The challenge of increasing uptake of pulmonary rehabilitation: What can we do to maximise the chances of success?

Abstract

The challenge of how to increase participation in pulmonary rehabilitation (PR) is a dilemma that everyone who runs a PR programme faces. We know that PR can be very effective in reducing breathlessness, improving fitness and muscle strength and enhancing a patient’s quality of life. The benefits of PR also extend to the improved management of exacerbations and decreased health care utilization. PR may even improve the survival. However, despite these many well-documented benefits, uptake of PR has remained modest at best. Many programmes report non-completion rates as high as 30–50% and the numbers of people offered PR but failing to attend for assessment is largely unknown. In these times of financial uncertainty and stringent examination of health care budgets, the question of how to maximise the uptake of rehabilitation and the utilisation of precious resources, has never been more pertinent. To this end, the article by Keating et al. in this edition of CRD is very timely. The authors have set out to establish the factors that influence whether people with COPD choose to attend PR at all and also those factors that prevent people from completing a programme. The article is a systematic review of both qualitative and quantitative studies which identified barriers to attendance and completion of rehabilitation. Of the 11 studies which fulfilled the necessary quality criteria for inclusion, 5 were qualitative and 6 were quantitative in design. The major findings of the review are that travel and transport difficulties were identified as a predominant barrier to attendance of PR. Lack of perceived benefit and the influence of the participant’s doctor were also identified as reasons for non-attendance. This is a notoriously difficult area to study as by definition these patients have chosen not to attend, probably do not recognise the value of rehabilitation and therefore are also less likely to participate in rehabilitation-related research. Once patients have started rehabilitation, the main barrier to completion is illness and co-morbidities, which were identified in all eight of the articles that documented the reasons for non-completion. Again, travel was also a major factor, with people living over 36 miles from the place of rehabilitation or travelling more than 30 minutes, being significantly less likely to complete than those with shorter travelling times. This finding would lend support to the growth of community-based rehabilitation programmes where travelling time is potentially reduced considerably. The review also aimed to identify certain patient groups who were more likely to drop out. Interestingly disease severity was not a consistent factor in non-completion whereas presence of depression, living alone or poor social support was. Current smokers were also found to have a higher drop out rate. These findings should prompt clinicians to highlight the importance and support of smoking cessation programmes to those still smoking and of screening for depression with a designated treatment pathway for those patients identified with depression to maximise the chances of success. Although PR has been