Social Determinants of Adherence to Pulmonary Rehabilitation for Chronic Obstructive Pulmonary Disease

Abstract

Adherence to pulmonary rehabilitation (PR) is low. Previous studies have focused on clinical predictors of PR completion. We aimed to identify social determinants of adherence to PR. A cross-sectional analysis of a database of COPD patients (N = 455) in an outpatient PR program was performed. Adherence, a ratio of attended-to-prescribed sessions, was coded as low (<35%), moderate (35-85%), and high (>85%). Individual-level measures included age, sex, race, BMI, smoking status, pack-years, baseline 6-minute walk distance (6MWD: <150, 150-249, ≥250), co-morbidities, depression, and prescribed PR sessions (≤20, 21-30, >30). Fifteen area-level measures aggregated to Census tracts were obtained from the U.S. Census after geocoding patients' addresses. Using exploratory factor analysis, a neighborhood socioeconomic disadvantage index was constructed, which included variables with factor loading >0.5: poverty, public assistance, households without vehicles, cost burden, unemployment, and minority population. Multivariate regression models were adjusted for clustering on Census tracts. Twenty-six percent of patients had low adherence, 23% were moderately adherent, 51% were highly adherent. In the best fitted full model, each decile increase in neighborhood socioeconomic disadvantage increased the risk of moderate vs high adherence by 14% (p < 0.01). Smoking tripled the relative risk of low adherence (p < 0.01), while each increase in 6MWD category decreased that risk by 72% (p < 0.01) and 84% (p < 0.001), respectively. These findings show that, relative to high adherence, low adherence is associated with limited functional capacity and current smoking, while moderate adherence is associated with socioeconomic disadvantage. The distinction highlights different pathways to suboptimal adherence and calls for tailored intervention approaches.

Nonadherence in Home-Based Pulmonary Rehabilitation Program for COPD Patients

“…Regarding the education level, the same previous study showed that education had no effect on adherence of PR [12]. In contrast to a recent prospective study which demonstrated that patients with lower levels of education would have more likely to drop out or did not attend the program [32], Oates et al recently indicated that moderate adherence was associated with socioeconomic disadvantage, for example, the income level, unemployment rate, and the number of household vehicles, and the low adherence was associated with limited function [33].…”

Patient assessment and selection for pulmonary rehabilitation

“…Given that PR resources are limited, selection of candidates for PR who are likely to adhere to and complete the programme is an important consideration. In studies conducted to date, current smoking, depression, social isolation, poor mobility, lack of perceived benefit, extremes of age, dyspnoea severity, long‐term oxygen therapy, transportation difficulty or travel distance, socio‐economic disadvantage and costs have been associated with non‐adherence and/or lack of programme completion . Despite these associations, many complex factors influence uptake, adherence to and completion of PR, and no individual adherence‐related parameters can be used reliably to predict consistently which people will complete the programme, hence patient candidacy for PR should not presently be based on these factors.…”

How are social determinants of health represented in German medical education?: a qualitative content analysis of key-curricular documents

“…Knowledge of and skills in the field of SDH can support physicians in their everyday practice, for example, by improving the understanding of patients' adherence to particular treatment regimens. [10][11][12] Acknowledging the importance of SDH, the WHO Commission on SDH (CSDH) emphasises the necessity and advantage of a SDH-framed mind-set for health professionals. It recommends that SDH should be a standard and compulsory part of the training of medical students and other health professionals.…”