Brimicombe, David

Deaton, Christi

Dickerson, Terry

Early, F

Fuld, Jonathan

Kuhn, I

Ward, James

Wellwood, Ian

Apollo (Cambridge)

Addenbrooke’s Hospital    Rosie HospitalInterventions to increase referral to and uptake of Pulmonary Rehabilitation programmes for people with Chronic Obstructive Pulmonary Disease (COPD):       a systematic reviewF. Early1, I. Wellwood2, I. Kuhn1, T. Dickerson3, J. Ward3, J. Brimicombe2, C. Deaton2, J. Fuld11Cambridge University Hospitals NHS Foundation Trust, 2Cambridge Institute of Public Health, 3University of Cambridge Engineering Design CentreBackground• People diagnosed with COPD experience breathlessness, inability to exercise, frequent infections and hospitalisation.  The cost to the NHS in England is over £800m/year.• NICE recommends Pulmonary Rehabilitation (PR), a course of supervised exercise and education.  PR reduces hospital admissions and improves quality of life.  In England and Wales in 2013/14 approximately 15% of eligible patients were referred (68,000 out of 446,000) and among referred patients uptake was less than 70%.1• We conducted a systematic review of interventions aimed at improving rates of referral and uptake to PR.Key question• How effective are interventions to improve referral and uptake to exercise-based pulmonary rehabilitation (PR) programmes in patients with COPD when compared to standard care or no intervention?Figure 1: Healthcare professionals’ conversations with patients are an opportunity for referral (Image: British Lung Foundation)Method• We used recognised systematic review methods, registering the protocol on PROSPERO and reporting using PRISMA guidance.• Databases searched: MEDLINE and EMBASE (via OVID), CINAHL and PsychINFO (via EbscoHost) ASSIA and BNI (via Proquest), Web of Science and Cochrane Library, review of reference lists and citation search. • Inclusion criteria:  Primary, community or secondary care settings;   interventions contrasted with standard care, alternative interventions or no comparator/control;  quantitative or mixed methods, systematic reviews, meta-analyses. No date or language restrictions.  • Independent quality assessment included Cochrane Collaboration’s tool for assessing risk of bias in randomized controlled trials and Cochrane Risk of Bias Assessment Tool for Non-Randomised Studies of Interventions. Results• 3,173 references screened.  Seven papers (6,345 patients, 22 clinicians) met the inclusion criteria (Table 1).• Interventions included a range of approaches at different stages of the COPD pathway.  Some were part of multifaceted evidence-based management of COPD. • Most reported improvements in referral or uptake of PR. However, most had methodological and reporting limitations with risk of bias and limited quality.  Participant populations were poorly described.• Designs, interventions and scope of studies were heterogeneous and not combinable in a meta-analysis.Conclusions• Our review using systematic methods showed insufficient evidence of interventions to improve referral and uptake to PR.  More studies are required to give guidance and improve access to evidence based PR for patients with COPD.  • A strength of the review is the systematic approach.• The authors have received funding from NIHR (RfPB) to develop a toolkit to support referral and uptake to PR.Study Design Participants Intervention Outcome measures relevant to PRResults / EffectAngus et al 2012UK2Observational feasibility study293 patients Computer-guided review by practice nurse covering several aspects of COPD management% referred to PR 24% of patients referred to PRFoster et al 2016UK3Participatory action research with strategies for increasing referrals for PR126 patients22 cliniciansIn-house education, changes to practice protocols, 'pop-ups' and memory aids (mugs, coasters) to prompt clinician/patient discussions about PRNumber of PR referralsPatient survey: number accepting referralNo change data available for PR referral or acceptance by patientsGraves et al2010UK4Before / After comparison600 patients(200 control / 400 intervention)Group opt-in session prior to assessment and entry to PR% taking up PR assessment% attending and completing PRNo effect on number of patients starting PRHarris et al 2009 Aust5Controlled Before / After study249 patients Patient-held manual of recommended COPD management% enrolment to PROther indicators of COPD managementSignificant increase in enrolment in most socio-economically disadvantaged participants (+12%)Hull et al2014UK6Quality improvement with repeated audit cycles3,391 patients on COPD registers across GP networksGP practice networks with supported case management, education and financial incentives for clinical performance% PR referralOther indicators of COPD management PR referrals rose 25% from 45% to 70%Roberts et al 2015UK7Pragmatic non-randomised controlled study1,235 patients(640 intervention / 595 control)Patients provided with individualised COPD care quality “score cards”% PR referrals  Significant increase (6.1%) in referrals in intervention groupZwar et al 2012Aust8Cluster randomisedcontrolled trial,  blinded outcome assessment 451 patients (257 confirmed COPD)Home visit by  COPD trained nurse working with GP to implement  individualised, guideline-based care plan% attendance at PROther COPD managementindicators Significant increase (21.5%) in PR attendanceTable 1: Details and outcomes of reviewed studiesReferences: [1] Steiner M, Holzhauer-Barrie J, Lowe D et al. Pulmonary Rehabilitation: Time to breathe better. National Chronic Obstructive Pulmonary Disease (COPD) Audit Programme: Resources and organisation of Pulmonary Rehabilitation services in England and Wales 2015. National organisational audit report. London: RCP, November 2015.  [2] Angus RM, Thompson EB, Davies L et al.  Feasibility and impact of a computer-guided consultation on guideline-based management of COPD in general practice. Prim Care Respir J 2012; 21(4): 425-430.  [3] Foster F, Piggott R, Riley L et al. Working with primary care clinicians and patients to introduce strategies for increasing referrals for pulmonary rehabilitation. Prim Health Care Res Dev 2015; 17(3): 226-37. [4] Graves J, Sandrey V, Graves T et al. Effectiveness of a group opt-in session on uptake and graduation rates for pulmonary rehabilitation. Chron Respir Dis 2010 Aug; 7(3): 159-64.[5] Harris M, Smith BJ, Veale AJ et al. Providing reviews of evidence to COPD patients: controlled prospective 12-month trial. Chron Respir Dis 2009; 6(3): 165-73. [6] Hull S, Mathur R, Lloyd-Owen S et al. Improving outcomes for people with COPD by developing networks of general practices: evaluation of a quality improvement project in east London. NPJ Prim Care Respir Med 2014 Oct 16; 24: 14082. [7] Roberts CM, Gungor G, Parker M et al. Impact of a patient-specific co-designed COPD care scorecard on COPD care quality: a quasi-experimental study. NPJ Prim Care Respir Med 2015 Mar 26; 25: 15017. [8] Zwar NA, Hermiz O, Comino E et al. Care of patients with a diagnosis of chronic obstructive pulmonary disease: a cluster randomised controlled trial. Med J Aust 2012 Oct 1; 197(7): 394-8.Clinical Nursing Research Group www.phpc.cam.ac.ukFollow us on Twitter@CNRGCAMContact: frances.early@addenbrookes.nhs.ukAcknowledgements:  Thanks to Lianne Jongepier, Ruth Barlow and the East of England Pulmonary Rehabilitation Network for their support with our work.IW21

Interventions to increase referral to and uptake of Pulmonary Rehabilitation programmes for people with Chronic Obstructive Pulmonary Disease (COPD): A systematic review

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Interventions to increase referral to and uptake of Pulmonary Rehabilitation programmes for people with Chronic Obstructive Pulmonary Disease (COPD): A systematic review

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