Equity in pulmonary rehabilitation delivery: a systematic review and meta-analysis

Barriers to delivery of pulmonary rehabilitation are not evenly distributed across people with chronic lung disease. The aim of this systematic review was to evaluate equity in pulmonary rehabilitation delivery and outcomes, in relation to the social determinants of health.

A systematic search of four online databases was undertaken. Two reviewers independently screened studies and extracted data. Social determinants of health were categorised according to the PROGRESS-Plus framework, and mapped to the Health Equity Implementation Framework. We reported the impact of PROGRESS-Plus factors on pulmonary rehabilitation access, uptake and completion, and outcomes of health-related quality of life and exercise capacity.

32 studies from 13 countries were included. Place of residence (rurality, travel distance) was consistently associated with poor access and uptake. Uptake was lower for Black people than White people (OR 0.87, 95% CI 0.81-0.95; two studies, n=1 128 623) and in those of low socioeconomic status (OR 0.63, 95% CI 0.55-0.73; two studies, n=1 134 811). Men were more likely to complete than women (OR 1.13, 95% CI 1.06-1.20; eight studies, n=20 509). People who were working were less likely to complete (OR 0.70, 95% CI 0.47-1.04; three studies, n=3292). There was no impact of PROGRESS-Plus features on improvements in health-related quality of life or exercise capacity with pulmonary rehabilitation.

There are inequities in delivery of pulmonary rehabilitation. Targeted efforts to improve pulmonary rehabilitation delivery in disadvantaged groups are required, to ensure that all people with chronic lung disease are able to realise its benefits.