Pulmonary rehabilitation delivers significant health benefits but too many patients are missing out, UK
The National Chronic Obstructive Pulmonary Disease (COPD) Audit Programme’s Pulmonary Rehabilitation (PR) Report reveals substantial health benefits received by patients who complete PR treatment yet many patients are not being referred, and many patients (40%) find it difficult to complete the PR programme.
COPD is the collective term for emphysema and chronic bronchitis, and it is mainly caused by smoking. People with COPD have breathing difficulties, which can affect the quality of their everyday life and prevent normal physical activity. PR is a combination of exercises to improve physical activity and fitness, together with advice and education about self-care: all of which help patients with COPD to cope with this long term medical condition.
The report also shows that over a third of patients (37%) in England and Wales are waiting longer than the 3 months recommended in the British Thoracic Society (BTS) quality standards.
The report entitled Pulmonary Rehabilitation: Steps to breathe better covers the second part of the COPD PR audit, reviewing the quality of care received by 7,413 patients across 210 PR services in the primary, secondary and community care sectors.
Overall, the report reveals many areas of good quality PR treatment for COPD patients, including widespread provision of walking (95%), cycle (70%) and aerobic and resistance exercise therapy (89%). However, not all patients are being provided with an on-going individual exercise plan.
There remain significant variations in waiting times and quality of care when patients attend PR, and unacceptably long waits for treatment are more common when PR is given as part of a group because patients have to wait until the start of the next scheduled programme.
The report highlights the need for greater awareness of the benefits of PR in primary and secondary care. It also urges commissioners and providers to ensure that all patients receive an offer to start PR treatment within the recommended 3 months following their referral.
The key findings and recommendations are set against BTS quality standards for PR. The full COPD PR audit report can be found at: www.rcplondon.ac.uk/COPD
Other key findings
- There is widespread provision of walking (95%), cycle (70%) and aerobic and resistance exercise training (89%).
- Most patients (74%) were provided with a written, on-going individualised exercise plan following discharge. However, this means that almost one-third (26%) of patients who attend a discharge assessment are not given an individualised plan.
- Significant numbers of patients who attend a PR assessment do not complete the treatment (40%).
- Patients that do complete PR, on average, show substantial improvements in quality of life and ability to exercise.
- Patients with a full range of self-reported exercise limitation were assessed and enrolled to PR. However, only 9% of patients who have the most severe disability were enrolled to PR.
Main recommendations for PR commissioners and providers
- Commissioners and providers should ensure that robust referral pathways for PR are in place and that PR programmes have sufficient capacity to assess and enrol all patients within 3 months of referral.
- PR programmes should examine their processes and ensure that they are performing exercise outcome measures to accepted standards, including exercise tests, where it is recommended.
- Referrers and patients should be provided with up-to-date and clear written information about the benefits of attending and completing PR.
- Programmes should ensure that they offer a sufficiently flexible service to encourage patients who are referred to PR to attend and complete the treatment (for example, flexibility about times and days of PR sessions and the availability of transport for patients who find travelling difficult).
Patients and commissioners can now begin to use these results in a practical way to understand the quality of their local services.
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 milestone PR clinical report and other PR audit reports will widen access to PR services and in turn, improve care for people with COPD. The enthusiasm with which the PR programmes have participated in the audit suggest the UK PR community is well placed to achieve this.
Dr Lisa Davies, chair of the British Thoracic Society, said:
The audit is an important step to really understanding the extent 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. However, we hope and expect that action will be taken to increase referral rates of eligible patients and it will be crucial that PR services are sufficiently resourced to meet this demand, whilst individual waits for treatment are acceptable and in line with BTS standards.
The National COPD Audit Programme is commissioned by the Healthcare Quality Improvement Partnership (HQIP) as part of the National Clinical Audit and Patient Outcomes Programme (NCAPOP). The National COPD Audit Programme is led by the Royal College of Physicians (RCP), working closely with stakeholders, including the British Thoracic Society (BTS), the Primary Care Respiratory Society UK (PCRS-UK), the British Lung Foundation (BLF) and the Royal College of General Practitioners (RCGP).
British Lung Foundation Response to Audit
Mike McKevitt, Head of Patient Services, the British Lung Foundation said:
Pulmonary rehabilitation is a very cost-effective way of enhancing the health and quality of life of people living with COPD. However, this vital report shows that too many patients are either not completing the course, or not getting the referral they need in the first place.
With over a million people living with diagnosed COPD in this country, it is of vital importance that the findings of this audit are acted on. We urgently need to make PR more consistently available throughout the country, to work with doctors to improve referral rates, and to support more patients to complete their course.