Patient characteristics and predictors of completion of a pulmonary rehabilitation programme in Auckland, New Zealand
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Chronic obstructive pulmonary disease (COPD) was the third leading cause of death in 20161 and resulted in more than three million deaths worldwide in 2015.2 In New Zealand, the population prevalence of COPD is estimated to be 14.2%.3 The disease is associated with a significant burden on the healthcare system.4 Internationally, COPD disproportionately affects people living in developing countries2 and indigenous people in developed countries.5 In New Zealand, COPD is more prevalent among Māori, Pacific Island people and those living in more deprived areas.3
Pulmonary rehabilitation (PR) is an evidence-based, multi-disciplinary programme, comprising exercise and education for people with chronic respiratory disease.6 It is an essential component of therapy for COPD.7 Pulmonary rehabilitation has been shown to improve exercise capacity, dyspnoea and health-related quality of life,6 reduce hospital readmissions and mortality.8 Despite this, rates of attendance at, and completion of PR programmes are poor; internationally, up to 50% of people referred to PR programmes fail to attend and rates of non-completion have been reported between 9.7% and 31.8%.9 One New Zealand-wide study estimated that only 0.9% of people over 40 with COPD were offered PR per year, and of those, only 56% completed the programme.10 Another PR programme in New Zealand found their programme enrolled less than 2% of the region’s population with COPD.11
Counties Manukau Health (CMH), in the Auckland region, is one of 20 district health boards in New Zealand. Better Breathing is a PR programme, which runs at four different sites in CMH—one acute care facility and three community-based sites. Patients attend a one-off initial assessment, then attend the exercise and education-based PR programme twice-weekly for eight weeks. The population at CMH is culturally diverse, with 16% Māori, 21% Pacific Island, 24% Asian and 38% New Zealand European/other.12 The population has a distinct socioeconomic makeup, with over 36% of people living in the most deprived deciles, based on the New Zealand Deprivation Index [NZDep2013].13 Within CMH, the prevalence of chronic respiratory disease is high14 especially among Māori, Pacific Island people and those living in deprived areas.3 With guidelines widely recommending PR as a gold-standard intervention,7,15,16 it is important to consider factors impacting upon engagement with PR in the context of contemporary practice in culturally and socioeconomically diverse populations, such as CMH.
The primary aim of this study was to identify and compare the key factors in predicting patients who complete and those who did not complete the PR programme. The secondary aim was to compare the characteristics of those who attended and those who never attended the PR programme.
Methods
Investigators performed a retrospective analysis of routinely collected health information data of 2,756 patients invited to attend the Better Breathing PR Programme, run across the four sites at CMH. We evaluated data from all patients who were invited to attend between 1 January 2010 and 31 December 2015. Patients were divided into four groups:
1. ‘Never-attenders’—who did not attend either the initial assessment or programme;
2. ‘Initial assessment-only attenders’—who attended an initial assessment but did not commence the programme;
3. ‘Non-completers’—who completed less than 75% of the programme;
4. ‘Completers’—who completed at least 75% of the programme.
Data for extraction and analysis were determined prior to commencement of the study and were extracted from routinely collected data from the CMH electronic patient information system by a Senior Analyst at Health Intelligence and Informatics at CMH and two researchers (NJ and SC). Following data extraction, retrieval of missing data was undertaken by two members of the research team (NJ and SC), who used the hospital’s patient information systems to extract any available missing data. Data collected included demographic characteristics (age, gender, self-reported ethnicity, marital status, smoking status, occupation, spoken language, level of deprivation) and clinical characteristics (referral source, percent predicted forced expiratory volume in one second (FEV1%), Hospital Anxiety and Depression Scale (HADS) score, Medical Research Council Dyspnoea Score (MRC), Body Mass Index (BMI) and six-minute walk test (6MWT) distance). The clinical data were taken at the initial assessment and therefore only available for those who attended at least an initial assessment.
Data were analysed in four ways:
1. To compare the characteristics of those who did not attend the programme (never-attenders and initial assessment-only attenders) to those who did attend the programme (completers and non-completers);
2. To compare the characteristics of never-attenders to initial assessment-only attenders;
3. To compare the characteristics of completers to non-completers;
4. To identify factors predicting completion of the programme.
Chi-square, two-sample t-tests and Kruskal-Wallis tests were undertaken to assess associations between demographic and clinical characteristics between the groups. Univariate and multiple logistic regression were carried out to test for significant factors that were associated with completion of the programme. To identify significant predictors in the model after accounting for the demographics variables, three model selection techniques were used, such as forward, backward and stepwise procedures, in SAS version 9.4. For those variables with more than 20% of missing data, the variables were not included for model selection. The model with the smallest Akaike Information Criterion was selected and variables that were deemed significant were kept in the model. A p-value <0.05 was considered statistically significant. Sensitivity analysis was also carried out by using a single imputation method and compared to the complete cases using likewise deletion. This involved replacing the missing values for the continuous variables by the median.
The New Zealand Health and Disability Ethics Committee stated ethical review was not required. Approval for the study was granted by CMH Research Committee on 21 April 2016 (Research Application Numbers 5 and 6).
Results
Of the 2,756 patients that were referred to the Better Breathing programme, 1,028 (37%) never attended and 33 (1%) attended the initial assessment only. The remaining 1,695 (62%) patients commenced the programme; 1,040 (61%) of those were completers and 655 (39%) were non-completers (see Figure 1). This shows that, of all referrals to the Better Breathing programme, 1,716 (62%) never attended or did not complete the programme.
Figure 1: Flow chart showing the numbers of referrals to, attendance at and completion of the Better Breathing Pulmonary Rehabilitation programme between 2010 and 2015.
Characteristics of those who attended the programme (completers and non-completers combined) and those who did not attend the programme (never-attenders and initial assessment-only attenders combined) are summarised in Table 1. There were significant differences between these groups in marital status (p=0.001), deprivation index (p=0.021), smoker (p=<0.001), distance from home to PR site (p=<0.001) and site location (p=<0.001). There were no statistically significant differences between attenders and non-attenders in age (p=0.64), gender (p=0.53), ethnicity (p=0.44), language spoken (p=0.75) or occupation (p=0.96).
Table 1: Demographic characteristics by group—attenders (completers and non-completers combined) and non-attenders (never attenders and initial assessment-only attenders combined).
‡The non-parametric p-value is calculated by the Kruskal-Wallis test and Mann-Whitney-U test for numerical covariates and Fisher’s exact test for categorical covariates.
KEY: kms, kilometres; IQR, inter quartile range; n, number; PR, pulmonary rehabilitation; SD, standard deviation.
Comparison between demographic characteristics of those who never attended (n=1,028) and initial assessment-only attenders (n=33) showed a statistically significant difference in ethnicity (p=0.001), with never-attenders having a larger proportion of European and Māori patients. The initial assessment-only group also had a significantly higher proportion of patients who did not speak English as a first language (22% vs 8%, p=0.02) and a larger proportion of married/partnered patients (80% vs 52%, p=0.03) compared to the never-attenders. The small sample size in the initial assessment-only group limits the significance of these findings.
When comparing demographic and clinical characteristics between the completer and non-completer groups, there were statistically significant differences between the two groups in all characteristics except for gender, distance from home to PR site and site location (Table 2). Furthermore, for each year increase in age, patients were 4% more likely to complete the programme (OR 1.04 95%CI 1.02–1.05, p=<0.001). For every 10m extra that a patient walked in their 6MWT at programme commencement, they were 3% more likely to complete the programme (OR 1.03, 95%CI 1.02–1.04, p=<0.001). Compared with Europeans, Māori were 53% (OR 0.47, 95% CI 0.35–0.65, p=<0.001) and Pacific Island people were 46% (OR 0.64, 95% CI 0.44–0.92, p=<0.001) less likely to complete the programme. Results of the univariate and logistic regression model predicting completion of the better breathing programme are displayed in Table 3. Results of multivariate logistic regression models for both complete and imputed cases can be seen in Table 4.
Table 2: Demographic and clinical characteristics by group–completers vs non-completers.
‡The non-parametric p-value is calculated by the Kruskal-Wallis test and Mann-Whitney-U test for numerical covariates and Fisher’s exact test for categorical covariates.
KEY: BMI, body mass index; FEV1, forced expiratory volume in one second; IQR, inter quartile range; kms, kilometres; MRC, Medical Research Council Dyspnoea Scale; n, number of patients; PR, pulmonary rehabilitation; SD, standard deviation, 6MWT, 6 minute walk test distance.
Table 3: Results of univariate logistic regression model showing variables predicting completion at the Better Breathing Pulmonary Rehabilitation Programme.
Table 4: Results of multivariate logistic regression model showing variables predicting completion of the Better Breathing Pulmonary Rehabilitation Programme for the complete and imputed cases.
Discussion
Data were collected on 2,756 patients referred to the Better Breathing programme in the period under investigation; this data set is larger than those previously described in other New Zealand studies.10,11 Our study has shown that 62% of all patients referred to the Better Breathing programme either do not take part in the programme at all, or do not complete the programme. An older study exploring attendance at a PR programme in an Auckland clinic reported that 41% of patients either did not attend, or failed to complete the programme.17 A more recent study in a different New Zealand region showed that 46% of those referred to PR completed the programme.11 Our results compare poorly with this, whereby only 38% of all patients referred completed the Better Breathing programme. In a review of 11 international studies, non-completion rates were reported to be up to 32%,9 so it is of concern that our non-completion rates in those who commenced the Better Breathing programme (39%) appear to be higher than those reported elsewhere.9
When comparing the characteristics of those who attended with those who did not attend, significant factors included distance travelled, site location, deprivation index and marital status. Other studies investigating reasons for non-completion of PR have cited transport and the distance from home to PR site as problematic.18,19 While we found that the distance from home to PR and the location of PR was significantly different between attenders and non-attenders, once patients commenced the programme, distance and location were no longer a significant factor influencing attendance. This suggests that factors relating to the running of the PR programme itself may be more important than geographical location when considering completion rates.
Some studies have demonstrated that people with lower socioeconomic status may find it harder to access transport and parking costs associated with attending primary healthcare services20,21 and these factors have also been linked to poor attendance at PR programmes.21 A widely used measure of social deprivation in New Zealand13 was used to investigate whether social deprivation affected completion rates at the Better Breathing programme. Even though there was an indication of deprivation index being a significant risk factor (Table 3), after accounting for other characteristics, the deprivation index was not strongly correlated. However, it should be noted that the univariate results indicate that for every one unit increase in deprivation index, the likelihood of completing the programme reduces by 8%.
In comparing participants who completed with those who did not complete the PR programme, many factors were significantly different between the groups. However, when all variables were included in a fully adjusted model, only three factors were identified as independent predictors of completion of PR: age, distance walked on 6MWT and ethnicity. Consistent with other literature,23–26 the results of our study found that patients had a greater likelihood of completing the programme as age increased. It is possible that this is related to work schedules. The Better Breathing programme, which runs during normal working hours, may be less accessible to the working population. Māori and Pacific Island people tend to develop COPD at an earlier age (the average age of onset of COPD in New Zealand is 70.3 years, but for Māori and Pacific Island people it is 62.6 and 62.5 years respectively),3 so these populations may be more severely impacted by timing of PR programmes. An increase in flexibility of services including; offering classes outside of working hours, a home-based service and/or a telehealth based programme may allow younger participants, who may be working or looking after dependents, the opportunity to complete PR.
Patients who walked further in their 6MWT at commencement of our programme were also more likely to complete the programme; this is consistent with other literature.26–28 6MWT distance correlates with MRC dyspnoea score and pulmonary function testing,29,30 and our study found that non-completers had significantly greater dyspnoea and disease severity. These factors may make exercise more challenging, potentially increasing the likelihood of non-completion. Potential strategies to overcome this challenge for participants may involve; increased time spent on orientation to PR including strategies to manage breathlessness, starting exercise at lower intensities and ensuring increased levels of supervision and/or support for people with lower exercise capacity. The location of PR, including access to the building and close parking facilities may also facilitate completion for this group.
An important finding of this study is that Māori and Pacific Island patients are significantly less likely to complete the programme compared with European patients, supporting the findings of others in New Zealand.11 Ethnicity was not significantly different when comparing attenders to non-attenders (p=0.44), but became significant when comparing completers to non-completers (p=0.001). When all variables were accounted for, ethnicity was found to be an independent predictor of completion of PR. This finding is important because the CMH population comprises large numbers of Māori and Pacific Island people in the community, who are disproportionately affected by chronic respiratory diseases in New Zealand.3 The results of this study, therefore, show that the people who may potentially benefit from PR the most are those who are least likely to complete the programme. Differences in attendance between people of various ethnicities may be related to differences in the culture of attendees or of the programme itself. Cultural factors appear to play an influential role in how well PR programmes are able to engage with Māori and Pacific Island people. Levack et al31 found that when the cultural needs of Māori attending PR were not addressed adequately, patients were less willing to attend those PR programmes.31 To our knowledge, two New Zealand-based studies11,31 are the only other studies to have specifically explored the influence of ethnic diversity on participants’ engagement with PR. We encourage others undertaking PR programmes with ethnically diverse populations to further explore issues with engagement and completion of PR programmes and identify factors that may improve these. Levack et al31 have suggested that indigenous-led PR programmes may overcome barriers for indigenous and minority participants and the feasibility of this requires further investigation. Other factors such as the venue in which PR programmes are held—such as a Marae—could be important for many Māori participants. Future research should ensure collaboration with cultural experts, and participants who have attended PR, to work towards co-design of culturally responsive PR programmes.
In our cohort, there was a significant difference in completion rates between English and non-English speaking participants. Indeed, in comparing the characteristics of never-attenders with initial assessment-only attenders, a large proportion of participants who reported English as a second language attended only the initial assessment and did not go to further attend or complete the programme. Additionally, while in our multivariate regression modelling, language was not found to be significant in predicting completion, following data imputation speaking English as a first language became statistically significant, suggesting this may be a relevant factor in completion of PR. Attention should be given to whether the delivery of programmes in different languages might improve completion rates in non-English speakers, and this together with how language aligns with delivering culturally relevant programmes should be considered.
Limitations
It should be noted that during the period of the study, we implemented several changes arising from quality improvement initiatives to the PR programme that may have influenced interpretation. During this period, the service expanded and the hospital outpatient programme moved from the hospital site to four community venues, which we considered may better fulfil the needs of our population. It is feasible that these changes may have impacted on the results of this study, particularly regarding distance from home to PR. However, because distance from home to PR was calculated using each individual’s home address and their closest PR site, we believe that this measure will account for these location changes.
The nature of the data collection and retrieval meant that not all data was available for all groups. For example, data from those who attended the PR programme was more extensive than those who did not attend, due to extensive assessment and monitoring undertaken during the PR programme. Even following completion of the programme, some data was missing on retrieval, eg, HADS. Reasons for some of this missing data could be spoken language/literacy issues, assessment burden or clinician or administration error. Where data were known to be missing, imputation of the continuous variables into the statistical modelling for analysis was carried out and compared with complete cases. Furthermore, we acknowledge a prospective matched cohort study could have improved the ability to account for the effect of confounding variables in our analyses, increasing the confidence regarding the impact of each of the different variables individually.
Conclusion
Of everyone referred to CMH Better Breathing PR programme during the period of our study, only 38% completed the programme. Considering that less than 2% of people with COPD in New Zealand are referred to a PR programme,10 it is problematic that so few patients are completing this gold-standard intervention. Age, 6MWT distance at commencement of PR and ethnicity were important predictors of completion of PR in this population. Strategies to make PR more engaging must be considered for varying age groups, those with poorer exercise tolerance, and, importantly, in different ethnic groups.
Summary
Abstract
Aim
Chronic respiratory diseases, such as chronic obstructive pulmonary disease, are a worldwide public health problem. Pulmonary rehabilitation is a gold-standard intervention for these diseases, yet attendance and completion rates are poor. Counties Manukau Health, in Auckland, New Zealand, has a high prevalence of chronic respiratory disease and a culturally diverse population, comprising large numbers of Māori and Pacific Island people, who are known to be disproportionately affected by chronic respiratory disease. The aim of this study was to investigate patient characteristics affecting engagement with the Counties Manukau Health pulmonary rehabilitation programme and identify factors predicting completion of the programme.
Method
Investigators performed a retrospective analysis using routinely collected data of 2,756 patients invited to attend the pulmonary rehabilitation programme at Counties Manukau Health. Data were analysed to compare demographic and clinical outcomes of patients who completed, did not complete or did not attend the programme, and identified factors predicting completion.
Results
Significant differences were found between groups in demographic and clinical characteristics. Increasing age, higher six-minute walk test distance at programme commencement and European ethnicity were significant predictors of completion of the PR programme.
Conclusion
Compared to European people, Māori were 52% less likely and Pacific Island people were 40% less likely to complete the programme. These findings are significant for the Counties Manukau Health population. Further work needs to focus on determining how to make programmes more engaging to different cultures and how we can aim to reduce health inequities in these populations.
Author Information
Acknowledgements
Correspondence
Correspondence Email
Competing Interests
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14. Chan WC, Papa D, Winnard D. Life Expectancy, Leading Causes of Death and Amenable Mortality in Counties Manukau: 2015 Update. Auckland: Counties Manukau Health; 2016. http://www.countiesmanukau.health.nz/assets/About-CMH/Performance-and-planning/health-status/2016.09.09-Life-expectancy-update.pdf Accessed January 23, 2017.
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Patient characteristics and predictors of completion of a pulmonary rehabilitation programme in Auckland, New Zealand
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Chronic obstructive pulmonary disease (COPD) was the third leading cause of death in 20161 and resulted in more than three million deaths worldwide in 2015.2 In New Zealand, the population prevalence of COPD is estimated to be 14.2%.3 The disease is associated with a significant burden on the healthcare system.4 Internationally, COPD disproportionately affects people living in developing countries2 and indigenous people in developed countries.5 In New Zealand, COPD is more prevalent among Māori, Pacific Island people and those living in more deprived areas.3
Pulmonary rehabilitation (PR) is an evidence-based, multi-disciplinary programme, comprising exercise and education for people with chronic respiratory disease.6 It is an essential component of therapy for COPD.7 Pulmonary rehabilitation has been shown to improve exercise capacity, dyspnoea and health-related quality of life,6 reduce hospital readmissions and mortality.8 Despite this, rates of attendance at, and completion of PR programmes are poor; internationally, up to 50% of people referred to PR programmes fail to attend and rates of non-completion have been reported between 9.7% and 31.8%.9 One New Zealand-wide study estimated that only 0.9% of people over 40 with COPD were offered PR per year, and of those, only 56% completed the programme.10 Another PR programme in New Zealand found their programme enrolled less than 2% of the region’s population with COPD.11
Counties Manukau Health (CMH), in the Auckland region, is one of 20 district health boards in New Zealand. Better Breathing is a PR programme, which runs at four different sites in CMH—one acute care facility and three community-based sites. Patients attend a one-off initial assessment, then attend the exercise and education-based PR programme twice-weekly for eight weeks. The population at CMH is culturally diverse, with 16% Māori, 21% Pacific Island, 24% Asian and 38% New Zealand European/other.12 The population has a distinct socioeconomic makeup, with over 36% of people living in the most deprived deciles, based on the New Zealand Deprivation Index [NZDep2013].13 Within CMH, the prevalence of chronic respiratory disease is high14 especially among Māori, Pacific Island people and those living in deprived areas.3 With guidelines widely recommending PR as a gold-standard intervention,7,15,16 it is important to consider factors impacting upon engagement with PR in the context of contemporary practice in culturally and socioeconomically diverse populations, such as CMH.
The primary aim of this study was to identify and compare the key factors in predicting patients who complete and those who did not complete the PR programme. The secondary aim was to compare the characteristics of those who attended and those who never attended the PR programme.
Methods
Investigators performed a retrospective analysis of routinely collected health information data of 2,756 patients invited to attend the Better Breathing PR Programme, run across the four sites at CMH. We evaluated data from all patients who were invited to attend between 1 January 2010 and 31 December 2015. Patients were divided into four groups:
1. ‘Never-attenders’—who did not attend either the initial assessment or programme;
2. ‘Initial assessment-only attenders’—who attended an initial assessment but did not commence the programme;
3. ‘Non-completers’—who completed less than 75% of the programme;
4. ‘Completers’—who completed at least 75% of the programme.
Data for extraction and analysis were determined prior to commencement of the study and were extracted from routinely collected data from the CMH electronic patient information system by a Senior Analyst at Health Intelligence and Informatics at CMH and two researchers (NJ and SC). Following data extraction, retrieval of missing data was undertaken by two members of the research team (NJ and SC), who used the hospital’s patient information systems to extract any available missing data. Data collected included demographic characteristics (age, gender, self-reported ethnicity, marital status, smoking status, occupation, spoken language, level of deprivation) and clinical characteristics (referral source, percent predicted forced expiratory volume in one second (FEV1%), Hospital Anxiety and Depression Scale (HADS) score, Medical Research Council Dyspnoea Score (MRC), Body Mass Index (BMI) and six-minute walk test (6MWT) distance). The clinical data were taken at the initial assessment and therefore only available for those who attended at least an initial assessment.
Data were analysed in four ways:
1. To compare the characteristics of those who did not attend the programme (never-attenders and initial assessment-only attenders) to those who did attend the programme (completers and non-completers);
2. To compare the characteristics of never-attenders to initial assessment-only attenders;
3. To compare the characteristics of completers to non-completers;
4. To identify factors predicting completion of the programme.
Chi-square, two-sample t-tests and Kruskal-Wallis tests were undertaken to assess associations between demographic and clinical characteristics between the groups. Univariate and multiple logistic regression were carried out to test for significant factors that were associated with completion of the programme. To identify significant predictors in the model after accounting for the demographics variables, three model selection techniques were used, such as forward, backward and stepwise procedures, in SAS version 9.4. For those variables with more than 20% of missing data, the variables were not included for model selection. The model with the smallest Akaike Information Criterion was selected and variables that were deemed significant were kept in the model. A p-value <0.05 was considered statistically significant. Sensitivity analysis was also carried out by using a single imputation method and compared to the complete cases using likewise deletion. This involved replacing the missing values for the continuous variables by the median.
The New Zealand Health and Disability Ethics Committee stated ethical review was not required. Approval for the study was granted by CMH Research Committee on 21 April 2016 (Research Application Numbers 5 and 6).
Results
Of the 2,756 patients that were referred to the Better Breathing programme, 1,028 (37%) never attended and 33 (1%) attended the initial assessment only. The remaining 1,695 (62%) patients commenced the programme; 1,040 (61%) of those were completers and 655 (39%) were non-completers (see Figure 1). This shows that, of all referrals to the Better Breathing programme, 1,716 (62%) never attended or did not complete the programme.
Figure 1: Flow chart showing the numbers of referrals to, attendance at and completion of the Better Breathing Pulmonary Rehabilitation programme between 2010 and 2015.
Characteristics of those who attended the programme (completers and non-completers combined) and those who did not attend the programme (never-attenders and initial assessment-only attenders combined) are summarised in Table 1. There were significant differences between these groups in marital status (p=0.001), deprivation index (p=0.021), smoker (p=<0.001), distance from home to PR site (p=<0.001) and site location (p=<0.001). There were no statistically significant differences between attenders and non-attenders in age (p=0.64), gender (p=0.53), ethnicity (p=0.44), language spoken (p=0.75) or occupation (p=0.96).
Table 1: Demographic characteristics by group—attenders (completers and non-completers combined) and non-attenders (never attenders and initial assessment-only attenders combined).
‡The non-parametric p-value is calculated by the Kruskal-Wallis test and Mann-Whitney-U test for numerical covariates and Fisher’s exact test for categorical covariates.
KEY: kms, kilometres; IQR, inter quartile range; n, number; PR, pulmonary rehabilitation; SD, standard deviation.
Comparison between demographic characteristics of those who never attended (n=1,028) and initial assessment-only attenders (n=33) showed a statistically significant difference in ethnicity (p=0.001), with never-attenders having a larger proportion of European and Māori patients. The initial assessment-only group also had a significantly higher proportion of patients who did not speak English as a first language (22% vs 8%, p=0.02) and a larger proportion of married/partnered patients (80% vs 52%, p=0.03) compared to the never-attenders. The small sample size in the initial assessment-only group limits the significance of these findings.
When comparing demographic and clinical characteristics between the completer and non-completer groups, there were statistically significant differences between the two groups in all characteristics except for gender, distance from home to PR site and site location (Table 2). Furthermore, for each year increase in age, patients were 4% more likely to complete the programme (OR 1.04 95%CI 1.02–1.05, p=<0.001). For every 10m extra that a patient walked in their 6MWT at programme commencement, they were 3% more likely to complete the programme (OR 1.03, 95%CI 1.02–1.04, p=<0.001). Compared with Europeans, Māori were 53% (OR 0.47, 95% CI 0.35–0.65, p=<0.001) and Pacific Island people were 46% (OR 0.64, 95% CI 0.44–0.92, p=<0.001) less likely to complete the programme. Results of the univariate and logistic regression model predicting completion of the better breathing programme are displayed in Table 3. Results of multivariate logistic regression models for both complete and imputed cases can be seen in Table 4.
Table 2: Demographic and clinical characteristics by group–completers vs non-completers.
‡The non-parametric p-value is calculated by the Kruskal-Wallis test and Mann-Whitney-U test for numerical covariates and Fisher’s exact test for categorical covariates.
KEY: BMI, body mass index; FEV1, forced expiratory volume in one second; IQR, inter quartile range; kms, kilometres; MRC, Medical Research Council Dyspnoea Scale; n, number of patients; PR, pulmonary rehabilitation; SD, standard deviation, 6MWT, 6 minute walk test distance.
Table 3: Results of univariate logistic regression model showing variables predicting completion at the Better Breathing Pulmonary Rehabilitation Programme.
Table 4: Results of multivariate logistic regression model showing variables predicting completion of the Better Breathing Pulmonary Rehabilitation Programme for the complete and imputed cases.
Discussion
Data were collected on 2,756 patients referred to the Better Breathing programme in the period under investigation; this data set is larger than those previously described in other New Zealand studies.10,11 Our study has shown that 62% of all patients referred to the Better Breathing programme either do not take part in the programme at all, or do not complete the programme. An older study exploring attendance at a PR programme in an Auckland clinic reported that 41% of patients either did not attend, or failed to complete the programme.17 A more recent study in a different New Zealand region showed that 46% of those referred to PR completed the programme.11 Our results compare poorly with this, whereby only 38% of all patients referred completed the Better Breathing programme. In a review of 11 international studies, non-completion rates were reported to be up to 32%,9 so it is of concern that our non-completion rates in those who commenced the Better Breathing programme (39%) appear to be higher than those reported elsewhere.9
When comparing the characteristics of those who attended with those who did not attend, significant factors included distance travelled, site location, deprivation index and marital status. Other studies investigating reasons for non-completion of PR have cited transport and the distance from home to PR site as problematic.18,19 While we found that the distance from home to PR and the location of PR was significantly different between attenders and non-attenders, once patients commenced the programme, distance and location were no longer a significant factor influencing attendance. This suggests that factors relating to the running of the PR programme itself may be more important than geographical location when considering completion rates.
Some studies have demonstrated that people with lower socioeconomic status may find it harder to access transport and parking costs associated with attending primary healthcare services20,21 and these factors have also been linked to poor attendance at PR programmes.21 A widely used measure of social deprivation in New Zealand13 was used to investigate whether social deprivation affected completion rates at the Better Breathing programme. Even though there was an indication of deprivation index being a significant risk factor (Table 3), after accounting for other characteristics, the deprivation index was not strongly correlated. However, it should be noted that the univariate results indicate that for every one unit increase in deprivation index, the likelihood of completing the programme reduces by 8%.
In comparing participants who completed with those who did not complete the PR programme, many factors were significantly different between the groups. However, when all variables were included in a fully adjusted model, only three factors were identified as independent predictors of completion of PR: age, distance walked on 6MWT and ethnicity. Consistent with other literature,23–26 the results of our study found that patients had a greater likelihood of completing the programme as age increased. It is possible that this is related to work schedules. The Better Breathing programme, which runs during normal working hours, may be less accessible to the working population. Māori and Pacific Island people tend to develop COPD at an earlier age (the average age of onset of COPD in New Zealand is 70.3 years, but for Māori and Pacific Island people it is 62.6 and 62.5 years respectively),3 so these populations may be more severely impacted by timing of PR programmes. An increase in flexibility of services including; offering classes outside of working hours, a home-based service and/or a telehealth based programme may allow younger participants, who may be working or looking after dependents, the opportunity to complete PR.
Patients who walked further in their 6MWT at commencement of our programme were also more likely to complete the programme; this is consistent with other literature.26–28 6MWT distance correlates with MRC dyspnoea score and pulmonary function testing,29,30 and our study found that non-completers had significantly greater dyspnoea and disease severity. These factors may make exercise more challenging, potentially increasing the likelihood of non-completion. Potential strategies to overcome this challenge for participants may involve; increased time spent on orientation to PR including strategies to manage breathlessness, starting exercise at lower intensities and ensuring increased levels of supervision and/or support for people with lower exercise capacity. The location of PR, including access to the building and close parking facilities may also facilitate completion for this group.
An important finding of this study is that Māori and Pacific Island patients are significantly less likely to complete the programme compared with European patients, supporting the findings of others in New Zealand.11 Ethnicity was not significantly different when comparing attenders to non-attenders (p=0.44), but became significant when comparing completers to non-completers (p=0.001). When all variables were accounted for, ethnicity was found to be an independent predictor of completion of PR. This finding is important because the CMH population comprises large numbers of Māori and Pacific Island people in the community, who are disproportionately affected by chronic respiratory diseases in New Zealand.3 The results of this study, therefore, show that the people who may potentially benefit from PR the most are those who are least likely to complete the programme. Differences in attendance between people of various ethnicities may be related to differences in the culture of attendees or of the programme itself. Cultural factors appear to play an influential role in how well PR programmes are able to engage with Māori and Pacific Island people. Levack et al31 found that when the cultural needs of Māori attending PR were not addressed adequately, patients were less willing to attend those PR programmes.31 To our knowledge, two New Zealand-based studies11,31 are the only other studies to have specifically explored the influence of ethnic diversity on participants’ engagement with PR. We encourage others undertaking PR programmes with ethnically diverse populations to further explore issues with engagement and completion of PR programmes and identify factors that may improve these. Levack et al31 have suggested that indigenous-led PR programmes may overcome barriers for indigenous and minority participants and the feasibility of this requires further investigation. Other factors such as the venue in which PR programmes are held—such as a Marae—could be important for many Māori participants. Future research should ensure collaboration with cultural experts, and participants who have attended PR, to work towards co-design of culturally responsive PR programmes.
In our cohort, there was a significant difference in completion rates between English and non-English speaking participants. Indeed, in comparing the characteristics of never-attenders with initial assessment-only attenders, a large proportion of participants who reported English as a second language attended only the initial assessment and did not go to further attend or complete the programme. Additionally, while in our multivariate regression modelling, language was not found to be significant in predicting completion, following data imputation speaking English as a first language became statistically significant, suggesting this may be a relevant factor in completion of PR. Attention should be given to whether the delivery of programmes in different languages might improve completion rates in non-English speakers, and this together with how language aligns with delivering culturally relevant programmes should be considered.
Limitations
It should be noted that during the period of the study, we implemented several changes arising from quality improvement initiatives to the PR programme that may have influenced interpretation. During this period, the service expanded and the hospital outpatient programme moved from the hospital site to four community venues, which we considered may better fulfil the needs of our population. It is feasible that these changes may have impacted on the results of this study, particularly regarding distance from home to PR. However, because distance from home to PR was calculated using each individual’s home address and their closest PR site, we believe that this measure will account for these location changes.
The nature of the data collection and retrieval meant that not all data was available for all groups. For example, data from those who attended the PR programme was more extensive than those who did not attend, due to extensive assessment and monitoring undertaken during the PR programme. Even following completion of the programme, some data was missing on retrieval, eg, HADS. Reasons for some of this missing data could be spoken language/literacy issues, assessment burden or clinician or administration error. Where data were known to be missing, imputation of the continuous variables into the statistical modelling for analysis was carried out and compared with complete cases. Furthermore, we acknowledge a prospective matched cohort study could have improved the ability to account for the effect of confounding variables in our analyses, increasing the confidence regarding the impact of each of the different variables individually.
Conclusion
Of everyone referred to CMH Better Breathing PR programme during the period of our study, only 38% completed the programme. Considering that less than 2% of people with COPD in New Zealand are referred to a PR programme,10 it is problematic that so few patients are completing this gold-standard intervention. Age, 6MWT distance at commencement of PR and ethnicity were important predictors of completion of PR in this population. Strategies to make PR more engaging must be considered for varying age groups, those with poorer exercise tolerance, and, importantly, in different ethnic groups.
Summary
Abstract
Aim
Chronic respiratory diseases, such as chronic obstructive pulmonary disease, are a worldwide public health problem. Pulmonary rehabilitation is a gold-standard intervention for these diseases, yet attendance and completion rates are poor. Counties Manukau Health, in Auckland, New Zealand, has a high prevalence of chronic respiratory disease and a culturally diverse population, comprising large numbers of Māori and Pacific Island people, who are known to be disproportionately affected by chronic respiratory disease. The aim of this study was to investigate patient characteristics affecting engagement with the Counties Manukau Health pulmonary rehabilitation programme and identify factors predicting completion of the programme.
Method
Investigators performed a retrospective analysis using routinely collected data of 2,756 patients invited to attend the pulmonary rehabilitation programme at Counties Manukau Health. Data were analysed to compare demographic and clinical outcomes of patients who completed, did not complete or did not attend the programme, and identified factors predicting completion.
Results
Significant differences were found between groups in demographic and clinical characteristics. Increasing age, higher six-minute walk test distance at programme commencement and European ethnicity were significant predictors of completion of the PR programme.
Conclusion
Compared to European people, Māori were 52% less likely and Pacific Island people were 40% less likely to complete the programme. These findings are significant for the Counties Manukau Health population. Further work needs to focus on determining how to make programmes more engaging to different cultures and how we can aim to reduce health inequities in these populations.
Author Information
Acknowledgements
Correspondence
Correspondence Email
Competing Interests
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14. Chan WC, Papa D, Winnard D. Life Expectancy, Leading Causes of Death and Amenable Mortality in Counties Manukau: 2015 Update. Auckland: Counties Manukau Health; 2016. http://www.countiesmanukau.health.nz/assets/About-CMH/Performance-and-planning/health-status/2016.09.09-Life-expectancy-update.pdf Accessed January 23, 2017.
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Patient characteristics and predictors of completion of a pulmonary rehabilitation programme in Auckland, New Zealand
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Chronic obstructive pulmonary disease (COPD) was the third leading cause of death in 20161 and resulted in more than three million deaths worldwide in 2015.2 In New Zealand, the population prevalence of COPD is estimated to be 14.2%.3 The disease is associated with a significant burden on the healthcare system.4 Internationally, COPD disproportionately affects people living in developing countries2 and indigenous people in developed countries.5 In New Zealand, COPD is more prevalent among Māori, Pacific Island people and those living in more deprived areas.3
Pulmonary rehabilitation (PR) is an evidence-based, multi-disciplinary programme, comprising exercise and education for people with chronic respiratory disease.6 It is an essential component of therapy for COPD.7 Pulmonary rehabilitation has been shown to improve exercise capacity, dyspnoea and health-related quality of life,6 reduce hospital readmissions and mortality.8 Despite this, rates of attendance at, and completion of PR programmes are poor; internationally, up to 50% of people referred to PR programmes fail to attend and rates of non-completion have been reported between 9.7% and 31.8%.9 One New Zealand-wide study estimated that only 0.9% of people over 40 with COPD were offered PR per year, and of those, only 56% completed the programme.10 Another PR programme in New Zealand found their programme enrolled less than 2% of the region’s population with COPD.11
Counties Manukau Health (CMH), in the Auckland region, is one of 20 district health boards in New Zealand. Better Breathing is a PR programme, which runs at four different sites in CMH—one acute care facility and three community-based sites. Patients attend a one-off initial assessment, then attend the exercise and education-based PR programme twice-weekly for eight weeks. The population at CMH is culturally diverse, with 16% Māori, 21% Pacific Island, 24% Asian and 38% New Zealand European/other.12 The population has a distinct socioeconomic makeup, with over 36% of people living in the most deprived deciles, based on the New Zealand Deprivation Index [NZDep2013].13 Within CMH, the prevalence of chronic respiratory disease is high14 especially among Māori, Pacific Island people and those living in deprived areas.3 With guidelines widely recommending PR as a gold-standard intervention,7,15,16 it is important to consider factors impacting upon engagement with PR in the context of contemporary practice in culturally and socioeconomically diverse populations, such as CMH.
The primary aim of this study was to identify and compare the key factors in predicting patients who complete and those who did not complete the PR programme. The secondary aim was to compare the characteristics of those who attended and those who never attended the PR programme.
Methods
Investigators performed a retrospective analysis of routinely collected health information data of 2,756 patients invited to attend the Better Breathing PR Programme, run across the four sites at CMH. We evaluated data from all patients who were invited to attend between 1 January 2010 and 31 December 2015. Patients were divided into four groups:
1. ‘Never-attenders’—who did not attend either the initial assessment or programme;
2. ‘Initial assessment-only attenders’—who attended an initial assessment but did not commence the programme;
3. ‘Non-completers’—who completed less than 75% of the programme;
4. ‘Completers’—who completed at least 75% of the programme.
Data for extraction and analysis were determined prior to commencement of the study and were extracted from routinely collected data from the CMH electronic patient information system by a Senior Analyst at Health Intelligence and Informatics at CMH and two researchers (NJ and SC). Following data extraction, retrieval of missing data was undertaken by two members of the research team (NJ and SC), who used the hospital’s patient information systems to extract any available missing data. Data collected included demographic characteristics (age, gender, self-reported ethnicity, marital status, smoking status, occupation, spoken language, level of deprivation) and clinical characteristics (referral source, percent predicted forced expiratory volume in one second (FEV1%), Hospital Anxiety and Depression Scale (HADS) score, Medical Research Council Dyspnoea Score (MRC), Body Mass Index (BMI) and six-minute walk test (6MWT) distance). The clinical data were taken at the initial assessment and therefore only available for those who attended at least an initial assessment.
Data were analysed in four ways:
1. To compare the characteristics of those who did not attend the programme (never-attenders and initial assessment-only attenders) to those who did attend the programme (completers and non-completers);
2. To compare the characteristics of never-attenders to initial assessment-only attenders;
3. To compare the characteristics of completers to non-completers;
4. To identify factors predicting completion of the programme.
Chi-square, two-sample t-tests and Kruskal-Wallis tests were undertaken to assess associations between demographic and clinical characteristics between the groups. Univariate and multiple logistic regression were carried out to test for significant factors that were associated with completion of the programme. To identify significant predictors in the model after accounting for the demographics variables, three model selection techniques were used, such as forward, backward and stepwise procedures, in SAS version 9.4. For those variables with more than 20% of missing data, the variables were not included for model selection. The model with the smallest Akaike Information Criterion was selected and variables that were deemed significant were kept in the model. A p-value <0.05 was considered statistically significant. Sensitivity analysis was also carried out by using a single imputation method and compared to the complete cases using likewise deletion. This involved replacing the missing values for the continuous variables by the median.
The New Zealand Health and Disability Ethics Committee stated ethical review was not required. Approval for the study was granted by CMH Research Committee on 21 April 2016 (Research Application Numbers 5 and 6).
Results
Of the 2,756 patients that were referred to the Better Breathing programme, 1,028 (37%) never attended and 33 (1%) attended the initial assessment only. The remaining 1,695 (62%) patients commenced the programme; 1,040 (61%) of those were completers and 655 (39%) were non-completers (see Figure 1). This shows that, of all referrals to the Better Breathing programme, 1,716 (62%) never attended or did not complete the programme.
Figure 1: Flow chart showing the numbers of referrals to, attendance at and completion of the Better Breathing Pulmonary Rehabilitation programme between 2010 and 2015.
Characteristics of those who attended the programme (completers and non-completers combined) and those who did not attend the programme (never-attenders and initial assessment-only attenders combined) are summarised in Table 1. There were significant differences between these groups in marital status (p=0.001), deprivation index (p=0.021), smoker (p=<0.001), distance from home to PR site (p=<0.001) and site location (p=<0.001). There were no statistically significant differences between attenders and non-attenders in age (p=0.64), gender (p=0.53), ethnicity (p=0.44), language spoken (p=0.75) or occupation (p=0.96).
Table 1: Demographic characteristics by group—attenders (completers and non-completers combined) and non-attenders (never attenders and initial assessment-only attenders combined).
‡The non-parametric p-value is calculated by the Kruskal-Wallis test and Mann-Whitney-U test for numerical covariates and Fisher’s exact test for categorical covariates.
KEY: kms, kilometres; IQR, inter quartile range; n, number; PR, pulmonary rehabilitation; SD, standard deviation.
Comparison between demographic characteristics of those who never attended (n=1,028) and initial assessment-only attenders (n=33) showed a statistically significant difference in ethnicity (p=0.001), with never-attenders having a larger proportion of European and Māori patients. The initial assessment-only group also had a significantly higher proportion of patients who did not speak English as a first language (22% vs 8%, p=0.02) and a larger proportion of married/partnered patients (80% vs 52%, p=0.03) compared to the never-attenders. The small sample size in the initial assessment-only group limits the significance of these findings.
When comparing demographic and clinical characteristics between the completer and non-completer groups, there were statistically significant differences between the two groups in all characteristics except for gender, distance from home to PR site and site location (Table 2). Furthermore, for each year increase in age, patients were 4% more likely to complete the programme (OR 1.04 95%CI 1.02–1.05, p=<0.001). For every 10m extra that a patient walked in their 6MWT at programme commencement, they were 3% more likely to complete the programme (OR 1.03, 95%CI 1.02–1.04, p=<0.001). Compared with Europeans, Māori were 53% (OR 0.47, 95% CI 0.35–0.65, p=<0.001) and Pacific Island people were 46% (OR 0.64, 95% CI 0.44–0.92, p=<0.001) less likely to complete the programme. Results of the univariate and logistic regression model predicting completion of the better breathing programme are displayed in Table 3. Results of multivariate logistic regression models for both complete and imputed cases can be seen in Table 4.
Table 2: Demographic and clinical characteristics by group–completers vs non-completers.
‡The non-parametric p-value is calculated by the Kruskal-Wallis test and Mann-Whitney-U test for numerical covariates and Fisher’s exact test for categorical covariates.
KEY: BMI, body mass index; FEV1, forced expiratory volume in one second; IQR, inter quartile range; kms, kilometres; MRC, Medical Research Council Dyspnoea Scale; n, number of patients; PR, pulmonary rehabilitation; SD, standard deviation, 6MWT, 6 minute walk test distance.
Table 3: Results of univariate logistic regression model showing variables predicting completion at the Better Breathing Pulmonary Rehabilitation Programme.
Table 4: Results of multivariate logistic regression model showing variables predicting completion of the Better Breathing Pulmonary Rehabilitation Programme for the complete and imputed cases.
Discussion
Data were collected on 2,756 patients referred to the Better Breathing programme in the period under investigation; this data set is larger than those previously described in other New Zealand studies.10,11 Our study has shown that 62% of all patients referred to the Better Breathing programme either do not take part in the programme at all, or do not complete the programme. An older study exploring attendance at a PR programme in an Auckland clinic reported that 41% of patients either did not attend, or failed to complete the programme.17 A more recent study in a different New Zealand region showed that 46% of those referred to PR completed the programme.11 Our results compare poorly with this, whereby only 38% of all patients referred completed the Better Breathing programme. In a review of 11 international studies, non-completion rates were reported to be up to 32%,9 so it is of concern that our non-completion rates in those who commenced the Better Breathing programme (39%) appear to be higher than those reported elsewhere.9
When comparing the characteristics of those who attended with those who did not attend, significant factors included distance travelled, site location, deprivation index and marital status. Other studies investigating reasons for non-completion of PR have cited transport and the distance from home to PR site as problematic.18,19 While we found that the distance from home to PR and the location of PR was significantly different between attenders and non-attenders, once patients commenced the programme, distance and location were no longer a significant factor influencing attendance. This suggests that factors relating to the running of the PR programme itself may be more important than geographical location when considering completion rates.
Some studies have demonstrated that people with lower socioeconomic status may find it harder to access transport and parking costs associated with attending primary healthcare services20,21 and these factors have also been linked to poor attendance at PR programmes.21 A widely used measure of social deprivation in New Zealand13 was used to investigate whether social deprivation affected completion rates at the Better Breathing programme. Even though there was an indication of deprivation index being a significant risk factor (Table 3), after accounting for other characteristics, the deprivation index was not strongly correlated. However, it should be noted that the univariate results indicate that for every one unit increase in deprivation index, the likelihood of completing the programme reduces by 8%.
In comparing participants who completed with those who did not complete the PR programme, many factors were significantly different between the groups. However, when all variables were included in a fully adjusted model, only three factors were identified as independent predictors of completion of PR: age, distance walked on 6MWT and ethnicity. Consistent with other literature,23–26 the results of our study found that patients had a greater likelihood of completing the programme as age increased. It is possible that this is related to work schedules. The Better Breathing programme, which runs during normal working hours, may be less accessible to the working population. Māori and Pacific Island people tend to develop COPD at an earlier age (the average age of onset of COPD in New Zealand is 70.3 years, but for Māori and Pacific Island people it is 62.6 and 62.5 years respectively),3 so these populations may be more severely impacted by timing of PR programmes. An increase in flexibility of services including; offering classes outside of working hours, a home-based service and/or a telehealth based programme may allow younger participants, who may be working or looking after dependents, the opportunity to complete PR.
Patients who walked further in their 6MWT at commencement of our programme were also more likely to complete the programme; this is consistent with other literature.26–28 6MWT distance correlates with MRC dyspnoea score and pulmonary function testing,29,30 and our study found that non-completers had significantly greater dyspnoea and disease severity. These factors may make exercise more challenging, potentially increasing the likelihood of non-completion. Potential strategies to overcome this challenge for participants may involve; increased time spent on orientation to PR including strategies to manage breathlessness, starting exercise at lower intensities and ensuring increased levels of supervision and/or support for people with lower exercise capacity. The location of PR, including access to the building and close parking facilities may also facilitate completion for this group.
An important finding of this study is that Māori and Pacific Island patients are significantly less likely to complete the programme compared with European patients, supporting the findings of others in New Zealand.11 Ethnicity was not significantly different when comparing attenders to non-attenders (p=0.44), but became significant when comparing completers to non-completers (p=0.001). When all variables were accounted for, ethnicity was found to be an independent predictor of completion of PR. This finding is important because the CMH population comprises large numbers of Māori and Pacific Island people in the community, who are disproportionately affected by chronic respiratory diseases in New Zealand.3 The results of this study, therefore, show that the people who may potentially benefit from PR the most are those who are least likely to complete the programme. Differences in attendance between people of various ethnicities may be related to differences in the culture of attendees or of the programme itself. Cultural factors appear to play an influential role in how well PR programmes are able to engage with Māori and Pacific Island people. Levack et al31 found that when the cultural needs of Māori attending PR were not addressed adequately, patients were less willing to attend those PR programmes.31 To our knowledge, two New Zealand-based studies11,31 are the only other studies to have specifically explored the influence of ethnic diversity on participants’ engagement with PR. We encourage others undertaking PR programmes with ethnically diverse populations to further explore issues with engagement and completion of PR programmes and identify factors that may improve these. Levack et al31 have suggested that indigenous-led PR programmes may overcome barriers for indigenous and minority participants and the feasibility of this requires further investigation. Other factors such as the venue in which PR programmes are held—such as a Marae—could be important for many Māori participants. Future research should ensure collaboration with cultural experts, and participants who have attended PR, to work towards co-design of culturally responsive PR programmes.
In our cohort, there was a significant difference in completion rates between English and non-English speaking participants. Indeed, in comparing the characteristics of never-attenders with initial assessment-only attenders, a large proportion of participants who reported English as a second language attended only the initial assessment and did not go to further attend or complete the programme. Additionally, while in our multivariate regression modelling, language was not found to be significant in predicting completion, following data imputation speaking English as a first language became statistically significant, suggesting this may be a relevant factor in completion of PR. Attention should be given to whether the delivery of programmes in different languages might improve completion rates in non-English speakers, and this together with how language aligns with delivering culturally relevant programmes should be considered.
Limitations
It should be noted that during the period of the study, we implemented several changes arising from quality improvement initiatives to the PR programme that may have influenced interpretation. During this period, the service expanded and the hospital outpatient programme moved from the hospital site to four community venues, which we considered may better fulfil the needs of our population. It is feasible that these changes may have impacted on the results of this study, particularly regarding distance from home to PR. However, because distance from home to PR was calculated using each individual’s home address and their closest PR site, we believe that this measure will account for these location changes.
The nature of the data collection and retrieval meant that not all data was available for all groups. For example, data from those who attended the PR programme was more extensive than those who did not attend, due to extensive assessment and monitoring undertaken during the PR programme. Even following completion of the programme, some data was missing on retrieval, eg, HADS. Reasons for some of this missing data could be spoken language/literacy issues, assessment burden or clinician or administration error. Where data were known to be missing, imputation of the continuous variables into the statistical modelling for analysis was carried out and compared with complete cases. Furthermore, we acknowledge a prospective matched cohort study could have improved the ability to account for the effect of confounding variables in our analyses, increasing the confidence regarding the impact of each of the different variables individually.
Conclusion
Of everyone referred to CMH Better Breathing PR programme during the period of our study, only 38% completed the programme. Considering that less than 2% of people with COPD in New Zealand are referred to a PR programme,10 it is problematic that so few patients are completing this gold-standard intervention. Age, 6MWT distance at commencement of PR and ethnicity were important predictors of completion of PR in this population. Strategies to make PR more engaging must be considered for varying age groups, those with poorer exercise tolerance, and, importantly, in different ethnic groups.
Summary
Abstract
Aim
Chronic respiratory diseases, such as chronic obstructive pulmonary disease, are a worldwide public health problem. Pulmonary rehabilitation is a gold-standard intervention for these diseases, yet attendance and completion rates are poor. Counties Manukau Health, in Auckland, New Zealand, has a high prevalence of chronic respiratory disease and a culturally diverse population, comprising large numbers of Māori and Pacific Island people, who are known to be disproportionately affected by chronic respiratory disease. The aim of this study was to investigate patient characteristics affecting engagement with the Counties Manukau Health pulmonary rehabilitation programme and identify factors predicting completion of the programme.
Method
Investigators performed a retrospective analysis using routinely collected data of 2,756 patients invited to attend the pulmonary rehabilitation programme at Counties Manukau Health. Data were analysed to compare demographic and clinical outcomes of patients who completed, did not complete or did not attend the programme, and identified factors predicting completion.
Results
Significant differences were found between groups in demographic and clinical characteristics. Increasing age, higher six-minute walk test distance at programme commencement and European ethnicity were significant predictors of completion of the PR programme.
Conclusion
Compared to European people, Māori were 52% less likely and Pacific Island people were 40% less likely to complete the programme. These findings are significant for the Counties Manukau Health population. Further work needs to focus on determining how to make programmes more engaging to different cultures and how we can aim to reduce health inequities in these populations.
Author Information
Acknowledgements
Correspondence
Correspondence Email
Competing Interests
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Contact diana@nzma.org.nz
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Patient characteristics and predictors of completion of a pulmonary rehabilitation programme in Auckland, New Zealand
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Chronic obstructive pulmonary disease (COPD) was the third leading cause of death in 20161 and resulted in more than three million deaths worldwide in 2015.2 In New Zealand, the population prevalence of COPD is estimated to be 14.2%.3 The disease is associated with a significant burden on the healthcare system.4 Internationally, COPD disproportionately affects people living in developing countries2 and indigenous people in developed countries.5 In New Zealand, COPD is more prevalent among Māori, Pacific Island people and those living in more deprived areas.3
Pulmonary rehabilitation (PR) is an evidence-based, multi-disciplinary programme, comprising exercise and education for people with chronic respiratory disease.6 It is an essential component of therapy for COPD.7 Pulmonary rehabilitation has been shown to improve exercise capacity, dyspnoea and health-related quality of life,6 reduce hospital readmissions and mortality.8 Despite this, rates of attendance at, and completion of PR programmes are poor; internationally, up to 50% of people referred to PR programmes fail to attend and rates of non-completion have been reported between 9.7% and 31.8%.9 One New Zealand-wide study estimated that only 0.9% of people over 40 with COPD were offered PR per year, and of those, only 56% completed the programme.10 Another PR programme in New Zealand found their programme enrolled less than 2% of the region’s population with COPD.11
Counties Manukau Health (CMH), in the Auckland region, is one of 20 district health boards in New Zealand. Better Breathing is a PR programme, which runs at four different sites in CMH—one acute care facility and three community-based sites. Patients attend a one-off initial assessment, then attend the exercise and education-based PR programme twice-weekly for eight weeks. The population at CMH is culturally diverse, with 16% Māori, 21% Pacific Island, 24% Asian and 38% New Zealand European/other.12 The population has a distinct socioeconomic makeup, with over 36% of people living in the most deprived deciles, based on the New Zealand Deprivation Index [NZDep2013].13 Within CMH, the prevalence of chronic respiratory disease is high14 especially among Māori, Pacific Island people and those living in deprived areas.3 With guidelines widely recommending PR as a gold-standard intervention,7,15,16 it is important to consider factors impacting upon engagement with PR in the context of contemporary practice in culturally and socioeconomically diverse populations, such as CMH.
The primary aim of this study was to identify and compare the key factors in predicting patients who complete and those who did not complete the PR programme. The secondary aim was to compare the characteristics of those who attended and those who never attended the PR programme.
Methods
Investigators performed a retrospective analysis of routinely collected health information data of 2,756 patients invited to attend the Better Breathing PR Programme, run across the four sites at CMH. We evaluated data from all patients who were invited to attend between 1 January 2010 and 31 December 2015. Patients were divided into four groups:
1. ‘Never-attenders’—who did not attend either the initial assessment or programme;
2. ‘Initial assessment-only attenders’—who attended an initial assessment but did not commence the programme;
3. ‘Non-completers’—who completed less than 75% of the programme;
4. ‘Completers’—who completed at least 75% of the programme.
Data for extraction and analysis were determined prior to commencement of the study and were extracted from routinely collected data from the CMH electronic patient information system by a Senior Analyst at Health Intelligence and Informatics at CMH and two researchers (NJ and SC). Following data extraction, retrieval of missing data was undertaken by two members of the research team (NJ and SC), who used the hospital’s patient information systems to extract any available missing data. Data collected included demographic characteristics (age, gender, self-reported ethnicity, marital status, smoking status, occupation, spoken language, level of deprivation) and clinical characteristics (referral source, percent predicted forced expiratory volume in one second (FEV1%), Hospital Anxiety and Depression Scale (HADS) score, Medical Research Council Dyspnoea Score (MRC), Body Mass Index (BMI) and six-minute walk test (6MWT) distance). The clinical data were taken at the initial assessment and therefore only available for those who attended at least an initial assessment.
Data were analysed in four ways:
1. To compare the characteristics of those who did not attend the programme (never-attenders and initial assessment-only attenders) to those who did attend the programme (completers and non-completers);
2. To compare the characteristics of never-attenders to initial assessment-only attenders;
3. To compare the characteristics of completers to non-completers;
4. To identify factors predicting completion of the programme.
Chi-square, two-sample t-tests and Kruskal-Wallis tests were undertaken to assess associations between demographic and clinical characteristics between the groups. Univariate and multiple logistic regression were carried out to test for significant factors that were associated with completion of the programme. To identify significant predictors in the model after accounting for the demographics variables, three model selection techniques were used, such as forward, backward and stepwise procedures, in SAS version 9.4. For those variables with more than 20% of missing data, the variables were not included for model selection. The model with the smallest Akaike Information Criterion was selected and variables that were deemed significant were kept in the model. A p-value <0.05 was considered statistically significant. Sensitivity analysis was also carried out by using a single imputation method and compared to the complete cases using likewise deletion. This involved replacing the missing values for the continuous variables by the median.
The New Zealand Health and Disability Ethics Committee stated ethical review was not required. Approval for the study was granted by CMH Research Committee on 21 April 2016 (Research Application Numbers 5 and 6).
Results
Of the 2,756 patients that were referred to the Better Breathing programme, 1,028 (37%) never attended and 33 (1%) attended the initial assessment only. The remaining 1,695 (62%) patients commenced the programme; 1,040 (61%) of those were completers and 655 (39%) were non-completers (see Figure 1). This shows that, of all referrals to the Better Breathing programme, 1,716 (62%) never attended or did not complete the programme.
Figure 1: Flow chart showing the numbers of referrals to, attendance at and completion of the Better Breathing Pulmonary Rehabilitation programme between 2010 and 2015.
Characteristics of those who attended the programme (completers and non-completers combined) and those who did not attend the programme (never-attenders and initial assessment-only attenders combined) are summarised in Table 1. There were significant differences between these groups in marital status (p=0.001), deprivation index (p=0.021), smoker (p=<0.001), distance from home to PR site (p=<0.001) and site location (p=<0.001). There were no statistically significant differences between attenders and non-attenders in age (p=0.64), gender (p=0.53), ethnicity (p=0.44), language spoken (p=0.75) or occupation (p=0.96).
Table 1: Demographic characteristics by group—attenders (completers and non-completers combined) and non-attenders (never attenders and initial assessment-only attenders combined).
‡The non-parametric p-value is calculated by the Kruskal-Wallis test and Mann-Whitney-U test for numerical covariates and Fisher’s exact test for categorical covariates.
KEY: kms, kilometres; IQR, inter quartile range; n, number; PR, pulmonary rehabilitation; SD, standard deviation.
Comparison between demographic characteristics of those who never attended (n=1,028) and initial assessment-only attenders (n=33) showed a statistically significant difference in ethnicity (p=0.001), with never-attenders having a larger proportion of European and Māori patients. The initial assessment-only group also had a significantly higher proportion of patients who did not speak English as a first language (22% vs 8%, p=0.02) and a larger proportion of married/partnered patients (80% vs 52%, p=0.03) compared to the never-attenders. The small sample size in the initial assessment-only group limits the significance of these findings.
When comparing demographic and clinical characteristics between the completer and non-completer groups, there were statistically significant differences between the two groups in all characteristics except for gender, distance from home to PR site and site location (Table 2). Furthermore, for each year increase in age, patients were 4% more likely to complete the programme (OR 1.04 95%CI 1.02–1.05, p=<0.001). For every 10m extra that a patient walked in their 6MWT at programme commencement, they were 3% more likely to complete the programme (OR 1.03, 95%CI 1.02–1.04, p=<0.001). Compared with Europeans, Māori were 53% (OR 0.47, 95% CI 0.35–0.65, p=<0.001) and Pacific Island people were 46% (OR 0.64, 95% CI 0.44–0.92, p=<0.001) less likely to complete the programme. Results of the univariate and logistic regression model predicting completion of the better breathing programme are displayed in Table 3. Results of multivariate logistic regression models for both complete and imputed cases can be seen in Table 4.
Table 2: Demographic and clinical characteristics by group–completers vs non-completers.
‡The non-parametric p-value is calculated by the Kruskal-Wallis test and Mann-Whitney-U test for numerical covariates and Fisher’s exact test for categorical covariates.
KEY: BMI, body mass index; FEV1, forced expiratory volume in one second; IQR, inter quartile range; kms, kilometres; MRC, Medical Research Council Dyspnoea Scale; n, number of patients; PR, pulmonary rehabilitation; SD, standard deviation, 6MWT, 6 minute walk test distance.
Table 3: Results of univariate logistic regression model showing variables predicting completion at the Better Breathing Pulmonary Rehabilitation Programme.
Table 4: Results of multivariate logistic regression model showing variables predicting completion of the Better Breathing Pulmonary Rehabilitation Programme for the complete and imputed cases.
Discussion
Data were collected on 2,756 patients referred to the Better Breathing programme in the period under investigation; this data set is larger than those previously described in other New Zealand studies.10,11 Our study has shown that 62% of all patients referred to the Better Breathing programme either do not take part in the programme at all, or do not complete the programme. An older study exploring attendance at a PR programme in an Auckland clinic reported that 41% of patients either did not attend, or failed to complete the programme.17 A more recent study in a different New Zealand region showed that 46% of those referred to PR completed the programme.11 Our results compare poorly with this, whereby only 38% of all patients referred completed the Better Breathing programme. In a review of 11 international studies, non-completion rates were reported to be up to 32%,9 so it is of concern that our non-completion rates in those who commenced the Better Breathing programme (39%) appear to be higher than those reported elsewhere.9
When comparing the characteristics of those who attended with those who did not attend, significant factors included distance travelled, site location, deprivation index and marital status. Other studies investigating reasons for non-completion of PR have cited transport and the distance from home to PR site as problematic.18,19 While we found that the distance from home to PR and the location of PR was significantly different between attenders and non-attenders, once patients commenced the programme, distance and location were no longer a significant factor influencing attendance. This suggests that factors relating to the running of the PR programme itself may be more important than geographical location when considering completion rates.
Some studies have demonstrated that people with lower socioeconomic status may find it harder to access transport and parking costs associated with attending primary healthcare services20,21 and these factors have also been linked to poor attendance at PR programmes.21 A widely used measure of social deprivation in New Zealand13 was used to investigate whether social deprivation affected completion rates at the Better Breathing programme. Even though there was an indication of deprivation index being a significant risk factor (Table 3), after accounting for other characteristics, the deprivation index was not strongly correlated. However, it should be noted that the univariate results indicate that for every one unit increase in deprivation index, the likelihood of completing the programme reduces by 8%.
In comparing participants who completed with those who did not complete the PR programme, many factors were significantly different between the groups. However, when all variables were included in a fully adjusted model, only three factors were identified as independent predictors of completion of PR: age, distance walked on 6MWT and ethnicity. Consistent with other literature,23–26 the results of our study found that patients had a greater likelihood of completing the programme as age increased. It is possible that this is related to work schedules. The Better Breathing programme, which runs during normal working hours, may be less accessible to the working population. Māori and Pacific Island people tend to develop COPD at an earlier age (the average age of onset of COPD in New Zealand is 70.3 years, but for Māori and Pacific Island people it is 62.6 and 62.5 years respectively),3 so these populations may be more severely impacted by timing of PR programmes. An increase in flexibility of services including; offering classes outside of working hours, a home-based service and/or a telehealth based programme may allow younger participants, who may be working or looking after dependents, the opportunity to complete PR.
Patients who walked further in their 6MWT at commencement of our programme were also more likely to complete the programme; this is consistent with other literature.26–28 6MWT distance correlates with MRC dyspnoea score and pulmonary function testing,29,30 and our study found that non-completers had significantly greater dyspnoea and disease severity. These factors may make exercise more challenging, potentially increasing the likelihood of non-completion. Potential strategies to overcome this challenge for participants may involve; increased time spent on orientation to PR including strategies to manage breathlessness, starting exercise at lower intensities and ensuring increased levels of supervision and/or support for people with lower exercise capacity. The location of PR, including access to the building and close parking facilities may also facilitate completion for this group.
An important finding of this study is that Māori and Pacific Island patients are significantly less likely to complete the programme compared with European patients, supporting the findings of others in New Zealand.11 Ethnicity was not significantly different when comparing attenders to non-attenders (p=0.44), but became significant when comparing completers to non-completers (p=0.001). When all variables were accounted for, ethnicity was found to be an independent predictor of completion of PR. This finding is important because the CMH population comprises large numbers of Māori and Pacific Island people in the community, who are disproportionately affected by chronic respiratory diseases in New Zealand.3 The results of this study, therefore, show that the people who may potentially benefit from PR the most are those who are least likely to complete the programme. Differences in attendance between people of various ethnicities may be related to differences in the culture of attendees or of the programme itself. Cultural factors appear to play an influential role in how well PR programmes are able to engage with Māori and Pacific Island people. Levack et al31 found that when the cultural needs of Māori attending PR were not addressed adequately, patients were less willing to attend those PR programmes.31 To our knowledge, two New Zealand-based studies11,31 are the only other studies to have specifically explored the influence of ethnic diversity on participants’ engagement with PR. We encourage others undertaking PR programmes with ethnically diverse populations to further explore issues with engagement and completion of PR programmes and identify factors that may improve these. Levack et al31 have suggested that indigenous-led PR programmes may overcome barriers for indigenous and minority participants and the feasibility of this requires further investigation. Other factors such as the venue in which PR programmes are held—such as a Marae—could be important for many Māori participants. Future research should ensure collaboration with cultural experts, and participants who have attended PR, to work towards co-design of culturally responsive PR programmes.
In our cohort, there was a significant difference in completion rates between English and non-English speaking participants. Indeed, in comparing the characteristics of never-attenders with initial assessment-only attenders, a large proportion of participants who reported English as a second language attended only the initial assessment and did not go to further attend or complete the programme. Additionally, while in our multivariate regression modelling, language was not found to be significant in predicting completion, following data imputation speaking English as a first language became statistically significant, suggesting this may be a relevant factor in completion of PR. Attention should be given to whether the delivery of programmes in different languages might improve completion rates in non-English speakers, and this together with how language aligns with delivering culturally relevant programmes should be considered.
Limitations
It should be noted that during the period of the study, we implemented several changes arising from quality improvement initiatives to the PR programme that may have influenced interpretation. During this period, the service expanded and the hospital outpatient programme moved from the hospital site to four community venues, which we considered may better fulfil the needs of our population. It is feasible that these changes may have impacted on the results of this study, particularly regarding distance from home to PR. However, because distance from home to PR was calculated using each individual’s home address and their closest PR site, we believe that this measure will account for these location changes.
The nature of the data collection and retrieval meant that not all data was available for all groups. For example, data from those who attended the PR programme was more extensive than those who did not attend, due to extensive assessment and monitoring undertaken during the PR programme. Even following completion of the programme, some data was missing on retrieval, eg, HADS. Reasons for some of this missing data could be spoken language/literacy issues, assessment burden or clinician or administration error. Where data were known to be missing, imputation of the continuous variables into the statistical modelling for analysis was carried out and compared with complete cases. Furthermore, we acknowledge a prospective matched cohort study could have improved the ability to account for the effect of confounding variables in our analyses, increasing the confidence regarding the impact of each of the different variables individually.
Conclusion
Of everyone referred to CMH Better Breathing PR programme during the period of our study, only 38% completed the programme. Considering that less than 2% of people with COPD in New Zealand are referred to a PR programme,10 it is problematic that so few patients are completing this gold-standard intervention. Age, 6MWT distance at commencement of PR and ethnicity were important predictors of completion of PR in this population. Strategies to make PR more engaging must be considered for varying age groups, those with poorer exercise tolerance, and, importantly, in different ethnic groups.
Summary
Abstract
Aim
Chronic respiratory diseases, such as chronic obstructive pulmonary disease, are a worldwide public health problem. Pulmonary rehabilitation is a gold-standard intervention for these diseases, yet attendance and completion rates are poor. Counties Manukau Health, in Auckland, New Zealand, has a high prevalence of chronic respiratory disease and a culturally diverse population, comprising large numbers of Māori and Pacific Island people, who are known to be disproportionately affected by chronic respiratory disease. The aim of this study was to investigate patient characteristics affecting engagement with the Counties Manukau Health pulmonary rehabilitation programme and identify factors predicting completion of the programme.
Method
Investigators performed a retrospective analysis using routinely collected data of 2,756 patients invited to attend the pulmonary rehabilitation programme at Counties Manukau Health. Data were analysed to compare demographic and clinical outcomes of patients who completed, did not complete or did not attend the programme, and identified factors predicting completion.
Results
Significant differences were found between groups in demographic and clinical characteristics. Increasing age, higher six-minute walk test distance at programme commencement and European ethnicity were significant predictors of completion of the PR programme.
Conclusion
Compared to European people, Māori were 52% less likely and Pacific Island people were 40% less likely to complete the programme. These findings are significant for the Counties Manukau Health population. Further work needs to focus on determining how to make programmes more engaging to different cultures and how we can aim to reduce health inequities in these populations.
Author Information
Acknowledgements
Correspondence
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Competing Interests
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Patient characteristics and predictors of completion of a pulmonary rehabilitation programme in Auckland, New Zealand
Chronic obstructive pulmonary disease (COPD) was the third leading cause of death in 2016 and resulted in more than three million deaths worldwide in 2015.2
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