Supporting referral to pulmonary rehabilitation from primary care: A systematic evaluation of interventions using the...

Pulmonary rehabilitation (PR) is a key component in managing chronic respiratory diseases (CRDs). Primary care, often the first point of contact for people with CRD, is well-positioned to facilitate referral to PR, yet referral rates are low. This systematic review aimed to identify the key components of primary care interventions to support referral to PR and synthesise their effect on referral rate.

Five electronic databases were searched to identify studies of any design that reported interventions implemented in primary care to support referral to PR for people with CRD. Interventions could target people with CRD and/or healthcare professionals. Screening, quality appraisal using the Downs and Black checklist, and data extraction were conducted independently by two reviewers. Interventions were mapped to the Expert Recommendations for Implementing Change (ERIC) taxonomy-a framework of 73 strategies seeking to enhance the adoption, implementation, and sustainability of evidence-based interventions.

Thirteen studies were included, employing a range of quasi-experimental, observational, and randomised designs. Overall, the studies were of moderate quality (mean total score 14, range 10 to 25 out of 27). Interventions incorporated a mean of 12 ERIC strategies across five domains, most commonly education and training, interactive assistance, clinician support, and audit and feedback. Impact of interventions on referral rates was minimal (n = 3 randomised controlled trials, pooled mean difference 0%, 95% confidence interval -0.24 to 0.25).

Multi-component interventions, including numerous implementation strategies, have achieved minimal improvement in PR referral rates from primary care. Understanding how strategies are delivered and applied, rather than simply the number of strategies or the combination they are used in, may be important for operationalisation of referral focussed interventions. Addressing the behavioural processes underpinning referral decisions, together with the use of theory-informed, context-specific approaches may enhance effectiveness of referral focussed interventions.