici L, Limberg T, Lareau SC, Yawn BP, Galwicki M, Troosters T, Steiner M, Casaburi R, Clini E, Goldstein RS, & Singh SJ (2021). Defining Modern Pulmonary Rehabilitation. An Official American Thoracic Society Workshop Report. Ann Am Thorac Soc, 18(5), e12-e29. https://doi.org/10.1513/AnnalsATS.202102-146ST
- Jones SE, Green SA, Clark AL, Dickson MJ, Nolan AM, Moloney C, Kon SSC, Kamal F, Godden J, Howe C, Bell D, Fleming S, Haselden BM, & Man WDC (2014). Pulmonary rehabilitation following hospitalisation for acute exacerbation of COPD: referrals, uptake and adherence. Thorax, 69(2), 181-182. https://doi.org/10.1136/thoraxjnl-2013-204227
- Hug S, Cavalheri V, Gucciardi DF, Hill K (2022) An Evaluation of Factors That Influence Referral to Pulmonary Rehabilitation Programs Among People With COPD. Chest, 162(1):82-91. https://doi.org/10.1016/j.chest.2022.01.006
- Cox NS, Holland AE (2022) Gambling on Pulmonary Rehabilitation: What Are the Odds of Being Referred? Chest, 162(1):17-8. https://doi.org/10.1016/j.chest.2022.02.033
- Hug S, Cavalheri V, Gucciardi DF, Norman R, Hill K (2020) OPTImising the implementation of pulMonary rehAbiLitation in people with chronic obstructive pulmonary disease (the OPTIMAL study): mixed methods study protocol. BMC Pulmonary Medicine, 20(1). https://doi.org/10.1186/s12890-020-01322-4
- Hayton C, Clark A, Olive S, Browne P, Galey P, Knights E, et al (2013) Barriers to pulmonary rehabilitation: Characteristics that predict patient attendance and adherence. Respiratory Medicine, 107(3):401-7. https://doi.org/10.1016/j.rmed.2012.11.016
- Fischer MJ, Scharloo M, Abbink JJ, van ‘t Hul AJ, van Ranst D, Rudolphus A, Weinman J, Rabe KF, & Kaptein AA (2009). Drop-out and attendance in pulmonary rehabilitation: The role of clinical and psychosocial variables. Respiratory Medicine, 103(10), 1564-1571. https://doi.org/https://doi.org/10.1016/j.rmed.2008.11.020
- Prochaska JO, Velicer WF (1997) The Transtheoretical Model of Health Behavior Change. American Journal of Health Promotion, 12(1):38-48. https://doi.org/10.4278/0890-1171-12.1.38
- Early F, Wilson PM, Deaton C, Wellwood I, Haque HW, Fox SE, et al (2020) Pulmonary rehabilitation referral and uptake from primary care for people living with COPD: a mixed-methods study. ERJ Open Research, 6(1):00219-2019. https://doi.org/10.1183/23120541.00219-2019
- Michie S, Richardson M, Johnston M, Abraham C, Francis J, Hardeman W, et al (2013) The behavior change technique taxonomy (v1) of 93 hierarchically clustered techniques: building an international consensus for the reporting of behavior change interventions. Ann Behav Med, 46(1):81-95. https://doi.org/10.1007/s12160-013-9486-6
- Teixeira PJ, Marques MM, Silva MN, Brunet J, Duda JL, Haerens L, et al (2020). A classification of motivation and behavior change techniques used in self-determination theory-based interventions in health contexts. Motivation Science, 6(4), 438-455. https://doi.org/10.1037/mot0000172
- Harrison SL, Robertson N, Apps L, C. Steiner M, Morgan MDL, Singh SJ (2015) “We are not worthy” – understanding why patients decline pulmonary rehabilitation following an acute exacerbation of COPD. Disability and Rehabilitation, 37(9):750-6. https://doi.org/10.3109/09638288.2014.939770
- Jerpseth H, Knutsen IR, Jensen KT & Halvorsen K (2021). Mirror of shame: Patients experiences of late-stage COPD. A qualitative study. Journal of Clinical Nursing, 30(19-20), 2854-2862. https://doi.org/https://doi.org/10.1111/jocn.15792
- Holland AE, Mahal A, Hill CJ, Lee AL, Burge AT, Cox NS, Moore R, Nicolson C, O'Halloran P, Lahham A, Gillies R & McDonald CF (2017). Home-based rehabilitation for COPD using minimal resources: a randomised, controlled equivalence trial. Thorax, 72(1), 57-65. https://doi.org/10.1136/thoraxjnl-2016-208514
- Cox NS, Dal Corso S, Hansen H, McDonald CF, Hill CJ, Zanaboni P, Alison J A, O'Halloran P, Macdonald H & Holland AE (2021). Telerehabilitation for chronic respiratory disease. Cochrane Database of Systematic Reviews(1). https://doi.org/10.1002/14651858.CD013040.pub2
No competing interests reported.