Today’s new report from the Royal College of Physicians shows significant health benefits associated with completion of pulmonary rehabilitation (PR) for people suffering with Chronic Obstructive Pulmonary Disease (COPD), yet many patients continue to wait too long for treatment.
The report from the RCP shows that only 60% of people with COPD referred for PR were enrolled to a PR programme within 90 days, and more than a third (38%) do not complete the treatment course once assessed. In addition, conduct of routine exercise assessments were not performed according to accepted standards in over 50% of patients.
However, the report also highlights some important improvements to services, with 84% now providing a written discharge exercise plan compared to only 65% in 2015, and more services now have a standard operating procedure detailing local policies (84% in 2017, compared with 67% in 2015). Overall, the report reveals many areas of good quality PR treatment and for patients that do complete therapy meaningful improvements are seen in their quality of life.
The RCP has called for PR services to enrol 85% of patients referred for PR within 90 days; ensure all exercise assessments are performed to the recommended standards and aim for at least 70% of patients assessed to have completed PR.
The report also identifies the need for PR programmes to adapt their services to increase convenience and acceptability of programmes. This includes offering flexible start dates, increasing the provision of rolling programmes, and ensuring that the location at which PR is held is accessible to as many people as possible. Inadequate funding exists for some PR services with 60% of PR services operating with a funding term of two years or less.
PR is one of the most effective and high value interventions for people suffering with COPD. Completing PR can reduce demands on the NHS, by helping people to manage their condition and thereby reducing risk of subsequent hospital admission.
It is clear referral rates to PR from other parts of the healthcare system are also still very low. The latest COPD primary care audit (Wales) 2015-17 reported that only half of patients (50.2%) most affected by breathlessness (i.e. MRC scores 3-5) had a record of a referral to Pulmonary Rehabilitation (PR) in the last three years .
Similarly, the secondary care national COPD organisational audit (2018) stated that only 46% of hospitals reported availability of PR within 4 weeks of discharge. The RCP calls for action to be taken in both primary and secondary care to enhance these referral rates. It urges commissioners and providers to ensure that all patients receive an offer to start PR treatment within the recommended 3 months following their referral, in addition to promoting the need for greater awareness of the benefits of PR.
The key findings and recommendations have been mapped to the BTS quality standards for PR. The full COPD PR audit report can be found at: www.rcplondon.ac.uk/an-exercise-in-improvement
Other key findings:
- The number of practice shuttle walk tests performed has increased to 39% compared with 26% in 2015.
- 27% of patients had an assessment of muscle strength at baseline compared to only 15% in 2015.
- The vast majority of services (92%) accepted those patients with more severe disability and self-reported breathlessness (MRC grade 5) compared with 81% in 2015.
- The number of patients who complete a PR programme has marginally improved to 62% compared with 59% of patients reported in 2015.
Other recommendations for PR commissioners and primary and secondary healthcare teams:
- Commissioners and providers should ensure that robust referral pathways for PR are in place, including developing integrated referral pathways, between PR services and other healthcare teams managing COPD.
- PR services should receive funding of sufficient quantity and duration to enable them to recruit and retain highly trained staff and develop processes to ensure that all patients are enrolled to PR within 90 days of receipt of referral.
- System leaders should ensure that there is an accessible PR service that can offer early post-discharge PR for patients leaving hospital after an exacerbation of COPD.
- Practices should review COPD registers to ensure all eligible patients are offered PR and that this offer is considered at each annual review.
- Hospital discharge teams should ensure that local discharge care bundles include the offer of early post-discharge PR, accompanied by information about the benefits of PR.
Professor Michael Steiner, national COPD audit clinical lead for pulmonary rehabilitation and a consultant respiratory physician, said:
The audit demonstrates the substantial health benefits received by people who complete PR. I hope the findings of this report and other PR audit reports will widen access to PR services and in turn, improve care for people with COPD. Patients and commissioners can also now begin to use these results in a practical way to understand the quality of their local services.
Dr Lisa Davies, chair of the British Thoracic Society, said:
The audit is an important step to really understanding the organisation and quality of care in PR services across England and Wales. We are pleased to see that there is an overall adherence to the BTS standards yet further action should be taken to increase referral rates of eligible patients. It will also be crucial that PR services are sufficiently resourced to meet this demand.
 A rolling programme is a continuing cycle of sessions, with patients joining when there is a space and leaving after completing a programme of sessions.
 British Thoracic Society Reports, Vol 4, Issue 2, 2012. IMPRESS Guide to the relative value of COPD interventions. www.respiratoryfutures.org.uk/media/1107/impress-pulmrehab-191211-lres.pdf
 Griffiths TL, Phillips CJ, Davies S, et al Cost effectiveness of an outpatient multidisciplinary pulmonary rehabilitation programme Thorax 2001;56:779-784.