School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK.
Health Soc Care Deliv Res. 2023 May;11(4):1-59. doi: 10.3310/KLWR9463.
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.
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.
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 An additional 11 unpublished interventions were also identified through internet searching of key websites.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 ( = 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.
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.
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.
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.
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.
The study protocol is registered with PROSPERO [CRD42022309214].
有大量系统评价证据表明康复方案对临床结局的有效性。然而，对于如何有效地让患者参与并坚持康复治疗，人们知之甚少。因此，我们需要了解各种潜在的干预策略。
我们对 2017 年至 2021 年期间发表的英国综述级别的证据进行了映射综述。我们检索了 MEDLINE、EMBASE 和 Cumulative Index to Nursing and Allied Health（CINAHL）数据库，并进行了叙述性综合。纳入的综述报告了影响心脏或肺部康复开始、继续或完成的因素，或促进这些因素的干预措施。研究选择由两名独立的评审员进行。
共确定了 20 篇符合纳入标准的综述论文。其中，偏向于心脏康复的综述有 16 篇。通过对关键网站的互联网搜索，还发现了另外 11 项未发表的干预措施。这些综述包括了 60 项可识别的英国初级研究，这些研究考虑了影响康复参与的因素；其中 42 项研究考虑了心脏康复，18 项研究考虑了肺部康复。它们从患者的角度以及参与转诊或治疗的专业人员的角度报告了各种因素。报告的因素更多的是阻碍而不是促进康复参与。我们将这些因素分为患者视角（支持、文化、人口统计学、实际、健康、情绪、知识/信念和服务因素）和专业人员视角（知识：员工和患者、人员配备、服务提供的充分性以及来自其他服务的转诊，包括支持和等待时间）。我们发现只有 3 篇综述研究了促进康复参与的干预措施。尽管大多数影响参与的因素都是从患者的角度报告的，但大多数确定的干预措施都是为了解决提供者视角下的获取障碍而实施的。因此，患者所识别的大多数获取障碍不太可能通过确定的干预措施得到解决。在 COVID-19 大流行期间实施的未经评估的新干预措施可能有潜力解决服务获取方面的一些患者障碍，包括旅行和服务时间不方便等问题。
影响心脏或肺部康复开始、继续或完成的因素包括一系列复杂且相互关联的因素，需要考虑患者和服务提供者的观点。我们确定的旨在改善获取机会的少数已发表的干预措施不太可能解决大多数这些因素，特别是那些被患者认为限制其获取机会的因素。更好地了解这些因素将使未来的干预措施更具循证依据，并明确改善获取机会的目标。
时间限制限制了对研究质量的考虑，并排除了其他搜索方法的纳入，如引文搜索和联系主要作者。这可能会对确定的证据基础的完整性产生影响。
应将重点放在改进康复治疗参与度的有前途的干预措施的高质量有效性研究上，包括总体和关键患者群体。
本报告介绍的独立研究由英国国家卫生研究所（NIHR）资助。作者在本出版物中表达的观点和意见仅代表作者本人的观点，不一定反映 NHS、NIHR、NETSCC、HSDR 计划或英国卫生部的观点。
该研究方案在 PROSPERO 上注册[CRD42022309214]。
