Implementation strategies for rehabilitation services in health systems: an overview of systematic reviews

Cochrane Rehabilitation and the World Health Organization (WHO) Rehabilitation Programme have collaborated to produce four Cochrane overviews of systematic reviews that synthesize current available evidence from health policy and systems research (HPSR) in rehabilitation. Each overview focuses on one of the four pillars of HPSR as identified by the Cochrane Effective Practice and Organisation of Care (EPOC) taxonomy: delivery arrangements, financial arrangements, governance arrangements, and implementation strategies. This overview examined implementation strategies, defined by EPOC as interventions designed to bring about changes in healthcare organizations, the behavior of healthcare professionals, or the use of health services by healthcare recipients.

This overview aimed to synthesize current evidence on implementation strategies in rehabilitation from a health policy and systems research (HPSR) perspective. Our series of four overviews have the following overarching objectives. • To offer a broad synthesis of the existing evidence on health policy and systems interventions' effects. • To direct end-users, including policymakers, towards systematic reviews that may address their health policy questions. • To identify current research gaps and set priorities for future primary HPSR. • To pinpoint the needs and priorities for new evidence syntheses where no reliable, up-to-date systematic reviews currently exist.

We searched the Epistemonikos database, the Health Systems Evidence database, and EPOC Group systematic reviews to identify reviews published between 1 January 2015 and 17 November 2024. We applied no language limitations. We included Cochrane and non-Cochrane systematic reviews of randomized controlled trials (RCTs) and non-randomized studies of interventions (NRSIs) that evaluated the effectiveness of health policy and systems interventions for rehabilitation in health systems, specifically related to implementation strategies as defined in the EPOC taxonomy. All four overview teams collaborated to screen reviews and extract data. We used AMSTAR 2 to critically appraise the quality of the reviews. Results were analyzed descriptively and are based on reviews with ratings of high-to-moderate confidence, with low-confidence reviews reported separately.

We identified 7882 systematic reviews, of which 15 met our inclusion criteria. Three reviews overlapped substantially with other reviews, and eight received low- or critically low-confidence ratings. Ultimately, four moderate- to high-confidence reviews contributed to the synthesis; two were Cochrane systematic reviews. Most primary studies were from high-income countries; none were from low-income countries. Most strategies targeting healthcare professionals (e.g. guideline dissemination, interactive workshops, opinion leaders, audit and feedback) or healthcare recipients (e.g. structured monitoring, telehealth support, counseling, motivational interviewing) included more than one component. Strategies targeting healthcare recipients' use of health services in cardiac rehabilitation may show small benefits in terms of participation (enrollment, adherence, completion), but effects on other outcomes are uncertain. The effects of strategies targeting older healthcare recipients via telehealth are uncertain. Strategies targeting healthcare professionals may have little to no effect on professional or patient and carer outcomes in stroke rehabilitation. For musculoskeletal conditions, there were no evidence-certainty ratings, so intervention effects are unclear. We found no reviews of strategies targeting health service organizations or specific types of rehabilitation practice. The evidence certainty was generally low; evidence of adverse events was missing or uncertain; and reporting on organizational, implementation, economic, and equity outcomes was scarce.

Current evidence on implementation strategies in rehabilitation is limited, mostly of low certainty, and derived from high-income countries. Multicomponent, patient-targeted strategies may modestly improve cardiac rehabilitation participation, but effects in other areas remain uncertain. Further high-quality research using well-defined frameworks is needed, especially in low- and middle-income countries, to identify effective strategies and evaluate organizational, implementation, and equity outcomes. Future Cochrane overviews of reviews in HPSR should consider including a broader range of study designs, such as observational, qualitative, and mixed-methods evidence, to better capture evidence on implementation strategies in rehabilitation.

This Cochrane review was funded by the Italian Ministry of Health (Ricerca Corrente). The funder played no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript.

The protocol was first published in the European Journal of Physical and Rehabilitation Medicine online on 27 January 2025. The manuscript was received on 11 November 2024 and was accepted on 26 November 2024.

DOI 10.23736/S1973-9087.24.08833-6.