Key messages
• There is little reliable evidence on how best to implement rehabilitation in health systems. Most evidence comes from high-income countries, and we found no evidence from low-income countries, so the findings may not apply everywhere.
• Giving extra support to help people start and complete cardiac rehabilitation (implementation strategies such as face-to-face contact, motivational counseling, or support from nurses or other health professionals) may provide small benefits in terms of participation.
• We are unsure about the effects of using telehealth (video or phone) to support older people who are in poorer health to exercise in terms of physical functioning. Telehealth may have little to no effect on quality of life.
• Changing how health professionals work through implementation strategies, such as giving training, guidelines, feedback, or checklists, does not clearly improve patient outcomes, but they may work about as well as traditional rehabilitation.
• More high-quality research is needed, especially in low- and middle-income countries, to better understand how these strategies influence people's health and recovery.
Why did we do this review?
Rehabilitation helps people regain or improve their physical, mental, or social abilities and independence after illness, injury, or surgery. The need for rehabilitation services is increasing worldwide. People are living longer and are surviving more illnesses and injuries than in the past. This often means living with long-term health problems. However, many people who need rehabilitation do not receive it, especially in low- and middle-income countries, where there are not enough trained rehabilitation professionals. This review looks at strategies (actions or approaches) that researchers have studied to improve how these rehabilitation services work better for patients around the world.
What are implementation strategies?
Implementation strategies are actions designed to improve how health services are delivered. In rehabilitation, these strategies can aim to change the behavior of health professionals, improve how services are organized, or better support people who would benefit from rehabilitation.
What did we want to find out?
We wanted to answer the following questions.
• What current evidence is available on implementation strategies used in rehabilitation across the globe?
• How could current evidence help health systems leaders make decisions about rehabilitation?
• Are there opportunities to conduct new kinds of health policy and systems research on implementation strategies in rehabilitation?
What did we do?
We searched for systematic reviews that studied existing information on implementation strategies in rehabilitation.
What did we find?
We found 15 systematic reviews, four of which we judged to be reliable. These four reviews included 55 primary studies and formed the basis of our findings. Most of the research came from high-income countries, and no studies were from low-income countries. The reviews were done during the COVID-19 pandemic and focused mainly on older adults, with average ages between 60 and 77 years. In general, our findings for each outcome are based on very few studies.
Main findings
Implementation strategies that support people to start and complete cardiac rehabilitation (for example, face-to-face contact, motivational counseling, or support from nurses or other health professionals) may improve patient adherence to treatment and attendance of cardiac rehabilitation sessions, and probably lead to a small increase in the number of patients who complete cardiac rehabilitation.
For older people, delivering exercise rehabilitation by video or phone instead of face to face may have little to no effect on quality of life. We are unsure about the effect on mobility, strength, and balance, because the results are very uncertain.
In stroke rehabilitation, implementation strategies to change how health professionals work (such as training workshops, distributing guidelines, performance feedback, or checklists to follow recommended care) probably have little to no effect on patient quality of life or ability to perform everyday activities, and may have little to no effect on patient psychological well-being or adherence to treatment. We are unsure about the effects on quality of care or unwanted events, because the results are very uncertain.
What are the limitations of the evidence?
Only a few studies contributed to each of the results, and some were of poor methodological quality. Overall, we have little confidence in the evidence for the effects of these interventions, so future research might change our conclusions. Most studies were conducted in high-income countries, which usually have more resources (for example, staff, equipment, facilities and support services) than low- and middle-income countries. This means that the results may not apply everywhere.
How up-to-date is this evidence?
This evidence is up-to-date to 17 November 2024.
Pročitajte cijeli sažetak
Cochrane Rehabilitation and the World Health Organization (WHO) Rehabilitation Programme have collaborated to produce four Cochrane overviews of systematic reviews that synthesize current available evidence from health policy and systems research (HPSR) in rehabilitation. Each overview focuses on one of the four pillars of HPSR as identified by the Cochrane Effective Practice and Organisation of Care (EPOC) taxonomy: delivery arrangements, financial arrangements, governance arrangements, and implementation strategies. This overview examined implementation strategies, defined by EPOC as interventions designed to bring about changes in healthcare organizations, the behavior of healthcare professionals, or the use of health services by healthcare recipients.
Ciljevi
This overview aimed to synthesize current evidence on implementation strategies in rehabilitation from a health policy and systems research (HPSR) perspective. Our series of four overviews have the following overarching objectives.
• To offer a broad synthesis of the existing evidence on health policy and systems interventions' effects.
• To direct end-users, including policymakers, towards systematic reviews that may address their health policy questions.
• To identify current research gaps and set priorities for future primary HPSR.
• To pinpoint the needs and priorities for new evidence syntheses where no reliable, up-to-date systematic reviews currently exist.
We searched the Epistemonikos database, the Health Systems Evidence database, and EPOC Group systematic reviews to identify reviews published between 1 January 2015 and 17 November 2024. We applied no language limitations. We included Cochrane and non-Cochrane systematic reviews of randomized controlled trials (RCTs) and non-randomized studies of interventions (NRSIs) that evaluated the effectiveness of health policy and systems interventions for rehabilitation in health systems, specifically related to implementation strategies as defined in the EPOC taxonomy. All four overview teams collaborated to screen reviews and extract data. We used AMSTAR 2 to critically appraise the quality of the reviews. Results were analyzed descriptively and are based on reviews with ratings of high-to-moderate confidence, with low-confidence reviews reported separately.
Glavni rezultati
We identified 7882 systematic reviews, of which 15 met our inclusion criteria. Three reviews overlapped substantially with other reviews, and eight received low- or critically low-confidence ratings. Ultimately, four moderate- to high-confidence reviews contributed to the synthesis; two were Cochrane systematic reviews. Most primary studies were from high-income countries; none were from low-income countries. Most strategies targeting healthcare professionals (e.g. guideline dissemination, interactive workshops, opinion leaders, audit and feedback) or healthcare recipients (e.g. structured monitoring, telehealth support, counseling, motivational interviewing) included more than one component. Strategies targeting healthcare recipients' use of health services in cardiac rehabilitation may show small benefits in terms of participation (enrollment, adherence, completion), but effects on other outcomes are uncertain. The effects of strategies targeting older healthcare recipients via telehealth are uncertain. Strategies targeting healthcare professionals may have little to no effect on professional or patient and carer outcomes in stroke rehabilitation. For musculoskeletal conditions, there were no evidence-certainty ratings, so intervention effects are unclear. We found no reviews of strategies targeting health service organizations or specific types of rehabilitation practice. The evidence certainty was generally low; evidence of adverse events was missing or uncertain; and reporting on organizational, implementation, economic, and equity outcomes was scarce.
Zaključak autora
Current evidence on implementation strategies in rehabilitation is limited, mostly of low certainty, and derived from high-income countries. Multicomponent, patient-targeted strategies may modestly improve cardiac rehabilitation participation, but effects in other areas remain uncertain. Further high-quality research using well-defined frameworks is needed, especially in low- and middle-income countries, to identify effective strategies and evaluate organizational, implementation, and equity outcomes. Future Cochrane overviews of reviews in HPSR should consider including a broader range of study designs, such as observational, qualitative, and mixed-methods evidence, to better capture evidence on implementation strategies in rehabilitation.
Funding
This Cochrane review was funded by the Italian Ministry of Health (Ricerca Corrente). The funder played no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Registration
The protocol was first published in the European Journal of Physical and Rehabilitation Medicine online on 27 January 2025. The manuscript was received on 11 November 2024 and was accepted on 26 November 2024.
Protocol: DOI 10.23736/S1973-9087.24.08833-6.
