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  • Title: Factors which facilitate or impede patient engagement with pulmonary and cardiac rehabilitation: a rapid evaluation mapping review.
    Author: Blank L, Cantrell A, Sworn K, Booth A.
    Journal: Health Soc Care Deliv Res; 2023 May; 11(4):1-59. PubMed ID: 37464900.
    Abstract:
    BACKGROUND: There is a considerable body of systematic review evidence considering the effectiveness of rehabilitation programmes on clinical outcomes. However, much less is known about effectively engaging and sustaining patients in rehabilitation. There is a need to understand the full range of potential intervention strategies. METHODS: We conducted a mapping review of UK review-level evidence published 2017-21. We searched MEDLINE, EMBASE and the Cumulative Index to Nursing and Allied Health (CINAHL) and conducted a narrative synthesis. Included reviews reported factors affecting commencement, continuation or completion of cardiac or pulmonary rehabilitation, or an intervention to facilitate these factors. Study selection was undertaken independently by two reviewers. RESULTS: In total, we identified 20 review papers that met our inclusion criteria. There was a bias towards reviews considering cardiac rehabilitation, with these numbering 16. An additional 11 unpublished interventions were also identified through internet searching of key websites. The reviews included 60 identifiable UK primary studies that considered factors which affected attendance at rehabilitation; 42 considered cardiac rehabilitation and 18 considering pulmonary rehabilitation. They reported on factors from the patients' point of view, as well as the views of professionals involved in referral or treatment. It was more common for factors to be reported as impeding attendance at rehabilitation rather than facilitating it. We grouped the factors into patient perspective (support, culture, demographics, practical, health, emotions, knowledge/beliefs and service factors) and professional perspective (knowledge: staff and patient, staffing, adequacy of service provision and referral from other services, including support and wait times). We found considerably fewer reviews (n = 3) looking at interventions to facilitate participation in rehabilitation. Although most of the factors affecting participation were reported from a patient perspective, most of the identified interventions were implemented to address barriers to access in terms of the provider perspective. The majority of access challenges identified by patients would not therefore be addressed by the identified interventions. The more recent unevaluated interventions implemented during the COVID-19 pandemic may have the potential to act on some of the patient barriers in access to services, including travel and inconvenient timing of services. CONCLUSIONS: The factors affecting commencement, continuation or completion of cardiac or pulmonary rehabilitation consist of a web of complex and interlinked factors taking into consideration the perspectives of the patients and the service providers. The small number of published interventions we identified that aim to improve access are unlikely to address the majority of these factors, especially those identified by patients as limiting their access. Better understanding of these factors will allow future interventions to be more evidence based with clear objectives as to how to address the known barriers to improve access. LIMITATIONS: Time limitations constrained the consideration of study quality and precluded the inclusion of additional searching methods such as citation searching and contacting key authors. This may have implications for the completeness of the evidence base identified. FUTURE WORK: High-quality effectiveness studies of promising interventions to improve attendance at rehabilitation, both overall and for key patient groups, should be the focus moving forward. FUNDING: This report presents independent research funded by the National Institute for Health Research (NIHR). The views and opinions expressed by authors in this publication are those of the authors and do not necessarily reflect those of the NHS, the NIHR, NETSCC, the HSDR programme or the Department of Health. STUDY REGISTRATION: The study protocol is registered with PROSPERO [CRD42022309214]. While we know quite a lot about what makes rehabilitation for heart (cardiac) or lung (pulmonary) conditions effective, less is known about how to engage people with these services and how to encourage them to continue to attend. We have looked at what studies have already been done to summarise the factors that affect whether someone chooses to attend rehabilitation and what is being tried to improve rates of attendance. We were particularly interested in people who are less likely to attend for rehabilitation. We searched in research databases for studies published since 2017 that included UK patients and services. We found 17 relevant summary papers which included a total of 52 UK studies. Most of these papers looked at the factors that affect attendance at rehabilitation, with far fewer studies considering ways to improve attendance. There were more studies looking at rehabilitation for cardiac than pulmonary conditions. Whether someone attended rehabilitation was affected by factors such as whether they felt supported, cultural and personal factors, practical factors such as travel and access, plus patient health, emotions, knowledge and beliefs about rehabilitation services. From a staff perspective, knowledge (staff and patient), staffing levels, level of service provision, and referral from other services were believed to affect attendance. We found a few studies where changes had been made to try to improve access including a number of studies of online delivery of rehabilitation services during COVID-19. Our summary of the factors that affect attendance at rehabilitation may be helpful to inform services about what changes they should make in the future to improve levels of attendance.
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