increasing uptake and completion of pulmonary rehabilitation with lay health workers: protocol of a cluster randomised controlled trial

Problem

We are reporting the design of an NIHR funded trial scheduled to start in September 2021.

Pulmonary rehabilitation (PR) is the most effective treatment for the symptoms and morbidity of COPD. Uptake and completion of PR is about 40% across the NHS and in other countries in Europe, North America, and Australasia. Causes of low uptake and completion are lack of perceived benefit by participants, travel difficulties, referrers' uncertainty of its effectiveness, inconvenient timing, current smoking and depression. Referrals by GPs are associated with the lowest rates of uptake and completion. No interventions have so far proved effective in increasing uptake and completion of PR. We have shown the feasibility, intervention fidelity and acceptability of an intervention based on a lay health worker (LHW) intervention in which the LHWs were patients with COPD who had undergone PR.

Approach

National cluster randomised controlled trial of the intervention in 38 NHS pulmonary rehabilitation services, 19 intervention sites and 19 control sites. COPD patients who have completed PR will be recruited and trained as lay health workers in each PR centre by trained PR teams. The aim of training is to prepare LHWs to support newly referred patients in the take-up and completion of PR. Training will include face to face and telephone communication skills, boundary setting, confidentiality, and behaviour change techniques to address obstacles. All communication will be recorded by smart phone. Intervention fidelity will be assessed using recorded interactions. Primary outcome will be the rate of uptake and completion of PR. Secondary outcomes will include quality of life, exercise capacity and breathlessness. A detailed process evaluation and a health economic evaluation will be carried out.

Findings

The LHW intervention is a novel approach to address a significant problem in the impact of GP referrals to PR of people with COPD. LHWs may significantly contribute also to the achievement of lifestyle changes in the secondary prevention or the amelioration of the impact of other chronic illnesses,

Consequences

If the LHW intervention is effective it will lead to considerable improvement in the burden of COPD across the NHS. The trial includes an implementation plan which will avoid the need for a Stage IV trial of effectiveness. The LHW model could be considered in a range of chronic illnesses in which the take up of important life style changes has been inconsistent.