## National Asthma And Chronic Obstructive Pulmonary Disease Audit Programme (Nacap) Pulmonary Rehabilitation Clinical Audit 2019

Clinical audit of pulmonary rehabilitation services in England, Scotland and Wales. Patients assessed between 1 March and 
31 May and discharged by 31 August 2019. 

## Clinical Audit Interim Report

Published July 2020
In association with:
Commissioned by:
The Royal College of Physicians The Royal College of Physicians (RCP) plays a leading role in the delivery of high‐quality patient care by setting standards of medical practice and promoting clinical excellence. The RCP provides physicians in over 30 medical specialties with education, training and support throughout their careers. As an independent charity representing over 38,000 fellows and members worldwide, the RCP advises and works with government, patients, allied healthcare professionals and the public to improve health and healthcare. Healthcare Quality Improvement Partnership The National Asthma and Chronic Obstructive Pulmonary Disease (COPD) Audit Programme (NACAP) is commissioned by the Healthcare Quality Improvement Partnership (HQIP) as part of the National Clinical Audit (NCA) Programme. HQIP is led by a consortium of the Academy of Medical Royal Colleges, the Royal College of Nursing and National Voices. Its aim is to promote quality improvement, and in particular, to increase the impact that clinical audit, outcome review programmes and registries have on healthcare quality in England and Wales. HQIP holds the contract to commission, manage and develop the National Clinical Audit and Patient Outcomes Programme (NCAPOP), comprising around 40 projects covering care provided to people with a wide range of medical, surgical and mental health conditions. The programme is funded by NHS England, the Welsh government and, with some individual projects, other devolved administrations and crown dependencies. To find out more about the HQIP visit: **www.hqip.org.uk/national-programmes**. National Asthma and Chronic Obstructive Pulmonary Disease (COPD) Audit Programme NACAP is a programme of work that aims to improve the quality of care, services and clinical outcomes for patients with asthma and COPD in England, Scotland and Wales. Spanning the entire patient care pathway, NACAP includes strong collaboration with asthma and COPD patients, as well as healthcare professionals, and aspires to set out a vision for a service which puts patient needs first. To find out more about the NACAP visit: www.rcplondon.ac.uk/nacap. Pulmonary rehabilitation: 2019 interim audit report This report was prepared by the following people, on behalf of the COPD advisory group (the full list of members can be found on the NACAP resources page here): **www.rcplondon.ac.uk/nacap-resources**. Prof Sally Singh, pulmonary rehabilitation clinical lead, NACAP, Care Quality Improvement Department (CQID), RCP, London; and head of pulmonary/cardiac rehabilitation and consultant clinical scientist, University of Leicester Mr Matt Legg, programme manager, NACAP, CQID, RCP Ms Neena Garnavos, project manager, NACAP, CQID, RCP Ms Kirsty Maclean-Steel, NACAP deputy programme manager, CQID, RCP Ms Rachael Andrews, NACAP deputy programme manager, CQID, RCP Ms Natasha Long, NACAP programme coordinator, CQID, RCP Mr Philip Stone, research assistant in statistics/epidemiology, National Heart & Lung Institute, Imperial College London Mr Alex Adamson, research assistant in medical statistics, National Heart & Lung Institute, Imperial College London Dr Jennifer Quint, reader in respiratory epidemiology, National Heart & Lung Institute, Imperial College London; honorary respiratory consultant, Royal Brompton and Imperial NHS Trusts Professor C Michael Roberts, senior clinical lead, NACAP, CQID, RCP, London; programme clinical lead, National COPD Audit Programme; and clinical academic lead for population health, UCLPartners. 

 
Citation for this document: Singh S, Legg M, Garnavos N, Maclean-Steel K, Andrews R, Long N, Stone P, Adamson A, Quint J, Roberts CM. National Asthma and Chronic Obstructive Pulmonary Disease Audit Programme (NACAP). Pulmonary rehabilitation clinical audit 2019. Clinical audit of pulmonary rehabilitation services in England, Scotland and Wales. Patients assessed between 1 March and 31 May and discharged by 31 August 2019. Interim report. London: RCP, 2020. 

## Copyright

 Royal College of Physicians Care Quality Improvement Department 11 St Andrews Place, Regent's Park, London NW1 4LE Registered charity no 210508 www.rcplondon.ac.uk/nacap @NACAPaudit #PRAudit #pulmrehab 

## Contents

|                                                                                    | How to use this report 5   |     |
|------------------------------------------------------------------------------------|----------------------------|-----|
| Foreword by Sally Singh, pulmonary rehabilitation audit clinical lead              | 7                          |     |
| Recommendations 8                                                                  |                            |     |
| Section 1:  Audit participation 9                                                  |                            |     |
| Section 2:  General information                                                    | 10                         |     |
| Section 3:  Programme referral 12                                                  |                            |     |
| Section 4:  Key clinical information at time of assessment 16                      |                            |     |
| Section 5:  Assessment tests and questionnaires 21                                 |                            |     |
| Section 6: Key information relating to the programme                               | 25                         |     |
| Section 7: Key information at discharge 28                                         |                            |     |
| Section 8: Discharge tests 33                                                      |                            |     |
| Section 9: Benchmarked key indicators 40                                           |                            |     |
| Appendix A: Methodology 85                                                         |                            |     |
| Appendix B: Definitions 89                                                         |                            |     |
| Appendix C: BTS Quality Standards for Pulmonary Rehabilitation in Adults (2014) 90 |                            |     |
| References 91                                                                      |                            |     |

## Report At A Glance Waiting Times For Pulmonary Rehabilitation (Pr) Practice Walk Tests Discharge Assessment / Completion Of Pr

of **patients assessed** between 1 March and 31 May 2019, subsequently enrolled and then discharged by 31 August 2019, had a discharge assessment. 

## Outcomes Of Pr How To Use This Report 1. Scope And Data Collection

This report presents the results from an analysis of data derived from the pulmonary rehabilitation (PR) clinical audit component of the National Asthma and COPD Audit Programme (NACAP). This continuous audit captures the process of treatment in patients who are treated by PR services in England, Scotland and Wales for chronic obstructive pulmonary disease (COPD). The continuous audit was launched in March 2019. This report, which is the first to use continuous data collection, presents data for patients that were assessed between 1 March and 31 May 2019 and discharged by 31 August 2019. The data represent over 6,000 patients assessed for PR within a 3-month time period and includes patients who: 

 completed an initial assessment but were not enrolled on a PR programme, or  enrolled and completed the PR programme by 31 August 2019, or  enrolled but were known to have dropped out of their PR programme. 
This audit works under a consent model, so only data from patients who consented to be part of the audit have been reported. Individuals who were assessed between 1 March and 31 May 2019, but who had not completed the PR programme before 31 August 2019 were excluded. The most likely reason that individuals would not have completed their PR programme before 31 August was because of delays between assessment and commencing PR. As such, this report may not reflect as accurately the current status of PR services against key metrics, as a longer data capture period may have allowed, ie by incorporating data from patients with higher than expected waiting times. In future PR audit reports, a longer data capture period will be applied to better represent the status of services. The data provide information about the delivery of rehabilitation and on the quality improvement (QI) targets for PR services.  
Contributing to the overarching national QI objectives of NACAP, this report aims to empower stakeholders to use audit data to facilitate improvements in the quality of care.  

## 2. Report Structure

The data are presented largely in tabular form with explanatory notes where appropriate. These data will also be made publicly available at PR service level on **www.data.gov.uk**, in line with the government's transparency agenda. Details of the statistical, data collection and information governance methodologies employed are provided in **Appendix A**. Nationally benchmarked results for participating services across England, Scotland and Wales have been provided in Section 9 of this report. The median values for each service are presented alongside the national medians for each indicator. The indicators have been selected based on national guidelines and standards. The service results for each indicator are colour coded in accordance with whether the service falls above, within the middle two, or below the lower quartile. Details of the methodology employed are also provided (**Appendix A**). 

## 3. Report Coverage

National breakdowns are given for England, Scotland and Wales, as well as 'All' figures.  
NACAP follows rules on suppression of small numbers in national reporting where it may be possible to identify an individual patient in any data presented. In this report, it was deemed appropriate and safe to include small numbers in national data tables without suppression for the following reasons: 

 These data are presented at national aggregate level. It is not possible to combine this national 
aggregate data in any way which could identify an individual. 
 These data are of a sample of the eligible patients that could have been included in the audit; it 
is not possible to ascertain which eligible patients were included, and which were not, in the data presented here. 

## 4. Audience And Links To Relevant Guidelines And Standards

The report is intended to be read by healthcare professionals; NHS managers, chief executives and board members, as well as service commissioners; policymakers; and voluntary organisations. A separate report has been produced for patients and the public and is available at: www.rcplondon.ac.uk/nacap-PR-interim. References to the appropriate British Thoracic Society (BTS) Quality Standards (**Appendix C**) are provided at the beginning of each section. Copies of our dataset, our good practice repository, and all other resources can be found via our website: **www.rcplondon.ac.uk/nacap-pr-resources**. 

# Foreword By Sally Singh, Pulmonary Rehabilitation Audit Clinical Lead

Welcome to the first report of the National Asthma and Chronic Obstructive Pulmonary Disease (COPD) Audit Programme (NACAP) pulmonary rehabilitation (PR) continuous clinical audit. This report describes data entered for over 6,000 patients assessed for PR within a 3-month period (1 March - 31 May 2019) and discharged by 31 August 2019. The data provide an insight into the processes of PR, the clinically important outcomes and the characteristics of populations most likely to complete a discharge assessment. The clinical outcomes for those completing a programme of PR are positive, with the majority of patients achieving important gains in exercise capacity and/or health status. The data also describe the characteristics associated with achieving the minimal clinically important difference (MCID) for a walking test and a health status measure. The audit data explored the impact of deprivation on uptake and outcomes, and it appears that those living within the least deprived areas of England, Scotland and Wales were more likely to attend their discharge assessment (odds ratio (OR) = 1.86 (95% confidence interval (CI) = 1.49–2.33)) compared with those within the most deprived areas. This inequality is a challenge that PR services must acknowledge and strive to even out. The audit data identify areas for improvement. There are still delays in patients accessing PR in a timely manner, with only 58.0% of patients starting a PR programme within the 90-day (from receipt of referral) target. Access to rehabilitation for the potentially sicker post-hospitalisation population is also poor. The report shows that just 383 (6.3%) patients assessed for PR were those referred after admission for an acute exacerbation of COPD. This suggests that either the offer of PR is not being made by teams in secondary care at the time of discharge or the offer is not being taken up by patients. We must endeavour to improve the rate of referrals to PR services and to ensure patients and clinical colleagues understand the benefits. Of course, this report would not be possible without the participation of the PR services across England, Scotland and Wales. We are delighted at the high level of participation (90.1% of PR 
services across England, Scotland and Wales) and we would like to thank services for their support of the audit and dedication to improving patient care. We hope this data will provide valuable insight into the provision and outcomes of rehabilitation and support services to continue to improve the standard of the PR programmes offered to patients. This report will be followed be a combined clinical and organisational audit report in late 2020.  

## Recommendations National

Services, providers and patient charities should work together to increase uptake of PR in patients with chronic obstructive pulmonary disease (COPD) after hospitalisation for an acute exacerbation of COPD. 

## For Providers Of Pulmonary Rehabilitation Services

This report outlines three key QI priorities for providers of PR. They were chosen because of the strong evidence base for their effectiveness in improving patient care and outcomes. National QI priority 1: Services should endeavour to enrol 85% of those referred for PR within 90 days 
(*BTS quality standards for pulmonary rehabilitation in adults (2014). Standard 1b*).1 

1 National QI priority 2: Services should ensure all exercise assessments are performed to accepted technical standards, including ensuring all patients undertake a practice exercise test at their initial PR 
assessment (*BTS quality standards for pulmonary rehabilitation in adults (2014). Standards 8 and 9*).1 
2 
 
3 
National QI priority 3: Ensure 70% of patients enrolled for PR go on to complete the programme and have a discharge assessment (BTS quality standards for pulmonary rehabilitation in adults (2014). Standard 
4).1  

## For Commissioners / Health Boards / Sustainability And Transformation Partnerships / Integrated Care Systems

1 
Services should work with commissioners to ensure that patients are seen in a timely manner (quality improvement (QI) priority: starting pulmonary rehabilitation (PR) within 90 days of receipt of referral)  
2 
(*BTS quality standards for pulmonary rehabilitation in adults (2014). Standard 1b*).1 Ensure that your local PR services are participating in the National Asthma and COPD Audit Programme (NACAP) PR audit.  
1 
 
2 
Ensure that all staff are adequately trained and aware of national and, where relevant, international 
guidance, ie *BTS quality standards for pulmonary rehabilitation in adults (2014)*.1 

## For Providers Of Primary And Secondary Copd Care

1 
Ensure that all eligible patients are offered a referral for PR (BTS quality standards for pulmonary 
rehabilitation in adults (2014). Standard 1).1 
2 
 
3 
Ensure that all staff working with patients with COPD are aware of the benefits of PR. 

## For People Living With Copd And Their Families And Carers

1 
When you visit your GP / practice nurse, make sure that you ask for information on pulmonary rehabilitation (PR) and discuss whether a referral to your local PR service maybe beneficial to you (BTS 
quality standards for pulmonary rehabilitation in adults (2014). Standard 1).1 
2 
 
3 
If you are admitted to hospital with a worsening of your chronic obstructive pulmonary disease (COPD), make sure arrangements are made to refer you to your local PR service (BTS quality standards for 
pulmonary rehabilitation in adults (2014). Standard 3).1 
 

## Section 1: Audit Participation Back To Contents

Key findings 
 A high proportion (90.1%) of services are participating in the PR continuous clinical audit. 
 Very few services either did not register (4.0%) or registered but did not submit any data 
(7.5%). 

## 1.1 Audit Participation

| Total         | Number of PR          | Audit               |
|---------------|-----------------------|---------------------|
| participation | number of             | services registered |
| PR services   | to participate in the |                     |
| identified    | audit                 |                     |
| England       | 194                   | 191 (98.5%)         |
| Scotland      | 18                    | 11 (61.1%)          |
| Wales         | 11                    | 11 (100%)           |
| All           | 223                   | 213 (95.5%)         |
| Number of PR         | Number of      |
|----------------------|----------------|
| services registered  | services       |
| participating in the | identified but |
| audit                | not registered |

## Section 2: General Information Back To Contents

Key findings 
 The median age at referral was 70 years (interquartile range (IQR) 64–76).  The proportion of males (51.7%) and females (48.2%) being assessed was similar.  In total, 6,056 patients were assessed for PR between 1 March and 31 May 2019 and 
discharged by 31 August 2019. 
 Patients within the most deprived areas (quintile 1) in England (25.9%) represented a higher 
proportion of those assessed for PR. However, patients in quintile 2 represented the higher proportions of those assessed for PR in Scotland (24.3%) and Wales (28.1%). 
This section contains the following tables and graphs. If you are viewing this report on a computer, you can select the table that you wish to see from the list below. 

 2.1 Age  2.2 Gender  2.3 Socioeconomic status 
− 
2.3.1 Index of Multiple Deprivation measures by national quintile in England, Scotland and Wales 

## 2.1 Age

|                           | 2019       |            |
|---------------------------|------------|------------|
| Scotland                  | Wales      | All        |
| Age at assessment (years) |            |            |
| England                   |            |            |
| (n=5,710)                 | (n=184)    | (n=162)    |
| Median (IQR*)             | 71 (64–76) | 67 (62–74) |

* Interquartile range 

## 2.2 Gender

|                                     | 2019          |             |
|-------------------------------------|---------------|-------------|
| Gender                              |               |             |
| England                             |               |             |
| (n=5,710)                           |               |             |
| Male                                | 2,967 (52.0%) | 80 (43.5%)  |
| Female                              | 2,737 (47.9%) | 104 (56.5%) |
| Transgender                         | 1 (0%)        | 0 (0.0%)    |
| Other*                              | 2 (0%)        | 0 (0.0%)    |
| Not recorded / preferred not to say | 3 (0.1%)      | 0 (0.0%)    |

## 2.3 Socioeconomic Status 2.3.1 Index Of Multiple Deprivation Measures By National Quintile In England, Scotland And Wales

 
 
% of audit sample living in each quintile of English, Scottish or Welsh Index of Multiple Deprivation 2019 
Q1 (most 
Index of Multiple Deprivation 
deprived) 
Q2 
Q3 
Q4 
Q5 (least 
2019 
1,459 
1,138 
England (IMD*) 
(n=5,634) 
(25.9%) 
(20.2%) 
2019 
42  
Scotland (SIMD**) 
(n=181) 
(23.2%) 
(24.3%) 
2019 
33  
Wales (WIMD***) 
(n=160) 
(20.6%) 
(28.1%) 

Indices of multiple deprivation are not directly comparable between countries.a 
***Index of Multiple Deprivation, England** ** **Scottish Index of Multiple Deprivation** *** **Welsh Index of Multiple Deprivation** 
 

| Scotland    | Wales    | All       |
|-------------|----------|-----------|
| (n=184)     | (n=162)  | (n=6,056) |
| deprived)   |          |           |
| 1,116       | 1,040    | 881       |
| (19.8%)     | (18.5%)  | (15.6%)   |
| 44          | 32       | 36        |
| (17.7%)     | (19.9%)  | (14.9%)   |
| 45          | 32       | 23        |
| (20.0%)     | (14.4%)  | (16.9%)   |

## Section 3: Programme Referral Back To Contents

Key standards BTS quality standards for pulmonary rehabilitation in adults (2014) [Standard 1b]: 1 Referral for PR: b. If accepted, people referred for PR are enrolled to commence within 3 months of receipt of referral. 

BTS quality standards for pulmonary rehabilitation in adults (2014) [Standard 3b]: 1 Referral for PR after hospitalisation for acute exacerbations of COPD: b. People referred for PR following admission with AECOPD are enrolled within 1 month of leaving hospital. 

NICE 2016 QS10 [QS5], statement 5:2 People admitted to hospital for an acute exacerbation of COPD start a PR programme within 4 weeks of discharge. 

Key findings 
 Overall, the highest proportion of patients (64.9%) were referred from primary care or the 
community with stable COPD. 
 A small proportion of patients (6.3%) were referred after admission to hospital for an acute 
exacerbation of COPD (AECOPD). 
 Overall, 58.0% of patients with stable COPD commenced PR within 90 days of receipt of 
referral. Waiting times were longest in Wales (median 136 days). 
 17.3% of patients referred after admission to hospital for AECOPD started PR within 30 days  
of referral. 
This section contains the following tables and graphs. If you are viewing this report on a computer, you can select the table that you wish to see from the list below. 

##  3.1 Source Of Patient Referral  3.2 Waiting Times

− 3.2.1 Length of time from receipt of referral to the start date for PR − 3.2.2 Did people with stable COPD start PR within 90 days of referral? − 3.2.3 Length of time from initial assessment to start date for PR − 3.2.4 Did patients with AECOPD start PR within 30 days of referral? 
 

## 3.1 Source Of Patient Referral

|                                             |
|---------------------------------------------|
| Patients referred from                      |
| England                                     |
| Primary/community - stable COPD*            |
| 3,741                                       |
| Secondary care - stable COPD                |
| 1,280                                       |
| Primary/community - after treatment for     |
| AECOPD**                                    |
| Secondary care - after admission for AECOPD |
| 363                                         |
| Self-referral                               |
| 87                                          |

 * Chronic obstructive pulmonary disease (COPD) **'Primary/community - after treatment for acute exacerbation of COPD (AECOPD)' - includes referrals for patients treated at home or in a community location for AECOPD, this includes referrals from primary care after AECOPD 
* Chronic obstructive pulmonary disease (COPD) **'Primary/community - after treatment for acute exacerbation of COPD (AECOPD)' - includes referrals for patients treated at home or in a community location for AECOPD, this includes referrals from primary care after AECOPD 
 

|           | Scotland    | Wales    | All       |
|-----------|-------------|----------|-----------|
| (n=5,710) | (n=184)     | (n=162)  | (n=6,056) |
| 116       | 76          | 3,933    |           |
| (65.5%)   | (63.0%)     | (46.9%)  | (64.9%)   |
| 35        | 81          | 1,396    |           |
| (22.4%)   | (19.0%)     | (50.0%)  | (23.1%)   |
| 239       | 10          | 1        | 250       |
| (4.2%)    | (5.4%)      | (0.6%)   | (4.1%)    |
| 16        | 4           | 383      |           |
| (6.4%)    | (8.7%)      | (2.5%)   | (6.3%)    |
| 7         | 0           | 94       |           |
| (1.5%)    | (3.8%)      | (0.0%)   | (1.6%)    |

## 3.2 Waiting Times 3.2.1 Length Of Time From Receipt Of Referral To Start Date For Pr

| England                              | Scotland    | Wales       | All          | Time from referral to start date for PR    |
|--------------------------------------|-------------|-------------|--------------|--------------------------------------------|
| (days) for patients with stable COPD | (n=4,525)   | (n=139)     | (n=153)      | (n=4,817)                                  |
| Median (IQR*)                        | 77 (49–117) | 84 (63–132) | 134 (71–236) | 78 (49–119)                                |

*Interquartile range 
 

Scotland 
Wales 
PR started within 90 days  
England 
(n=4,525) 
(n=139) 
(n=153) 
(n=4,817) 
Yes 
2,667 (58.9%) 
74 (53.2%) 
51 (33.3%) 
2,792 (58.0%) 

*Denominator for Fig 3.2 is all those patients who started pulmonary rehabilitation 

## 3.2.3 Length Of Time From Initial Assessment To Start Date For Pr

|                                         | 2019                                   |          |
|-----------------------------------------|----------------------------------------|----------|
| England                                 | Days from assessment to start date for |          |
| PR (days) for patients with stable COPD | (n=4, 585)                             |          |
| Median (IQR*)                           | 14 (7–27)                              | 9 (7–16) |

*Interquartile range 3.2.4 Did people with AECOPD start PR within 30 days of referral? 

|                                     | 2019       |        |
|-------------------------------------|------------|--------|
| PR started with 30 days of referral |            |        |
| England                             |            |        |
| (n=537)                             |            |        |
| Yes                                 | 96 (17.9%) | 2 (8%) |

## 1 National Qi Priority: Ensure 85% Of Patients Referred For Pr Start It Within 90 Days Of Receipt Of Referral (Bts Quality Standards For Pulmonary Rehabilitation In Adults (2014). Standard 1B).1

Rationale The British Thoracic Society (BTS) quality standard for pulmonary rehabilitation (PR) in adults (2014) 1b states that people with stable chronic obstructive pulmonary disease (COPD) who are referred for PR should start it within 3 months of receipt of referral. This audit reported 58.0% of patients with stable COPD started PR within 90 days of receipt of referral. Longer waiting times for PR have been linked with an increased risk of admission to hospital.3 
Therefore ensuring patients start PR within 90 days is of the utmost importance. 

| Scotland    | Wales    | All       |
|-------------|----------|-----------|
| (n=145)     | (n=155)  | (n=4,885) |
| Scotland    | Wales    | All       |
| (n=25)      | (n=5)    | (n=567)   |

Tips to achieve this priority 
 Incorporate a process of monitoring the 
data to check waiting times. 
 Have a list of patients willing to attend at 
short notice if there is a cancellation. 
 Ensure there is capacity in the class to 
reduce wait times into rehabilitation after assessment (rolling vs cohort programmes). 

## Section 4: Key Clinical Information At Time Of Assessment Back To Contents

Key standards: 
NICE 2013 QS43 [QS1]:4 People are asked if they smoke by their healthcare practitioner, and those who smoke are offered advice on how to stop.  
BTS quality standards for pulmonary rehabilitation in adults (2014) [Standard 5]: 1 Pulmonary rehabilitation programmes include supervised, individually tailored and prescribed progressive exercise training, including both aerobic and resistance training. 

BTS quality standards for pulmonary rehabilitation in adults (2014) [Standard 8]: 1 People attending pulmonary rehabilitation have the outcome of treatment assessed using as a minimum, measures of exercise capacity, dyspnoea and health status. 

BTS quality standards for pulmonary rehabilitation in adults (2014) [Standard 1a]: 1 Referral for PR: a. People with COPD and self-reported exercise limitation (MRC dyspnoea 3–5) are offered PR. 

BTS quality standards for pulmonary rehabilitation in adults (2014) [Standard 2]: 1 PR 
programmes accept and enrol patients with functional limitation due to other chronic respiratory diseases (for example bronchiectasis, interstitial lung disease (ILD) and asthma) or COPD MRC dyspnoea 2 if referred. 

Key findings 
Of patients assessed for PR: 
 A large proportion were either ex-smokers (70.0%) or current smokers (20.7%).  The majority had either a Medical Research Council (MRC) score 3 (35.5%) or 4 
(31.5%). 
 52.4% had a measure of FEV1/FVC ratio and 63.1% had a measure of FEV1. 
 35.6% had a history of cardiovascular disease and 35.9% a history of lower limb or  
lower back musculoskeletal disorders. 
 18.6% had a history of mental illness. 
This section contains the following tables and graphs. If you are viewing this report on a computer, you can select the table that you wish to see from the list below.  

 4.1 Smoking status  4.2 Spirometry  4.3 Patient's body mass index (BMI)  4.4 What was the patient reported Medical Research Council (MRC) score at assessment?  4.5 Physical comorbidities  4.6 Mental health comorbidities 
− 4.6.1 Type of mental illness recorded 

## 4.1 Smoking Status

Smoking status 
England 
(n=5,710) 
Never smoked 
312 (5.5%) 
8 (4.3%) 
7 (4.3%) 
327 (5.4%) 
Ex-smoker 
4,009 (70.2%) 
115 (62.5%) 
115 (71.0%) 
4,239 (70.0%) 
Current smoker 
1,177 (20.6%) 
49 (26.6%) 
30 (18.5%) 
1,256 (20.7%) 
Ex-smoker and current vaper 
96 (1.7%) 
10 (5.4%) 
8 (4.9%) 
114 (1.9%) 
Never smoked and current vaper 
4 (0.1%)  
0 (0.0%) 
0 (0.0%) 
4 (0.1%) 
Not recorded 
112 (2.0%) 
2 (1.1%) 
2 (1.2) 
116 (1.9%) 

 
* Due to the small numbers 'Never smoked and current vaper' has not been included in this figure. 

| Scotland    | Wales     | All       |
|-------------|-----------|-----------|
| (n=184)     | (n=162)   | (n=6,056) |

## 4.2 Spirometry

|                           | 2019             |
|---------------------------|------------------|
| Spirometry                |                  |
| Number of patients with a |                  |
| FEV1% predicted           |                  |
| England (n=5,710)         |                  |
| 3,601 (63.1%)             | 56 (41–70)       |
| Scotland (n=184)          |                  |
| 40 (21.7%)                | 54 (46–65)       |
| Wales (n=162)             |                  |
| 117 (72.2%)               | 51 (38–65)       |
| All (n=6,056)             |                  |
| 3,758 (62.1%)             | 55 (41–70)       |
| FEV1/FCV ratio            |                  |
| England (n=5,710)         |                  |
| 2,990 (52.4%)             | 0.56 (0.44–0.67) |
| Scotland (n=184)          |                  |
| 19 (10.3%)                | 0.59 (0.42–0.69) |
| Wales (n=162)             |                  |
| 103 (63.6%)               | 0.53 (0.43–0.63) |
| All (n=6,056)             |                  |
| 3,112 (51.4%)             | 0.56 (0.44–0.67) |

* Interquartile range  
 
4.3 Patient's body mass index (BMI) 

|               | 2019                               |
|---------------|------------------------------------|
| BMI           |                                    |
| England       |                                    |
| (n=5,710)     |                                    |
| 3,748         | Number of patients with a recorded |
| value         | (65.6%)                            |
| Median (IQR*) |                                    |
| 27.3          |                                    |
| (23.4–31.9)   |                                    |

* Interquartile range 

recorded value  
Median (IQR*) value 
Scotland 
Wales 
All 
(n=184) 
(n=162) 
(n=6,056) 
52  
108  
3,908  
(28.3%) 
(66.7%) 
(64.5%) 
28.0  
28.0  
27.3  
(23.1–33.0) 
(23.5–33.1) 
(23.4–32.0) 

## 4.4 What Was The Patient-Reported Medical Research Council (Mrc) Score At Assessment?

MRC score * 
England 
(n=5,710) 
Grade 1 
112 (2.0%) 
3 (1.6%) 
1 (0.6%) 
116 (1.9%) 
Grade 2 
946 (16.6%) 
30 (16.3%) 
22 (13.6%) 
998 (16.5%) 
Grade 3 
2,046 (35.8%) 
66 (35.9%) 
35 (21.6%) 
2,147 (35.5%) 
Grade 4 
1,772 (31.0%) 
69 (37.5%) 
67 (41.4%) 
1,908 (31.5%) 
Grade 5 
483 (8.5%) 
9 (4.9%) 
32 (19.8%) 
524 (8.7%) 
Not recorded 
351 (6.1%) 
7 (3.8%) 
5 (3.1%) 
363 (6.0%) 

* Grade 1 - not troubled by breathlessness or strenuous exercise Grade 2 - short of breath when hurrying or walking up a slight hill Grade 3 - walks slower than contemporaries on level ground because of breathlessness or has to stop for breath Grade 4 - stops to breathe after walking 100 metres (109 yards) or after a few minutes walking on level ground Grade 5 - too breathless to leave the house or breathless when dressing or undressing

2019 
Scotland 
Wales 
All 
(n=184) 
(n=162) 
(n=6,056) 

## 4.5 Physical Comorbidities

|                            | 2019                              |
|----------------------------|-----------------------------------|
| England                    | Was a history of physical illness |
| recorded for this patient? | (n=5,710)                         |
| Cardiovascular disease*    |                                   |
| 2,053                      |                                   |
| (36.0%)                    |                                   |
| 2,014                      | Lower limb or lower back          |
| musculoskeletal disorder** | (35.3%)                           |

* Including but not limited to, angina, atrial fibrillation, myocardial infarction, stroke, peripheral vascular disease or heart failure ** Including but not limited to, osteoarthritis in the knee, hip or ankle, or lower back pain 

## 4.6 Mental Health Comorbidities

|                                    | 2019          |            |
|------------------------------------|---------------|------------|
| History of mental illness recorded | England       |            |
| (n=5,710)                          |               |            |
| Mental illness                     | 1,041 (18.2%) | 38 (20.7%) |

## 4.6.1 Type Of Mental Illness Recorded

|                                 | 2019        |            |
|---------------------------------|-------------|------------|
| Type of mental illness recorded |             |            |
| England                         |             |            |
| (n=1,041)                       |             |            |
| Anxiety                         | 617 (59.3%) | 22 (57.9%) |
| Depression                      | 734 (70.5%) | 31 (81.6%) |
| Severe mental illness*          | 92 (8.8%)   | 3 (7.9%)   |

* Severe mental illness includes clinically diagnosed psychosis; schizophrenia-spectrum disorders, including schizophrenia schizoaffective disorder; severe mood disorders, including bipolar disorder; personality disorders; and behavioural disorders, including eating, sleep or 

| Scotland    | Wales    | All       |
|-------------|----------|-----------|
| (n=184)     | (n=162)  | (n=6,056) |
| 51          | 54       | 2,158     |
| (27.7%)     | (33.3%)  | (35.6%)   |
| 90          | 68       | 2,172     |
| (48.9%)     | (42.0%)  | (35.9%)   |
| Scotland    | Wales    | All       |
| (n=184)     | (n=162)  | (n=6,056) |
| Scotland    | Wales    | All       |
| (n=38)      | (n=50)   | (n=1,129) |

## Section 5: Assessment Tests And Questionnaires Back To Contents

Key standards BTS quality standards for pulmonary rehabilitation in adults (2014) [Standard 8]: 1 People attending PR have the outcome of treatment assessed using as a minimum, measures of exercise capacity, dyspnoea and health status. 

BTS quality standards for pulmonary rehabilitation in adults (2014) [Standard 9]: 1 PR 
programmes conduct an annual audit of individual outcomes and progress. 

Technical standard: field walking tests in chronic respiratory disease5 

Key findings 
Of patients assessed for PR: 
 92.3% completed an incremental shuttle walk test (ISWT) or a 6-minute walk test (6MWT); 
7.7% of patients completed neither test.  
 52.0% of those completing an ISWT and 30.2% of those completing a 6MWT test performed a 
practice walk test at assessment. 
This section contains the following tables and graphs. If you are viewing this report on a computer, you can select the table that you wish to see from the list below. 

 
5.1 Walk tests  
− 
5.1.1 Walk tests recorded at initial assessment 
− 
5.1.2 Walk test values at initial assessment 
 
5.2 Health status questionnaires  
− 
5.2.1 Health status questionnaires recorded at initial assessment 
− 
5.2.2 COPD assessment test (CAT) values at initial assessment  
− 
5.2.3 Chronic respiratory questionnaire (CRQ) values at initial assessment 
 

## 5.1 Walk Tests 5.1.1 Walk Tests Recorded At Initial Assessment

|                                      | 2019                               |
|--------------------------------------|------------------------------------|
| Test recorded at initial assessment  |                                    |
| England                              |                                    |
| (n=5,710)                            |                                    |
| Incremental shuttle walk test (ISWT) |                                    |
| 2,333                                |                                    |
| (40.9%)                              |                                    |
| 6-minute walk test (6MWT)            |                                    |
| 2,399                                |                                    |
| (42.0%)                              |                                    |
| 526                                  | ISWT + endurance shuttle walk test |
| (ESWT)*                              | (9.2%)                             |
| Neither ISWT or 6MWT**               |                                    |
| 452                                  |                                    |
| (7.9%)                               |                                    |

*99.5% of those who did both tests did the ISWT **Two people who did neither the ISWT or the 6MWT did however do the endurance test 

## 5.1.2 Walk Test Values At Initial Assessment

|                      | 2019                   |               |
|----------------------|------------------------|---------------|
| England              | Walking test values at |               |
| assessment (metres)  | (n=2,856)              |               |
| ISWT                 |                        |               |
| Median (IQR*)        | 200 (120–280)          | 185 (103–298) |
| Practice walk test   |                        |               |
| completed            |                        |               |
| 1,543 (54%)          | 0 (0.0%)               | 3 (11.5%)     |
|                      |                        |               |
| England              |                        |               |
| (n=2,402)            |                        |               |
| 6MWT                 |                        |               |
| Median (IQR*)        | 250 (168–330)          | 200 (140–280) |
| Practice walk test   |                        |               |
| completed            |                        |               |
| 733 (30.5%)          | 0 (0.0%)               | 59 (47.6%)    |
|                      |                        |               |
| England              |                        |               |
| (n=528)              |                        |               |
| ESWT                 |                        |               |
| Median (IQR)         | 225 (144–371)          | 135 (91–190)  |
| *Interquartile range |                        |               |
| Scotland    | Wales    | All       |
|-------------|----------|-----------|
| (n=184)     | (n=162)  | (n=6,056) |
| 59          | 26       | 2,418     |
| (32.1%)     | (16.0%)  | (39.9%)   |
| 99          | 124      | 2,622     |
| (53.8%)     | (76.5%)  | (43.3%)   |
| 23          | 0        | 549       |
| (12.5%)     | (0.0%)   | (9.1%)    |
| 3           | 12       | 467       |
| (1.6%)      | (7.4%)   | (7.7%)    |
| Scotland    | Wales    | All       |
| (n=82)      | (n=26)   | (n=2,964) |
| Scotland    | Wales    | All       |
| (n=99)      |          | (n=124)   |
| Scotland    | Wales    | All       |
| (n=23)      | (n=0)    | (n=551)   |

Rationale Accurate measurement of baseline is critical for exercise prescription and outcome assessment. However, only 52.0% of patients who performed an ISWT and 30.2% of patients who performed a 6MWT undertook a practice walk test. Ensuring that walk tests are conducted to recommended standards, including performing 
a practice walk test, will ensure: 
 assessments are reliable  exercise can be accurately prescribed  
 that outcome assessments following PR  
are unbiased.5 

## 5.2 Health Status Questionnaires

|                                         | 2019          |             |
|-----------------------------------------|---------------|-------------|
| Health status questionnaire completion  |               |             |
| England                                 |               |             |
| (n=5,710)                               |               |             |
| COPD assessment test (CAT)              | 4,089 (71.6%) | 102 (55.4%) |
| Chronic respiratory questionnaire (CRQ) | 2,031 (35.6%) | 45 (24.5%)  |

Tips to achieve this priority 
 Ensure adequate assessment time for 
patients to complete a practice walk test. 
 Ensure the order of tests and 
questionnaires allows adequate rest between walk tests. 
 Ensure patients understand the importance 
of the practice walk to optimise benefits of rehabilitation. 
 

| Scotland    | Wales     | All       |
|-------------|-----------|-----------|
| (n=184)     | (n=162)   | (n=6,056) |
COPD assessment test (CAT)* 
England 
(n=4,089) 
Median (IQR**) 
22 (16–27) 
24 (19–29) 
23 (17–30) 
22 (16–27) 

* COPD assessment test values: 0–40 ** Interquartile range 

Wales
|                                  | 2019          |               |
|----------------------------------|---------------|---------------|
| England                          | CRQ values at |               |
| assessment                       | (n=2,031)     |               |
| Dyspnoea average score (1.0–7.0) |               |               |
| Median (IQR*)                    | 2.6 (2.0–3.4) | 2.4 (2.0–3.0) |
| Fatigue average score (1.0–7.0)  |               |               |
| Median (IQR*)                    | 3.2 (2.2–4.2) | 3.2 (2.0–3.8) |
| Emotion average score (1.0–7.0)  |               |               |
| Median (IQR*)                    | 4.1 (3.2–5.3) | 4.1 (3.3–5.1) |
| Mastery average score (1.0–7.0)  |               |               |
| Median (IQR*)                    | 4.2 (3.2–5.5) | 4.2 (3.0–5.2) |
| Scotland    | Wales     | All       |
|-------------|-----------|-----------|
| (n=102)     | (n=144)   | (n=4,335) |
| Scotland    | Wales     | All       |
| (n=45)      | (n=30)    | (n=2,106) |

## Section 6 Key Information Relating To The Programme Back To Contents

Key findings 
 After the initial assessment 91.6% of patients were enrolled onto a PR programme.  The majority of PR programmes offered were centre-based (98.2%). 
 66.0% of PR programmes were rolling programmes. 
This section contains the following tables and graphs. If you are viewing this report on a computer, you can select the table that you wish to see from the list below. 

 6.1 Post assessment, was the patient enrolled onto a PR programme?  6.2 Where is the patient's PR programme located?  6.3 Type of centre-based PR  6.4 Total number of supervised centre-based PR sessions scheduled 
− 
6.4.1 Group and individual centre-based sessions 
 6.5 Number of supervised centre-based PR sessions received  6.6 Total number of home-based PR sessions scheduled 
− 
6.6.1 Method of home-based PR sessions 
 6.7 Number of home-based PR sessions received 
 

## 6.1 Post Assessment, Was The Patient Enrolled Onto A Pr Programme?

|                               |               |             | 2019        |                                  |
|-------------------------------|---------------|-------------|-------------|----------------------------------|
| England                       | Scotland      | Wales       | All         | Post-assessment, was the patient |
| enrolled onto a PR programme? | (n=5,710)     | (n=184)     | (n=162)     | (n=6,056)                        |
| Yes                           | 5,213 (91.3%) | 177 (96.2%) | 160 (98.8%) | 5,550 (91.6%)                    |
| No - clinically unsuitable    | 214 (3.7%)    | 3 (1.6%)    | 1 (0.6%)    | 218 (3.6%)                       |
| No - patient choice           | 283 (5.0%)    | 4 (2.2%)    | 1 (0.6%)    | 288 (4.8%)                       |

## 6.2 Where Is The Patient'S Pr Programme Located?

|                    | 2019          |              |
|--------------------|---------------|--------------|
| Scotland           | Wales         | All          |
| Programme location |               |              |
| England            |               |              |
| (n=5,213)          | (n=177)       | (n=160)      |
| Centre-based       | 5,114 (98.1%) | 177 (100.0%) |
| Home-based         | 71 (1.4%)     | 0 (0.0%)     |
| Both               | 28 (0.5%)     |              |
|                    |               |              |

## 6.3 Type Of Centre-Based Pr

|            | 2019                           |             |
|------------|--------------------------------|-------------|
| England    | If centre-based,* what type of |             |
| programme? |                                | (n=5,114)   |
| Rolling    | 3,352 (65.5%)                  | 156 (88.1%) |
| Cohort     | 1,762 (34.5%)                  | 21 (11.9%)  |

* Excludes patients who were enrolled in both centre-based and home-based programmes 

## 6.4 Total Number Of Supervised Centre-Based Pr Sessions Scheduled

|                     | 2019                          |            |
|---------------------|-------------------------------|------------|
| England             | Total number of supervised PR |            |
| sessions scheduled* |                               | (n=5,114)  |
| Median (IQR**)      | 12 (12–13)                    | 12 (12–14) |

* Excludes patients who were enrolled in both centre-based and home-based programmes ** Interquartile range 

## 6.4.1 Group And Individual Centre-Based Sessions

|                     | 2019                               |     |
|---------------------|------------------------------------|-----|
| England             | Group and individual centre-based  |     |
| sessions*           | (n=5,114)                          |     |
| 4,786               | Patients who received centre-based |     |
| group sessions      | (93.6%)                            |     |
| 485                 | Patients who received centre-based |     |
| individual sessions | (9.5%)                             |     |

*Some patients had group sessions and 1:1 sessions so numbers may add up to more than 100% 

## 6.5 Number Of Supervised Centre-Based Pr Sessions Received*

|                                   | 2019      |           |
|-----------------------------------|-----------|-----------|
| England                           |           |           |
| (n=5,114)                         |           |           |
| Number of supervised centre-based |           |           |
| PR sessions received              |           |           |
| Median (IQR*)                     |           |           |
| Group sessions**                  | 11 (7–12) | 12 (6–13) |
| 1:1 sessions***                   | 1 (1–2)   | 2 (2–2)   |
| Total                             | 11 (6–12) | 12 (6–14) |

* Interquartile range ** Excludes patients who had both group and 1:1 sessions *** Out of those who did at least one session 

|          |         | Scotland    | Wales     | All       |
|----------|---------|-------------|-----------|-----------|
| (n=177)  |         | (n=160)     |           | (n=5,451) |
| Scotland | Wales   | All         |           |           |
| (n=177)  |         | (n=160)     |           | (n=5,451) |
| Scotland | Wales   | All         |           |           |
| (n=177)  | (n=160) | (n=5,451)   |           |           |
| 166      | 158     | 5,110       |           |           |
| (93.8%)  | (98.8%) | (93.7%)     |           |           |
| 29       | 8       | 522         |           |           |
| (16.4%)  |         | (5.0%)      |           | (9.6%)    |
| Scotland | Wales   | All         |           |           |
| (n=177)  | (n=160) | (n=5,451)   |           |           |

## 6.6 Total Number Of Home-Based Pr Sessions Scheduled*

A small number of patients participated in home-based PR (n=71, 1.3%). The median (IQR) range of supervised sessions scheduled in the home was 4 (4–6). All home-based PR was delivered in England. 

*Excluding those who were enrolled in both centre-based and home-based 6.6.1 Method of home-based PR sessions 

The majority of the home-based PR sessions were supervised in person (n=56, 78.9%). Other homebased contact included: 
 
 telephone calls (n=37, 52.1%)  technology based PR (video conferencing) (n=1, 1.4%)  other digital communication (n=6, 8.5%).  
 
No services offered group-based video conferencing sessions. These home-based programmes were all based in England. 

## 6.7 Number Of Home-Based Pr Sessions Received*

The median (IQR) number of in person home-based supervised sessions received was 3 (1–4), phone supervision was 2 (1–3) and digital communication was 1 (1–2). No services selected video conferencing - group sessions. 

*Out of those who did at least one session 
 

## Section 7 Key Information At Discharge Back To Contents

Key standards BTS quality standards for pulmonary rehabilitation in adults (2014) [Standard 4]: 1  
PR programmes are of at least 6 weeks duration and include a minimum of twice-weekly supervised sessions. 

BTS quality standards for pulmonary rehabilitation in adults (2014) [Standard 7]: 1 People completing PR are provided with an individualised structured, written plan for ongoing exercise maintenance. 

Key findings 
Of patients assessed between 1 March and 31 May 2019, subsequently enrolled and then discharged by 31 August 2019: 
 69.3% had a discharge assessment.  of those with a history of cardiovascular disease (OR = 0.85 (95% CI = 0.74–0.97)) and 
depression (OR = 0.73 (95% CI = 0.59–0.50)) there was reduced likelihood of completing a discharge assessment 
 those in the least deprived areas of England, Scotland and Wales were more likely to attend 
their discharge assessment (OR = 1.86 (95% CI = 1.49–2.33)) compared with those in the most deprived areas 
 79.3% of patients received an individualised discharge plan. 
This section contains the following tables and graphs. If you are viewing this report on a computer, you can select the table that you wish to see from the list below. 
 7.1 Discharge assessment   
− 7.1.1 Discharge assessment performed − 7.1.2 Discharge assessment by programme type: rolling and cohort − 7.1.3 Likelihood of completing a discharge assessment based on demographic characteristics − 7.1.4 Number of patients receiving an individualised discharge plan − 7.1.5 Days from initial assessment to discharge assessment 
 

## 7.1 Discharge Assessment 7.1.1 Discharge Assessment Performed

England 
Discharge assessment performed 
(n=5,213) 
Yes  
3,617 (69.4%) 
107 (60.5%) 
124 (77.5%) 
3,848 (69.3%) 
No 
1,596 (30.6%) 
70 (39.5%) 
36 (22.5%) 
1,702 (30.7%) 
Completion ratio* 
2.3:1 
1.5:1 
3.4:1 
2.3:1 
| England                                            | Discharge assessment    |
|----------------------------------------------------|-------------------------|
| by programme type                                  | (n=3,352)               |
| Discharge assessment performed: rolling programmes |                         |
| Yes                                                | 2,262 (67.5%)           |
|                                                    |                         |
| England                                            |                         |
| (n=1,762)                                          |                         |
| Discharge assessment performed: cohort programmes  |                         |
| Yes                                                | 1,301 (73.8%)           |
| Scotland     | Wales     | All       |
|--------------|-----------|-----------|
| (n=177)      | (n=160)   | (n=5,550) |
| Scotland     | Wales     | All       |
| (n=156)      | (n=92)    | (n=3,600) |
| Scotland     | Wales     | All       |
| (n=21)       | (n=68)    | (n=1,851) |

For home-based programmes a smaller proportion of patients completed a discharge assessment compared with either cohort- or centre-based rolling programmes (n=38, 53.5%). These were all completed in England. For patients who received a hybrid model of home and centre-based sessions 16 (57.1%) completed a discharge assessment. This model was only delivered in England. 

## 7.1.3 Likelihood Of Completing A Discharge Assessment Based On Demographic Characteristics

|                                                                                                         | 2019                    |           |
|---------------------------------------------------------------------------------------------------------|-------------------------|-----------|
| Unadjusted odds ratio                                                                                   |                         |           |
| Variable                                                                                                |                         |           |
| Unadjusted                                                                                              |                         |           |
| odds ratio*                                                                                             | 95% confidence interval |           |
| Female                                                                                                  | 0.85                    | 0.76–0.96 |
| Quintile of Index of Multiple Deprivation, England (IMD) / Welsh Index of Multiple Deprivation (WIMD) / |                         |           |
| Scotland (SIMD)                                                                                         |                         |           |
| 1 (most                                                                                                 |                         |           |
| deprived)                                                                                               |                         |           |
| 1                                                                                                       | -                       | 1         |
| 2                                                                                                       | 1.40                    | 1.17–1.68 |
| 3                                                                                                       | 1.73                    | 1.43–2.09 |
| 4                                                                                                       | 1.74                    | 1.44–2.11 |
| 5 (least                                                                                                |                         |           |
| deprived)                                                                                               |                         |           |
| 2.27                                                                                                    | 1.83–2.81               | 1.86      |
| Age                                                                                                     |                         |           |
| 35–44                                                                                                   | 0.28                    | 0.16–0.50 |
| 45–54                                                                                                   | 0.44                    | 0.34–0.57 |
| 55–64                                                                                                   | 0.57                    | 0.49–0.66 |
| 65–74                                                                                                   | 1                       | -         |
| 75–84                                                                                                   | 1.19                    | 1.01–1.39 |
| 85+                                                                                                     | 0.71                    | 0.53–0.95 |
| Comorbidities                                                                                           |                         |           |
| Cardiovascular                                                                                          |                         |           |
| history                                                                                                 |                         |           |
| 0.94                                                                                                    | 0.83–1.07               | 0.85      |
| Musculoskeletal                                                                                         |                         |           |
| history                                                                                                 |                         |           |
| 0.82                                                                                                    | 0.73–0.94               | 0.89      |
| Serious mental                                                                                          |                         |           |
| illness                                                                                                 |                         |           |
| 0.44                                                                                                    | 0.28–0.69               | 0.66      |
| Anxiety                                                                                                 | 0.61                    | 0.51–0.74 |
| Depression                                                                                              | 0.52                    | 0.44–0.61 |
| CAT** score at initial visit                                                                            |                         |           |
| 0–10                                                                                                    | 1.75                    | 1.32–2.30 |
| 11–20                                                                                                   | 1.65                    | 1.39–1.94 |
| 21–30                                                                                                   | 1                       | -         |
| 31–40                                                                                                   | 0.51                    | 0.41–0.63 |

* Centre remains as a random intercept to account for clustering ** Adjusted for all other variables in the model *** COPD assessment test  

| Adjusted     | Adjusted odds ratio     |
|--------------|-------------------------|
| odds ratio** | 95% confidence interval |

In the unadjusted analyses, those with a higher IMD score, a higher age (except for those aged 85+) and a lower CAT score were more likely to attend their discharge assessment in both the adjusted and unadjusted analyses. Those with a cardiovascular disease history, musculoskeletal disease history, serious mental illness, anxiety or depression, were less likely to attend their discharge assessment in the unadjusted analyses. However, after adjusting for all other variables, only a history of cardiovascular disease and depression remained statistically significant. In the unadjusted analysis, those who were female were less likely to attend their discharge assessment; however, this association did not reach statistical significance in the adjusted analysis.  

| England                       | Patients receiving    |
|-------------------------------|-----------------------|
| individualised discharge plan | (n=3,617)             |
| Yes                           | 2,890 (79.9%)         |

* Of those patients who had a discharge assessment 

|                      |            | England    | Days from initial assessment to    |
|----------------------|------------|------------|------------------------------------|
| discharge assessment |            | (n=3,617)  |                                    |
| Median (IQR**)       | 69 (56–86) | 74 (61–92) | 63 (54–80)                         |

* Refer to table 3.2.1 for the referral to start time for PR to understand were the blocks may be ** Interquartile range 

| Scotland     | Wales     | All       |
|--------------|-----------|-----------|
| (n=107)      | (n=124)   | (n=3,848) |
|         |    | Scotland    | Wales     | All       |
|---------|----|-------------|-----------|-----------|
| (n=107) |    | (n=124)     |           | (n=3,848) |

 *Denominator for Fig 7.3 is all those patients discharged from pulmonary rehabilitation. 

 

## 3 National Qi Priority: Ensure 70% Of Patients Enrolled For Pr Go On To Have A Discharge Assessment. (Bts Quality Standards For Pulmonary Rehabilitation In Adults (2014). Standards 4)1

Rationale  
There are substantial patient-centred benefits of completing PR, namely a marked improvement in exercise capacity and health status. There is also an association between PR completion and lower hospital admission rates at 180 days.3 

Tips to achieve this priority 

 
Incorporate a process to contact patients who have stopped attending to encourage completion. 
 
Involve graduates from rehabilitation with the programme to support completion. 
 
Ensure the patient receives clear information about the rehabilitation programme and the required commitment.  

## Section 8: Discharge Tests Back To Contents

Key standards BTS quality standards for pulmonary rehabilitation in adults (2014) [Standard 8]:1 People attending PR have the outcome of treatment assessed using as a minimum, measures of exercise capacity, dyspnoea and health status. 

BTS quality standards for pulmonary rehabilitation in adults (2014) [Standard 9]: 1 PR 
programmes conduct an annual audit of individual outcomes and progress. 

Key findings 
Of patients completing a discharge assessment: 
 for those with a medical research council (MRC) score reported at initial and discharge 
assessment, 41.9% reported an improved score. 
 67.2% who performed the 6-minute walk test (6MWT) achieved improvements in exercise 
capacity and 53.4% who performed the incremental shuttle walk test (ISWT) achieved improvements.  
 58.0% who completed the COPD assessment test (CAT) achieved improvements in health 
status and 58.6% who completed the dyspnoea domain of the chronic respiratory questionnaire (CRQ) achieved improvements.  
This section contains the following tables and graphs. If you are viewing this report on a computer, you can select the table that you wish to see from the list below. 

 8.1 What was the patient-reported Medical Research Council (MRC) score at discharge? 
− 8.1.1 MRC score at assessment and at discharge 
 8.2 Walk tests 
− 8.2.1 Walk tests recorded at discharge assessment − 8.2.2 Difference in walk test values between initial assessment and discharge assessment 
 8.3 Difference between initial assessment and discharge assessment in walk test values: tests 
meeting MCID 
− 8.3.1 ISWT and 6MWT scores meeting MCID − 8.3.2 Relationship between demographic characteristics and meeting at the MCID for 
exercise  
 8.4 Health status questionnaires 
− 8.4.1 Health status questionnaires recorded for those patients who completed at both initial 
and discharge assessments 
− 8.4.2 Difference in health status questionnaire values between initial assessment and 
discharge assessment 
 8.5 Difference between initial assessment and discharge assessment in health status 
questionnaire values: change data in relation to MCID 
− 8.5.1 Health status questionnaire scores meeting MCID − 8.5.2 Association between demographic characteristics and meeting MCID for at least one 
health status 

## 8.1 What Was The Patient-Reported Medical Research Council (Mrc) Score At Discharge?

|              | 2019          |            |
|--------------|---------------|------------|
| MRC score*   |               |            |
| England      |               |            |
| (n=3,617)    |               |            |
| Grade 1      | 184 (5.1%)    | 2 (1.9%)   |
| Grade 2      | 940 (26.0%)   | 10 (9.3%)  |
| Grade 3      | 1,061 (29.3%) | 19 (17.8%) |
| Grade 4      | 521 (14.4%)   | 7 (6.5%)   |
| Grade 5      | 66 (1.8%)     | 1 (0.9%)   |
| Not recorded | 845 (23.4%)   | 68 (63.6%) |

* N = people who received a discharge assessment 

## 8.1.1 Mrc Score At Assessment And At Discharge

The answers in the table below have been calculated using the answers to 7.1 (MRC score at discharge) and 3.5 (MRC score at initial assessment). MRC grade was known at both initial and discharge assessments for 2,892 patients. In 1,211 (41.9%) patients the MRC grade improved (green shading), in 1,503 (52.0%) it stayed the same (orange shading) and in 178 (6.2%) it was worse (red shading). 

Score at discharge (top) Score at initial assessment (left) 
Grade 1 
Grade 2 
Grade 3 
Grade 4 
Grade 5 
Not 
Grade 1 
44 
23 
1 
1 
0 
11 
Grade 2 
91 
403 
57 
9 
0 
152 
Grade 3 
40 
392 
618 
64 
5 
327 
Grade 4 
14 
136 
373 
392 
18 
214 
Grade 5 
0 
19 
49 
97 
46 
45 
Not recorded 
3 
10 
14 
3 
1 
176 

## 8.2 Walk Tests 8.2.1 Walk Tests Recorded At Discharge Assessment

|                                        | 2019          |            |
|----------------------------------------|---------------|------------|
| Test recorded at discharge assessment  | England       |            |
| (n=3,534)                              |               |            |
| Incremental shuttle walk test (ISWT)   | 1,541 (43.6%) | 30 (28.0%) |
| 6-minute walk test (6MWT)              | 1,521 (43.0%) | 56 (52.3%) |
| Incremental shuttle walk test (ISWT) + |               |            |
| Endurance shuttle walk test (ESWT)     |               |            |
| 363 (10.3%)                            | 0 (0.0%)      | 0 (0.0%)   |
| None                                   | 109 (3.1%)    | 21 (19.6%) |
| Scotland    | Wales     | All       |
|-------------|-----------|-----------|
| (n=107)     | (n=124)   | (n=3,848) |
| recorded    |           |           |
| Scotland    | Wales     | All       |
| (n=107)     | (n=120)   | (n=3,761) |

## 8.2.2 Difference In Walk Test Values Between Initial Assessment And Discharge Assessment

|                              | 2019    |              |
|------------------------------|---------|--------------|
| Scotland                     | Wales   | All          |
| Median difference (IQR)*, ** |         |              |
| England                      |         |              |
| (n=3,534)                    | (n=107) | (n=120)      |
| ISWT (mins) (n=1,952)        |         | 50 (10–90)   |
| 6MWT (mins) (n=1,675)        |         | 50 (20–97)   |
| ESWT (secs) (n=393)          |         | 239 (80–581) |

 * Interquartile range.  N = people who received any test (including those who received ESWT but not ISWT or 6MWT). ** It is important to note that the data in this table only refers to those who received a discharge assessment and performed a walk test at discharge.  

## 8.3 Difference Between Initial Assessment And Discharge Assessment In Walk Test Values: Tests Meeting Mcid

The scientific evidence provides thresholds for changes in these outcome measures that are judged important by patients (termed the minimal clinically important difference (MCID)).5, 6 For the ISWT 
the MCID is 48 metresb and for the 6MWT the MCID is 30 metres. For the ESWT the scientific evidence for the MCID is less clear and is therefore not reported in this audit. 

## 8.3.1 Iswt And 6Mwt Scores Meeting Mcid

|              |               |            | 2019       |               |
|--------------|---------------|------------|------------|---------------|
| England      | Scotland      | Wales      | All        | ISWT and 6MWT |
| meeting MCID | (n=1,902)     | (n=30)     | (n=20)     | (n=1,952)     |
| ISWT         |               |            |            |               |
| Yes          | 1,013 (53.3%) | 16 (53.3%) | 14 (70.0%) | 1,043 (53.4%) |
|              | (n=1,523)     | (=56)      |            | (n=96)        |
| 6MWT         |               |            |            |               |
| Yes          | 1,030 (67.6%) | 35 (62.5%) | 61 (63.5%) | 1,126 (67.2%) |

## 8.3.2 Relationship Between Demographic Characteristics And Meeting At The Mcid For Exercise

 
2019 
Unadjusted 
Unadjusted odds ratio 
Variable 
odds ratio* 
Female 
1.01 
0.88–1.16 
0.96 
0.83–1.1 
Quintile of Index of Multiple Deprivation, England (IMD) / Welsh Index of Multiple Deprivation (WIMD) / Scotland (SIMD) 1 
1 
- 
1 
- 
2 
1.15 
0.92–1.45 
1.18 
0.94–1.48 
3 
1.00 
0.80–1.26 
1.06 
0.84–1.33 
4 
0.93 
0.74–1.17 
1.01 
0.80–1.27 
5 
0.84 
0.66–1.07 
0.92 
0.72–1.17 
Age 35–44 
1.42 
0.57–3.51 
1.41 
0.57–3.51 
45–54 
1.73 
1.20–2.51 
1.70 
1.17–2.48 
55–64 
1.26 
1.03–1.54 
1.25 
1.02–1.53 
65–74 
1 
- 
1 
- 
75–84 
0.86 
0.73–1.02 
0.88 
0.74–1.04 
85+ 
0.88 
0.61–1.28 
0.89 
0.62–1.29 
Comorbidities Cardiovascular history 
0.95 
0.82–1.10 
0.97 
0.83–1.13 
Musculoskeletal history 
1.25 
1.07–1.45 
1.27 
1.09–1.48 
Serious mental illness 
1.32 
0.68–2.55 
1.04 
0.54–2.03 
Anxiety 
1.17 
0.91–1.49 
1.00 
0.76–1.32 
Depression 
1.21 
0.96–1.53 
1.06 
0.81–1.38 
CAT score at initial visit 0–10 
0.96 
0.72–1.27 
1.04 
0.78–1.38 
11–20 
0.85 
0.71–1.02 
0.91 
0.76–1.09 
21–30 
1 
- 
1 
- 
31–40 
0.99 
0.73–1.33 
0.92 
0.68–1.25 

 *Centre remains as a random intercept–account for clustering **Adjusted for all other variables in the model 

People with musculoskeletal disease history and those who were younger tended to be more likely to meet their MCID for a walk test. It is worth noting that the analysis does not include those who did not receive a discharge assessment, and so variables associated with an increased likelihood of meeting the MCID may in fact also be associated with an increased likelihood of not completing a discharge assessment.  


|                | Adjusted odds    | Adjusted odds ratio    |
|----------------|------------------|------------------------|
| 95% confidence | ratio*           | 95% confidence         |
| interval       | interval         |                        |

## 8.4 Health Status Questionnaires 8.4.1 Health Status Questionnaires Recorded For Those Patients Who Completed At Both Initial And Discharge Assessments

|                                         | 2019   |           |
|-----------------------------------------|--------|-----------|
| Health status questionnaire recorded at |        |           |
| discharge assessment                    |        |           |
| COPD assessment test (CAT)              |        |           |
| 2,552                                   |        |           |
| Chronic respiratory questionnaire (CRQ) |        | (n=1,372) |
| CRQ                                     |        |           |
| 1,372                                   |        |           |

## 8.4.2 Difference In Health Status Questionnaire Values Between Initial Assessment And Discharge Assessment

|                           | 2019          |                |
|---------------------------|---------------|----------------|
| Mean difference (95% CI*) |               |                |
| England                   |               |                |
| (n=2,552)                 |               |                |
| CAT values (n=2,708)      | –2 (–6–1)     | –3 (–6.5–2)    |
| CRQ                       | (n=1,372)     | (n=31)         |
| CRQ - Dyspnoea (n=1,425)* | 0.8 (0.0–1.6) | 1.0 (-0.2–1.7) |
| CRQ - Fatigue (n=1,425)*  | 0.7 (0.0–1.5) | 0.8 (-0.4–1.6) |
| CRQ - Emotion (n=1,425)*  | 0.6 (0.0–1.3) | 0.6 (0.1–1.0)  |
| CRQ - Mastery (n=1,425)*  | 0.7 (0.0–1.5) | 0.5 (0.3–1.1)  |

* 95% confidence interval 

| England    | Scotland     | Wales     | All       |
|------------|--------------|-----------|-----------|
| (n=2,552)  | (n=47)       | (n=109)   | (n=2,708) |
| 47         | 109          | 2,708     |           |
| (95.6%)    | (94.0%)      | (98.2%)   | (95.7%)   |
| 31         | 22           | 1,425     |           |
| (97.7%)    | (91.2%)      | (100.0%)  | (97.6%)   |
| Scotland   | Wales        | All       |           |
| (n=47)     | (n=109)      | (n=2,708) |           |

## 8.5 Difference Between Initial Assessment And Discharge Assessment In Health Status Questionnaire Values: Change Data In Relation To Mcid

The scientific literature provides thresholds for changes in these health status outcome measures that are judged important by patients (termed the minimal clinically important difference (MCID).7 8 For the CAT the MCID is a reduction in 2 points and for the CRQ the MCID is an increase in 0.5 points for each domain.   

|                 |               | 2019      |
|-----------------|---------------|-----------|
| Scotland        | Wales         | All       |
| Meeting MCID    |               |           |
| England         |               |           |
| (n=2,552)       | (n=47)        | (n=109)   |
| CAT values      | 1,481 (58.0%) |           |
| CRQ             |               | (n=1,372) |
| Dyspnoea values | 809 (59.0%)   |           |
| Fatigue values  | 810 (59.0%)   |           |
| Emotion values  | 739 (53.9%)   |           |
| Mastery values  | 808 (58.9%)   |           |

## 8.5.2 Association Between Demographic Characteristics And Meeting Mcid For At Least One Health Status

|                                                                                                         | 2019                      |            |
|---------------------------------------------------------------------------------------------------------|---------------------------|------------|
| Unadjusted                                                                                              | Unadjusted odds ratio 95% |            |
| Variable                                                                                                |                           |            |
| odds ratio*                                                                                             | confidence interval       |            |
| Female                                                                                                  | 1.03                      | 0.88–1.21  |
| Quintile of Index of Multiple Deprivation, England (IMD) / Welsh Index of Multiple Deprivation (WIMD) / |                           |            |
| Scotland (SIMD)                                                                                         |                           |            |
| 1                                                                                                       | 1                         | -          |
| 2                                                                                                       | 1.16                      | 0.90–1.51  |
| 3                                                                                                       | 0.98                      | 0.76–1.27  |
| 4                                                                                                       | 0.92                      | 0.71–1.19  |
| 5                                                                                                       | 0.86                      | 0.66–1.14  |
| Age                                                                                                     |                           |            |
| 35–44                                                                                                   | 2.91                      | 0.81–10.43 |
| 45–54                                                                                                   | 0.79                      | 0.53–1.18  |
| 55–64                                                                                                   | 0.90                      | 0.72–1.12  |
| 65–74                                                                                                   | 1                         | -          |
| 75–84                                                                                                   | 0.82                      | 0.68–0.98  |
| 85+                                                                                                     | 0.79                      | 0.53–1.18  |
| Comorbidities                                                                                           |                           |            |
| Cardiovascular                                                                                          |                           |            |
| history                                                                                                 |                           |            |
| 1.15                                                                                                    | 0.97–1.36                 | 1.11       |
| Musculoskeletal                                                                                         |                           |            |
| history                                                                                                 |                           |            |
| 1.26                                                                                                    | 1.06–1.49                 | 1.15       |
| Serious mental                                                                                          |                           |            |
| illness                                                                                                 |                           |            |
| 3.29                                                                                                    | 1.24–8.74                 | 3.16       |
| Anxiety                                                                                                 | 1.18                      | 0.89–1.55  |
| Depression                                                                                              | 1.50                      | 1.14–1.96  |
| CAT score at initial visit                                                                              |                           |            |
| 0–10                                                                                                    | 0.24                      | 0.17–0.32  |
| 11–20                                                                                                   | 0.62                      | 0.51–0.76  |
| 21–30                                                                                                   | 1                         | -          |
| 31–40                                                                                                   | 2.33                      | 1.61–3.37  |

*Centre remains as a random intercept to account for clustering **Adjusted for all other variables in the model Analyses show the association between each variable and the likelihood of meeting at least one MCID at discharge assessment. In the unadjusted analyses, a history of musculoskeletal disease, depression, and serious mental illness (SMI), and a higher CAT score at initial assessment were associated with an increased likelihood of meeting the MCID. In the analysis in which variables were adjusted for the effect of other variables, only a history of SMI and a higher CAT score at initial assessment remained associated with meeting the MCID. This may be because those with more serious disease and disease history find PR of greater benefit with regards to their perceived health status than those with milder disease and disease history. It is worth noting that the analysis does not include those who did not receive a discharge assessment, and so variables associated with an increased likelihood of meeting the MCID may in fact also be associated with an increased likelihood of not completing a discharge assessment.  

| Adjusted     | Adjusted odds ratio 95%    |
|--------------|----------------------------|
| odds ratio** | confidence interval        |

## Section 9: Benchmarked Key Indicators Back To Contents 9.1 Benchmarking Of Key Indicators For Participating Services

The process and outcome performance indicators identified in the dashboard (**Table 2**) have been chosen as they are: 

 objective and easily recordable  map to accepted quality standards (**Appendix B**)  have been discriminatory in the current audit cycle 
 can be quantitatively compared with national data. 

| Benchmarking dashboard performance indicator                                                       | Rationale    |
|----------------------------------------------------------------------------------------------------|--------------|
| Process items                                                                                      |              |
|                                                                                                   |              |
|                                                                                                    |              |
| Poor current performance nationally.                                                               |              |
|                                                                                                   |              |
|                                                                                                    |              |
| Maps to                                                                                            | QS1          |
| 1                                                                                                  |              |
|                                                                                                    |              |
| Start date offered within 90 days of receipt of referral                                           |              |
| (if known)                                                                                         |              |
|                                                                                                   |              |
|                                                                                                    |              |
| Improvement is likely to enhance patient outcomes, particularly PR uptake rates.                   |              |
|                                                                                                   |              |
|                                                                                                    |              |
| Poor current performance nationally.                                                               |              |
|                                                                                                   |              |
|                                                                                                    |              |
| Maps to                                                                                            | QS8          |
|                                                                                                    | 1            |
|                                                                                                    |              |
| Patients undertaking practice walk test (for incremental                                           |              |
| shuttle walk test (ISWT) or 6-minute walk test (6MWT))                                             |              |
|                                                                                                   |              |
|                                                                                                    |              |
| Performance of practice tests linked to better uptake and outcome in sub-analysis of 2015 audit.   |              |
| 3, 4                                                                                               |              |
|                                                                                                    |              |
|                                                                                                   |              |
|                                                                                                    |              |
| Likely to improve clinical outcomes through more accurate exercise prescription.                   |              |
|                                                                                                   |              |
|                                                                                                    |              |
| Substantial numbers of patients currently do not complete PR.                                      |              |
|                                                                                                   |              |
|                                                                                                    |              |
| Improvement in completion rates would extend benefits of PR to larger number of patients.          |              |
| Patients enrolled for PR who subsequently have a                                                   |              |
| discharge assessment                                                                               |              |
|                                                                                                   |              |
|                                                                                                    |              |
| Could reduce subsequent hospitalisation rates as suggested by 2015 outcomes report.                |              |
| 3                                                                                                  |              |
|                                                                                                    |              |
|                                                                                                   |              |
|                                                                                                    |              |
| Causes of non-completion are multifactorial and therefore will prompt quality improvement activity |              |
| across the system.                                                                                 |              |
|                                                                                                   |              |
|                                                                                                    |              |
| Poor current performance nationally.                                                               |              |
|                                                                                                   |              |
|                                                                                                    |              |
| Maps to                                                                                            | QS7          |
|                                                                                                    | 1            |
|                                                                                                    |              |
| Patients with a discharge assessment who receive a                                                 |              |
| written discharge exercise plan                                                                    |              |
|                                                                                                    |              |
|                                                                                                   |              |
|                                                                                                    |              |
| Improvement will increase the likelihood of benefits of PR being maintained in longer term.        |              |
| Outcome items                                                                                      |              |
|                                                                                                   |              |
|                                                                                                    |              |
| Key patient-centred measure of outcome.                                                            |              |
|                                                                                                   |              |
|                                                                                                    |              |
| May identify services where care processes are suboptimal.                                         |              |
|                                                                                                   |              |
|                                                                                                    |              |
| Maps to                                                                                            | QS8.         |
| 1                                                                                                  |              |
|                                                                                                    |              |
| Patients experience an improvement in exercise                                                     |              |
| capacity (evidenced by achieving the minimal clinically                                            |              |
| important differences (MCID) for ISWT or 6MWT)                                                     |              |
|                                                                                                   |              |
|                                                                                                    |              |
| Key patient-centred measure of outcome.                                                            |              |
|                                                                                                   |              |
|                                                                                                    |              |
| May identify services where care processes are suboptimal.                                         |              |
|                                                                                                   |              |
|                                                                                                    |              |
| Maps to                                                                                            | QS8.         |
| 1                                                                                                  |              |
|                                                                                                    |              |
| Patients experience an improvement in health status                                                |              |
| (evidenced by achieving at least one health status                                                 |              |
| MCID)                                                                                              |              |

Table 2 shows the median, lower quartile and upper quartile for the key indicators that have been presented in the unadjusted benchmarking of services (Table 3). The values presented in Table 2 have been derived by the method shown visually in the box and whisker plot (**Fig 1**). More specifically, to create the 'box', data for each key indicator were ordered numerically from smallest (whisker; P0), to largest (whisker; P100) to find the median (P50), the middle point of the values, the data is divided into two halves. These two halves are then divided in half again, to identify the lower quartile (P25) and the upper quartile (P75). 

|                        |                | Process items            | Outcome items          |
|------------------------|----------------|--------------------------|------------------------|
| Start date             | Patients       | Patients enrolled for PR | Median and             |
| interquartile ranges % |                |                          |                        |
| c                      |                |                          |                        |
|                        | within 90 days | undertaking              | who subsquently have a |
| of receipt of          | practice walk  | discharge assessment     |                        |
| referral*              | test           |                          |                        |
| Lower quartile         |                | 29                       | 0                      |
| Median                 |                | 63                       | 10                     |
| Upper quartile         |                | 84                       | 88                     |

* This metric is only reported for non-AECOPD patients. Data is not directly comparable to the 2017 snapshot audit, as data was reported for all patients in 2017.9 
The colours refer to the quartile in which each result lies: 

Red = Result equal to or below lower quartile for that indicator Amber = Result above lower quartile but below upper quartile for that indicator Green = Result equal to or above upper quartile for that indicator <5 = Sample size too small for meaningful interpretation (<5 records) 

| Patients with a         | Improvement in    | Improvement      |
|-------------------------|-------------------|------------------|
| discharge assessment    | exercise capacity | in health status |
| who receive a written   |                   |                  |
| discharge exercise plan |                   |                  |

 
This benchmarking data is provided for patients that were assessed between 1 March and 31 May 2019 and discharged by 31 August 2019. The data represents in total over 6,000 patients. This table provides service data for four process and two outcome performance indicators that map onto the BTS quality standards.1  

## Process

 Start date within 90 days of receipt of referral  Patients undertaking practice walk test  Patients enrolled for PR who go on to have a discharge assessment  Patients with a discharge assessment who received a written individualised exercise plan 

## Outcomes

 Improvement in exercise capacity  
 Improvement in health status 
 
These outcomes have been selected based on previous data reports and allow a comparison with the national medians and performance. It is important to note that the wait times as presented in this report may be shorter than might be reported from a longer data capture period. Patients with a protracted journey through the programme have be excluded from the analysis in this report. This is because, while individuals may have been assessed between 1 March and 31 May 2019, they may not have completed the PR programme before 31 August 2019, and this is likely to be because of delays between assessment and commencing PR. However, data for the other process and outcomes indicators will be representative of the patient cohort reported and can be used to help PR services to understand their performance against these indicators. We hope that services will use this data to check whether their performance has improved in the next report. For some services the number of patients entered is very low and makes interpretation at a local level difficult. Services with less than five data points to analyse have been included in the table in name only; their data has been supressed as per the NACAP policy for supressing small numbers if there is a risk of individual patients being identified. 

 

Process items 
Outcome items 
| Start date within      | Patients     |
|------------------------|--------------|
| 90 days of             | undertaking  |
| receipt of             | practice     |
| board name             | Service name |
| Cases                  |              |
| audited                | referral*    |
| National QI aim        | 85%          |
| National result        | 2,792        |
| England                |              |
| 20                     | 6            |
| Airedale NHS           |              |
| Foundation Trust       |              |
| Airedale, Wharfedale   |              |
| and Craven Pulmonary   |              |
| Rehabilitation Service |              |
Rehabilitation Service 
34 
18 
62% 
21 
66% 
18 
Enterprise Interest Company Atrium Health Ltd 
11 
10 
100% 
0 
0% 
8 
Warwickshire Pulmonary Rehabilitation Service 
| Patients     | Patients with    |
|--------------|------------------|
| enrolled for |                  |
| PR who       |                  |
| a discharge  |                  |
| assessment   |                  |
| subsequently | who received     |
| have a       | a written        |
| discharge    | individualised   |
| assessment   | exercise plan    |
Outcome items 
| Start date within      | Patients     |
|------------------------|--------------|
| 90 days of             | undertaking  |
| receipt of             | practice     |
| board name             | Service name |
| Cases                  |              |
| audited                | referral*    |
| National QI aim        | 85%          |
| National result        | 2,792        |
| Enfield Respiratory    |              |
| Service                |              |
| 13                     | <5           |
| Barnet, Enfield        |              |
| and Haringey           |              |
| Mental Health          |              |
| NHS Trust              |              |
| 14                     | 8            |
| Barts Health NHS       |              |
| Trust                  |              |
| Tower Hamlets          |              |
| Pulmonary              |              |
| Rehabilitation Service |              |
| 89                     | 71           |
| Bedford Hospital       |              |
| NHS Trust              |              |
| Bedford Hospital       |              |
| Pulmonary              |              |
| Rehabilitation         |              |
| 47                     | 5            |
| Berkshire              |              |
| Healthcare NHS         |              |
| Foundation Trust       |              |
| Berkshire West Cardiac |              |
| and Respiratory        |              |
| Specialist Services    |              |
| BCHC Community         |              |
| Respiratory Service    |              |
| 21                     | 12           |
| Birmingham             |              |
| Community              |              |
| Healthcare NHS         |              |
| Foundation Trust       |              |
| Patients     | Patients with    |
|--------------|------------------|
| enrolled for |                  |
| PR who       |                  |
| a discharge  |                  |
| assessment   |                  |
| subsequently | who received     |
| have a       | a written        |
| discharge    | individualised   |
| assessment   | exercise plan    |
Process items 
Outcome items 
| Start date within       | Patients     |
|-------------------------|--------------|
| 90 days of              | undertaking  |
| receipt of              | practice     |
| board name              | Service name |
| Cases                   |              |
| audited                 | referral*    |
| National QI aim         | 85%          |
| National result         | 2,792        |
| 30                      | 17           |
| Pulmonary               |              |
| Rehabilitation Service  |              |
| Fylde and Wyre          |              |
| Blackpool               |              |
| Teaching                |              |
| Hospitals NHS           |              |
| Foundation Trust        |              |
| BOC LTD                 |              |
| Blackpool Pulmonary     |              |
| Rehabilitation Service  |              |
| 27                      | 22           |
| BOC LTD                 |              |
| Bradford Pulmonary      |              |
| Rehabilitation Service  |              |
| 47                      | 29           |
| BOC LTD                 | 6            |
| East Staffordshire      |              |
| Pulmonary               |              |
| Rehabilitation Service  |              |
| BOC LTD                 |              |
| Hounslow Community      |              |
| Respiratory Team        |              |
| 13                      | 7            |
| BOC LTD                 |              |
| Newcastle Healthy Lungs |              |
| Programme               |              |
| 30                      | 19           |
| Patients     | Patients with    |
|--------------|------------------|
| enrolled for |                  |
| PR who       |                  |
| a discharge  |                  |
| assessment   |                  |
| subsequently | who received     |
| have a       | a written        |
| discharge    | individualised   |
| assessment   | exercise plan    |
Process items 
Outcome items 
| Start date within        | Patients     |
|--------------------------|--------------|
| 90 days of               | undertaking  |
| receipt of               | practice     |
| board name               | Service name |
| Cases                    |              |
| audited                  | referral*    |
| National QI aim          | 85%          |
| National result          | 2,792        |
| BOC LTD                  | 12           |
| Nottingham West          |              |
| Pulmonary                |              |
| Rehabilitation           |              |
| BOC LTD                  |              |
| Somerset Pulmonary       |              |
| Rehabilitation Service   |              |
| 28                       | 16           |
| BOC LTD                  | 27           |
| South East Staffordshire |              |
| Pulmonary                |              |
| Rehabilitation Service   |              |
| BOC LTD                  |              |
| The North Lincolnshire   |              |
| Respiratory Service      |              |
| 17                       | 14           |
| BOC LTD                  | 40           |
| West Norfolk BOC         |              |
| Pulmonary                |              |
| Rehabilitation Service   |              |
| Bristol Community        |              |
| Respiratory Service      |              |
| 62                       | 13           |
| Bristol                  |              |
| Community                |              |
| Health                   |              |
| Patients     | Patients with    |
|--------------|------------------|
| enrolled for |                  |
| PR who       |                  |
| a discharge  |                  |
| assessment   |                  |
| subsequently | who received     |
| have a       | a written        |
| discharge    | individualised   |
| assessment   | exercise plan    |
Process items 
Outcome items 
| Start date within       | Patients     |
|-------------------------|--------------|
| 90 days of              | undertaking  |
| receipt of              | practice     |
| board name              | Service name |
| Cases                   |              |
| audited                 | referral*    |
| National QI aim         | 85%          |
| National result         | 2,792        |
| Bromley                 |              |
| Healthcare              |              |
| Bromley Pulmonary       |              |
| Rehabilitation          |              |
| 58                      | 34           |
| 79                      | 6            |
| Buckinghamshire         |              |
| Healthcare NHS          |              |
| Trust                   |              |
| Buckinghamshire         |              |
| Pulmonary               |              |
| Rehabilitation Services |              |
| Calderdale Pulmonary    |              |
| Rehabilitation Service  |              |
| 25                      | 15           |
| Calderdale and          |              |
| Huddersfield NHS        |              |
| Foundation Trust        |              |
| Huntingdon Pulmonary    |              |
| Rehabilitation          |              |
| 10                      | 7            |
| Cambridgeshire          |              |
| and Peterborough        |              |
| NHS Foundation          |              |
| Trust                   |              |
| Luton Community         |              |
| Respiratory Service     |              |
| 18                      | 10           |
| Cambridgeshire          |              |
| Community               |              |
| Services NHS            |              |
| Trust                   |              |
| Care Plus Group         |              |
| Hope Street Specialist  |              |
| Service                 |              |
| 52                      | 29           |
| Patients     | Patients with    |
|--------------|------------------|
| enrolled for |                  |
| PR who       |                  |
| a discharge  |                  |
| assessment   |                  |
| subsequently | who received     |
| have a       | a written        |
| discharge    | individualised   |
| assessment   | exercise plan    |
Process items 
Outcome items 
| Start date within       | Patients     |
|-------------------------|--------------|
| 90 days of              | undertaking  |
| receipt of              | practice     |
| board name              | Service name |
| Cases                   |              |
| audited                 | referral*    |
| National QI aim         | 85%          |
| National result         | 2,792        |
| Camden COPD and         |              |
| Home Oxygen Service     |              |
| 23                      | 15           |
| Central and North       |              |
| West London NHS         |              |
| Foundation Trust        |              |
| 28                      | 8            |
| Central and North       |              |
| West London NHS         |              |
| Foundation Trust        |              |
| Milton Keynes           |              |
| Community Pulmonary     |              |
| Rehabilitation Service  |              |
| Barnet COPD Respiratory |              |
| Service                 |              |
| 40                      | 33           |
| Central London          |              |
| Community               |              |
| Healthcare NHS          |              |
| Trust                   |              |
| Harrow COPD             |              |
| Respiratory Service     |              |
| 14                      | 9            |
| Central London          |              |
| Community               |              |
| Healthcare NHS          |              |
| Trust                   |              |
| Merton Pulmonary        |              |
| Rehabilitation Service  |              |
| 36                      | 27           |
| Central London          |              |
| Community               |              |
| Healthcare NHS          |              |
| Trust                   |              |
| Patients     | Patients with    |
|--------------|------------------|
| enrolled for |                  |
| PR who       |                  |
| a discharge  |                  |
| assessment   |                  |
| subsequently | who received     |
| have a       | a written        |
| discharge    | individualised   |
| assessment   | exercise plan    |
Outcome items 
| Start date within       | Patients     |
|-------------------------|--------------|
| 90 days of              | undertaking  |
| receipt of              | practice     |
| board name              | Service name |
| Cases                   |              |
| audited                 | referral*    |
| National QI aim         | 85%          |
| National result         | 2,792        |
| 66                      | 34           |
| West Hertfordshire      |              |
| Community Respiratory   |              |
| Service                 |              |
| Central London          |              |
| Community               |              |
| Healthcare NHS          |              |
| Trust                   |              |
| 32                      | 6            |
| Cheshire and Wirral     |              |
| Partnership Respiratory |              |
| Service                 |              |
| Cheshire and            |              |
| Wirral                  |              |
| Partnership NHS         |              |
| Foundation Trust        |              |
11 
City Health Care Partnership CIC 
East Riding Pulmonary Rehabilitation Programme 
City Health Care Partnership CIC 
Rehabilitation Team 
Cornwall Partnership NHS Foundation Trust 
Cornwall (ICRTEC) 
| Patients     | Patients with    |
|--------------|------------------|
| enrolled for |                  |
| PR who       |                  |
| a discharge  |                  |
| assessment   |                  |
| subsequently | who received     |
| have a       | a written        |
| discharge    | individualised   |
| assessment   | exercise plan    |
| Start date within    | Patients     |
|----------------------|--------------|
| 90 days of           | undertaking  |
| receipt of           | practice     |
| board name           | Service name |
| Cases                |              |
| audited              | referral*    |
| National QI aim      | 85%          |
| National result      | 2,792        |
9 
0 
0% 
Partnership NHS Foundation Trust 
Cornwall Pulmonary Rehabilitation Programme 
and Darlington NHS Foundation 
| Patients     | Patients with    |
|--------------|------------------|
| enrolled for |                  |
| PR who       |                  |
| a discharge  |                  |
| assessment   |                  |
| subsequently | who received     |
| have a       | a written        |
| discharge    | individualised   |
| assessment   | exercise plan    |
Process items 
Outcome items 
| Start date within       | Patients     |
|-------------------------|--------------|
| 90 days of              | undertaking  |
| receipt of              | practice     |
| board name              | Service name |
| Cases                   |              |
| audited                 | referral*    |
| National QI aim         | 85%          |
| National result         | 2,792        |
| 38                      | 20           |
| Croydon Health          |              |
| Services NHS            |              |
| Trust                   |              |
| Croydon Pulmonary       |              |
| Rehabilitation          |              |
| Programme               |              |
| CSH Surrey              | 29           |
| CSH Surrey Pulmonary    |              |
| Rehabilitation          |              |
| Programme               |              |
| CSH Surrey              |              |
| North West Surrey       |              |
| Respiratory Care Team   |              |
| 15                      | <5           |
| 14                      | 0            |
| North Derbyshire        |              |
| Community Respiratory   |              |
| Service                 |              |
| Derbyshire              |              |
| Community               |              |
| Health Services         |              |
| NHS Foundation          |              |
| Trust                   |              |
| Doncaster Pulmonary     |              |
| Rehabilitation Services |              |
| 60                      | 41           |
| Doncaster And           |              |
| Bassetlaw               |              |
| Teaching                |              |
| Hospitals NHS           |              |
| Foundation Trust        |              |
| Patients     | Patients with    |
|--------------|------------------|
| enrolled for |                  |
| PR who       |                  |
| a discharge  |                  |
| assessment   |                  |
| subsequently | who received     |
| have a       | a written        |
| discharge    | individualised   |
| assessment   | exercise plan    |
Process items 
Outcome items 
| Start date within       | Patients     |
|-------------------------|--------------|
| 90 days of              | undertaking  |
| receipt of              | practice     |
| board name              | Service name |
| Cases                   |              |
| audited                 | referral*    |
| National QI aim         | 85%          |
| National result         | 2,792        |
| Dorset Pulmonary        |              |
| Rehabilitation service  |              |
| 33                      | 21           |
| Dorset County           |              |
| Hospital NHS            |              |
| Foundation Trust        |              |
| 63                      | 16           |
| Dorset Healthcare       |              |
| University NHS          |              |
| Foundation Trust        |              |
| Dorset Healthcare       |              |
| Pulmonary               |              |
| Rehabilitation          |              |
| Programme               |              |
| East Cheshire NHS       |              |
| Trust                   |              |
| East Cheshire Pulmonary |              |
| Rehabilitation Service  |              |
| 10                      | 7            |
| ELHT Pulmonary          |              |
| Rehabilitation Service  |              |
| 24                      | 10           |
| East Lancashire         |              |
| Hospitals NHS           |              |
| Trust                   |              |
| East Suffolk Pulmonary  |              |
| Rehabilitation Service  |              |
| 84                      | 29           |
| East Suffolk and        |              |
| North Essex NHS         |              |
| Foundation Trust        |              |
| 35                      | 14           |
| East Sussex             |              |
| Healthcare NHS          |              |
| Trust                   |              |
| Regional East Sussex    |              |
| Pulmonary Service       |              |
| (RESPS)                 |              |
| Patients     | Patients with    |
|--------------|------------------|
| enrolled for |                  |
| PR who       |                  |
| a discharge  |                  |
| assessment   |                  |
| subsequently | who received     |
| have a       | a written        |
| discharge    | individualised   |
| assessment   | exercise plan    |
Outcome items 
| Start date within      | Patients     |
|------------------------|--------------|
| 90 days of             | undertaking  |
| receipt of             | practice     |
| board name             | Service name |
| Cases                  |              |
| audited                | referral*    |
| National QI aim        | 85%          |
| National result        | 2,792        |
| 23                     | 12           |
| Essex Partnership      |              |
| University NHS         |              |
| Foundation Trust       |              |
| EPUT Pulmonary         |              |
| Rehabilitation         |              |
| Programme              |              |
| 12                     | <5           |
| First Community        |              |
| Health and Care        |              |
| CIC                    |              |
| First Community Health |              |
| and Care - Surrey      |              |
| Community Respiratory  |              |
| Service                |              |
| AIR Service            | 44           |
| Frimley Health         |              |
| NHS Foundation         |              |
| Trust                  |              |
| 24                     | <5           |
| Gateshead Health       |              |
| NHS Foundation         |              |
| Trust                  |              |
| Gateshead Acute        |              |
| Pulmonary              |              |
| Rehabilitation Service |              |
| 10                     | 5            |
| George Eliot           |              |
| Hospital NHS           |              |
| Trust                  |              |
| George Eliot Hospital  |              |
| Pulmonary              |              |
| Rehabilitation -       |              |
| Physiotherapy          |              |
| One Gloucestershire    |              |
| Respiratory Service    |              |
| 40                     | 21           |
| Gloucestershire        |              |
| Care Services NHS      |              |
| Trust                  |              |
| Patients     | Patients with    |
|--------------|------------------|
| enrolled for |                  |
| PR who       |                  |
| a discharge  |                  |
| assessment   |                  |
| subsequently | who received     |
| have a       | a written        |
| discharge    | individualised   |
| assessment   | exercise plan    |
| Start date within    | Patients     |
|----------------------|--------------|
| 90 days of           | undertaking  |
| receipt of           | practice     |
| board name           | Service name |
| Cases                |              |
| audited              | referral*    |
| National QI aim      | 85%          |
| National result      | 2,792        |
| 55                   | 15           |
| Guy's and St         |              |
| Thomas' NHS          |              |
| Foundation Trust     |              |
| St Thomas' Hospital  |              |
| Pulmonary            |              |
| Rehabilitation       |              |
| Programme            |              |
18 
10 
<5 
Harrogate and District NHS Foundation Trust 
Harrogate Respiratory and Cardiac Physiotherapy 
Hertfordshire Community NHS Trust 
Hertfordshire Community Pulmonary Rehab Service 
Homerton University Hospital NHS Foundation Trust 
Cardiorespiratory Enhanced and Responsive service (ACERs) 
| Patients     | Patients with    |
|--------------|------------------|
| enrolled for |                  |
| PR who       |                  |
| a discharge  |                  |
| assessment   |                  |
| subsequently | who received     |
| have a       | a written        |
| discharge    | individualised   |
| assessment   | exercise plan    |
| Start date within    | Patients     |
|----------------------|--------------|
| 90 days of           | undertaking  |
| receipt of           | practice     |
| board name           | Service name |
| Cases                |              |
| audited              | referral*    |
| National QI aim      | 85%          |
| National result      | 2,792        |
Richmond Respiratory Care Team 
15 
86% 
5 
Richmond Community Healthcare NHS Healthcare NHS Healthcare NHS 
enrolled for 
PR who 
a discharge 
assessment 
subsequently 
who received 
have a 
a written 
Improvement 
Improvement 
discharge 
individualised 
in exercise 
in health 
assessment 
exercise plan 
capacity 
status 
Outcome items 
| Start date within       | Patients     |
|-------------------------|--------------|
| 90 days of              | undertaking  |
| receipt of              | practice     |
| board name              | Service name |
| Cases                   |              |
| audited                 | referral*    |
| National QI aim         | 85%          |
| National result         | 2,792        |
| 147                     | 29           |
| Kent Community          |              |
| Health NHS              |              |
| Foundation Trust        |              |
| Kent Community Health   |              |
| Pulmonary               |              |
| Rehabilitation Team     |              |
| Rocket Team Kettering   |              |
| General Hospital        |              |
| 70                      | 43           |
| Kettering General       |              |
| Hospital NHS            |              |
| Foundation Trust        |              |
| 34                      | <5           |
| King's College          |              |
| Hospital NHS            |              |
| Foundation Trust        |              |
| King's College Hospital |              |
| Pulmonary               |              |
| Rehabilitation Team     |              |
10 
Lancashire Care NHS Foundation Trust 
Blackburn with Darwen Pulmonary Rehabilitation Team 
53 
22 
Lancashire Care NHS Foundation Trust 
Central Lancashire Pulmonary Rehabilitation Service 
| Patients     | Patients with    |
|--------------|------------------|
| enrolled for |                  |
| PR who       |                  |
| a discharge  |                  |
| assessment   |                  |
| subsequently | who received     |
| have a       | a written        |
| discharge    | individualised   |
| assessment   | exercise plan    |
Outcome items 
| Start date within      | Patients     |
|------------------------|--------------|
| 90 days of             | undertaking  |
| receipt of             | practice     |
| board name             | Service name |
| Cases                  |              |
| audited                | referral*    |
| National QI aim        | 85%          |
| National result        | 2,792        |
| 23                     | 5            |
| Leeds Community        |              |
| Healthcare NHS         |              |
| Trust                  |              |
| Leeds Community        |              |
| Healthcare, Community  |              |
| Respiratory Service    |              |
| 54                     | 28           |
| Leicestershire         |              |
| Partnership NHS        |              |
| Trust                  |              |
| Leicestershire         |              |
| Partnership Pulmonary  |              |
| Rehabilitation Team    |              |
| Guy's and St Thomas'   |              |
| NHS Foundation Trust   |              |
| 21                     | 16           |
| Lewisham and           |              |
| Greenwich NHS          |              |
| Trust                  |              |
| 12                     | <5           |
| Lincolnshire           |              |
| Community              |              |
| Health Services        |              |
| NHS Trust              |              |
| Lincolnshire Community |              |
| Health Services        |              |
| Pulmonary              |              |
| Rehabilitation Service |              |
Knowsley Community Respiratory Service 
28 
12 
57% 
74% 
9 
Liverpool Heart and Chest Hospital NHS Foundation Trust 
| Patients     | Patients with    |
|--------------|------------------|
| enrolled for |                  |
| PR who       |                  |
| a discharge  |                  |
| assessment   |                  |
| subsequently | who received     |
| have a       | a written        |
| discharge    | individualised   |
| assessment   | exercise plan    |
| Start date within     | Patients     |
|-----------------------|--------------|
| 90 days of            | undertaking  |
| receipt of            | practice     |
| board name            | Service name |
| Cases                 |              |
| audited               | referral*    |
| National QI aim       | 85%          |
| National result       | 2,792        |
| The Breathe Programme | 56           |
| Liverpool Heart       |              |
| and Chest             |              |
| Hospital NHS          |              |
| Foundation Trust      |              |
University Hospitals NHS Foundation Trust Southwest 
| Patients     | Patients with    |
|--------------|------------------|
| enrolled for |                  |
| PR who       |                  |
| a discharge  |                  |
| assessment   |                  |
| subsequently | who received     |
| have a       | a written        |
| discharge    | individualised   |
| assessment   | exercise plan    |
Outcome items 
| Start date within      | Patients     |
|------------------------|--------------|
| 90 days of             | undertaking  |
| receipt of             | practice     |
| board name             | Service name |
| Cases                  |              |
| audited                | referral*    |
| National QI aim        | 85%          |
| National result        | 2,792        |
| Ealing Pulmonary       |              |
| Rehabilitation service |              |
| <5                     | <5           |
| London North           |              |
| West University        |              |
| Healthcare NHS         |              |
| Trust                  |              |
| 70                     | 36           |
| Luton and Dunstable    |              |
| Hospital Pulmonary     |              |
| Rehabilitation Service |              |
| Luton and              |              |
| Dunstable              |              |
| University             |              |
| Hospital NHS           |              |
| Foundation Trust       |              |
| West Kent Pulmonary    |              |
| Rehabilitation Service |              |
| 41                     | 7            |
| Maidstone and          |              |
| Tunbridge Wells        |              |
| NHS Trust              |              |
| Manchester Community   |              |
| Respiratory Service    |              |
| 36                     | 21           |
| Manchester             |              |
| University NHS         |              |
| Foundation Trust       |              |
| 24                     | 13           |
| Manchester             |              |
| University NHS         |              |
| Foundation Trust       |              |
| Manchester Integrated  |              |
| Lung Service - Central |              |
| site                   |              |
| Patients     | Patients with    |
|--------------|------------------|
| enrolled for |                  |
| PR who       |                  |
| a discharge  |                  |
| assessment   |                  |
| subsequently | who received     |
| have a       | a written        |
| discharge    | individualised   |
| assessment   | exercise plan    |
Process items 
Outcome items 
| Start date within      | Patients     |
|------------------------|--------------|
| 90 days of             | undertaking  |
| receipt of             | practice     |
| board name             | Service name |
| Cases                  |              |
| audited                | referral*    |
| National QI aim        | 85%          |
| National result        | 2,792        |
| 9                      | 5            |
| Manchester             |              |
| University NHS         |              |
| Foundation Trust       |              |
| Manchester Royal       |              |
| Infirmary Pulmonary    |              |
| Rehabilitation Service |              |
| Medway Community       |              |
| Respiratory Team       |              |
| 45                     | 19           |
| Medway                 |              |
| Community              |              |
| Healthcare             |              |
| Mersey Care NHS        |              |
| Foundation Trust       |              |
| Sefton Community       |              |
| Respiratory Service    |              |
| 24                     | 6            |
| 32                     | <5           |
| Mid Cheshire           |              |
| Hospitals NHS          |              |
| Foundation Trust       |              |
| Central Cheshire       |              |
| Integrated Care        |              |
| Partnership Pulmonary  |              |
| Rehabilitation Service |              |
| 49                     | 33           |
| Mid Yorkshire          |              |
| Hospitals NHS          |              |
| Trust                  |              |
| Mid Yorkshire Therapy  |              |
| Services - Community   |              |
| Pulmonary              |              |
| Rehabilitation         |              |
| Midland Partnership    |              |
| South Respiratory Team |              |
| 23                     | 17           |
| Midlands               |              |
| Partnership NHS        |              |
| Foundation Trust       |              |
| Patients     | Patients with    |
|--------------|------------------|
| enrolled for |                  |
| PR who       |                  |
| a discharge  |                  |
| assessment   |                  |
| subsequently | who received     |
| have a       | a written        |
| discharge    | individualised   |
| assessment   | exercise plan    |
| Start date within       | Patients     |
|-------------------------|--------------|
| 90 days of              | undertaking  |
| receipt of              | practice     |
| board name              | Service name |
| Cases                   |              |
| audited                 | referral*    |
| National QI aim         | 85%          |
| National result         | 2,792        |
| 102                     | 29           |
| Midlands                |              |
| Partnership NHS         |              |
| Foundation Trust        |              |
| Midlands Partnership -  |              |
| North Staffordshire and |              |
| Stoke on Trent          |              |
| Pulmonary               |              |
| Rehabilitation Team     |              |
6 
0 
0% 
6 
0 
0% 
Norfolk and Norwich Pulmonary Rehabilitation Service 
Norfolk and Norwich University Hospitals NHS Foundation Trust 
75 
44 
60% 
Norfolk Community Pulmonary Rehabilitation Service 
Norfolk Community Health and Care NHS Trust Trust 
Programme (LEEP) 
Integrated Care NHS Foundation 
| Patients     | Patients with    |
|--------------|------------------|
| enrolled for |                  |
| PR who       |                  |
| a discharge  |                  |
| assessment   |                  |
| subsequently | who received     |
| have a       | a written        |
| discharge    | individualised   |
| assessment   | exercise plan    |
Outcome items 
| Start date within       | Patients     |
|-------------------------|--------------|
| 90 days of              | undertaking  |
| receipt of              | practice     |
| board name              | Service name |
| Cases                   |              |
| audited                 | referral*    |
| National QI aim         | 85%          |
| National result         | 2,792        |
| 12                      | <5           |
| North Cumbria           |              |
| Integrated Care         |              |
| NHS Foundation          |              |
| Trust                   |              |
| North Cumbria Hospitals |              |
| Pulmonary               |              |
| Rehabilitation          |              |
| Programme               |              |
Solway Community Respiratory Team 
11 
0 
0% 
8 
80% 
North Cumbria Integrated Care NHS Foundation Trust 
38 
Community Respiratory 
North Cumbria Integrated Care NHS Foundation Trust Foundation Trust Foundation Trust 
| Patients     | Patients with    |
|--------------|------------------|
| enrolled for |                  |
| PR who       |                  |
| a discharge  |                  |
| assessment   |                  |
| subsequently | who received     |
| have a       | a written        |
| discharge    | individualised   |
| assessment   | exercise plan    |
| Start date within     | Patients     |
|-----------------------|--------------|
| 90 days of            | undertaking  |
| receipt of            | practice     |
| board name            | Service name |
| Cases                 |              |
| audited               | referral*    |
| National QI aim       | 85%          |
| National result       | 2,792        |
| Redbridge Respiratory |              |
| Service               |              |
| 30                    | <5           |
| North East            |              |
| London NHS            |              |
| Foundation Trust      |              |
Foundation Trust 
| Patients     | Patients with    |
|--------------|------------------|
| enrolled for |                  |
| PR who       |                  |
| a discharge  |                  |
| assessment   |                  |
| subsequently | who received     |
| have a       | a written        |
| discharge    | individualised   |
| assessment   | exercise plan    |
Outcome items 
| Start date within      | Patients     |
|------------------------|--------------|
| 90 days of             | undertaking  |
| receipt of             | practice     |
| board name             | Service name |
| Cases                  |              |
| audited                | referral*    |
| National QI aim        | 85%          |
| National result        | 2,792        |
| 25                     | 16           |
| North West             |              |
| Anglia NHS             |              |
| Foundation Trust       |              |
| Peterborough           |              |
| Pulmonary              |              |
| Rehabilitation Service |              |
| St. Helens Pulmonary   |              |
| Rehabilitation Service |              |
| 62                     | 37           |
| North West             |              |
| Boroughs               |              |
| Healthcare NHS         |              |
| Foundation Trust       |              |
| 28                     | 10           |
| Northampton            |              |
| General Hospital       |              |
| NHS Trust              |              |
| Restart Team -         |              |
| Northampton General    |              |
| Hospital               |              |
| North Devon Pulmonary  |              |
| Rehabilitation Service |              |
| 9                      | <5           |
| Northern Devon         |              |
| Healthcare NHS         |              |
| Trust                  |              |
| 81                     | 29           |
| Northumbria            |              |
| Healthcare NHS         |              |
| Foundation Trust       |              |
| Northumbria Healthcare |              |
| Pulmonary              |              |
| Rehabilitation Service |              |
| Nottingham Integrated  |              |
| Respiratory Service    |              |
| 59                     | 39           |
| Nottingham             |              |
| Citycare               |              |
| Partnership            |              |
| Patients     | Patients with    |
|--------------|------------------|
| enrolled for |                  |
| PR who       |                  |
| a discharge  |                  |
| assessment   |                  |
| subsequently | who received     |
| have a       | a written        |
| discharge    | individualised   |
| assessment   | exercise plan    |
Process items 
Outcome items 
| Start date within         | Patients     |
|---------------------------|--------------|
| 90 days of                | undertaking  |
| receipt of                | practice     |
| board name                | Service name |
| Cases                     |              |
| audited                   | referral*    |
| National QI aim           | 85%          |
| National result           | 2,792        |
| Mansfield and Ashfield    |              |
| Respiratory Service       |              |
| 21                        | 13           |
| Nottinghamshire           |              |
| Healthcare NHS            |              |
| Foundation Trust          |              |
| 14                        | 6            |
| Nottinghamshire           |              |
| Healthcare NHS            |              |
| Foundation Trust          |              |
| Nottingham North and      |              |
| East Adult Community      |              |
| Services                  |              |
| Rushcliffe                |              |
| Cardiorespiratory service |              |
| 21                        | <5           |
| Nottinghamshire           |              |
| Healthcare NHS            |              |
| Foundation Trust          |              |
| Oxfordshire Pulmonary     |              |
| Rehabilitation Service    |              |
| 59                        | 6            |
| Oxford Health             |              |
| NHS Foundation            |              |
| Trust                     |              |
| Oxleas NHS                |              |
| Foundation Trust          |              |
| Greenwich Pulmonary       |              |
| Rehabilitation Team       |              |
| 17                        | 9            |
| 40                        | 18           |
| Pennine Acute             |              |
| Hospitals NHS             |              |
| Trust                     |              |
| Acute Respiratory         |              |
| Assessment Service        |              |
| (ARAS) COPD support       |              |
| team - North              |              |
| Manchester                |              |
| Patients     | Patients with    |
|--------------|------------------|
| enrolled for |                  |
| PR who       |                  |
| a discharge  |                  |
| assessment   |                  |
| subsequently | who received     |
| have a       | a written        |
| discharge    | individualised   |
| assessment   | exercise plan    |
| Process items              | Outcome items    |
|----------------------------|------------------|
|                            |                  |
| Start date within          | Patients         |
| 90 days of                 | undertaking      |
| receipt of                 | practice         |
| board name                 | Service name     |
| Cases                      |                  |
| audited                    | referral*        |
| National QI aim            | 85%              |
| National result            | 2,792            |
| <5                         | -                |
| Pennine Acute              |                  |
| Hospitals NHS              |                  |
| Trust                      |                  |
| Enhanced Respiratory       |                  |
| Service (ERS) - Rochdale   |                  |
| Infirmary                  |                  |
| Pennine Lung Service       | 51               |
| Pennine Acute              |                  |
| Hospitals NHS              |                  |
| Trust                      |                  |
| 6                          | 0                |
| Pennine Acute              |                  |
| Hospitals NHS              |                  |
| Trust                      |                  |
| Pennine Pulmonary          |                  |
| Rehabilitation - Fairfield |                  |
| Hospital                   |                  |
| Pennine Care NHS           |                  |
| Foundation Trust           |                  |
| Trafford Pulmonary         |                  |
| Rehabilitation Service     |                  |
| 38                         | 10               |
| Provide                    | 15               |
| Provide -                  |                  |
| Cambridgeshire             |                  |
| Pulmonary                  |                  |
| Rehabilitation             |                  |
| Provide                    | 33               |
| Provide - Mid-Essex        |                  |
| Pulmonary                  |                  |
| Rehabilitation             |                  |
| Respiricare                |                  |
| Limited                    |                  |
| Swale Pulmonary            |                  |
| Rehabilitation             |                  |
| 14                         | -                |
| Patients     | Patients with    |
|--------------|------------------|
| enrolled for |                  |
| PR who       |                  |
| a discharge  |                  |
| assessment   |                  |
| subsequently | who received     |
| have a       | a written        |
| discharge    | individualised   |
| assessment   | exercise plan    |
Outcome items 
| Start date within        | Patients     |
|--------------------------|--------------|
| 90 days of               | undertaking  |
| receipt of               | practice     |
| board name               | Service name |
| Cases                    |              |
| audited                  | referral*    |
| National QI aim          | 85%          |
| National result          | 2,792        |
| 6                        | <5           |
| Royal Berkshire          |              |
| NHS Foundation           |              |
| Trust                    |              |
| Royal Berkshire Hospital |              |
| Pulmonary                |              |
| Rehabilitation Service   |              |
| 78                       | 46           |
| Royal Brompton           |              |
| & Harefield NHS          |              |
| Foundation Trust         |              |
| Harefield Hospital       |              |
| Pulmonary                |              |
| Rehabilitation           |              |
| <5                       | <5           |
| Royal Brompton           |              |
| & Harefield NHS          |              |
| Foundation Trust         |              |
| Royal Brompton           |              |
| Pulmonary                |              |
| Rehabilitation Service   |              |
| 7                        | <5           |
| Royal Devon and          |              |
| Exeter NHS               |              |
| Foundation Trust         |              |
| Royal Devon and Exeter   |              |
| Pulmonary                |              |
| Rehabilitation/Physiothe |              |
| rapy Service             |              |
Royal Surrey County Hospital NHS Foundation Trust 
| Patients     | Patients with    |
|--------------|------------------|
| enrolled for |                  |
| PR who       |                  |
| a discharge  |                  |
| assessment   |                  |
| subsequently | who received     |
| have a       | a written        |
| discharge    | individualised   |
| assessment   | exercise plan    |
Outcome items 
| Start date within     | Patients     |
|-----------------------|--------------|
| 90 days of            | undertaking  |
| receipt of            | practice     |
| board name            | Service name |
| Cases                 |              |
| audited               | referral*    |
| National QI aim       | 85%          |
| National result       | 2,792        |
| RUH Respiratory       |              |
| Outpatient Department |              |
| <5                    | <5           |
| Royal United          |              |
| Hospitals Bath        |              |
| NHS Foundation        |              |
| Trust                 |              |
25 
12 
71% 
0 
8 
19 
Salford Royal NHS Foundation Trust 
Salford's Breathing Better Pulmonary Rehabilitation Programme 
14 
8 
Salisbury NHS Foundation Trust 
and Education Programme (LEEP) 
Sandwell and West Birmingham Hospitals NHS Trust Sheffield Teaching Hospitals NHS Foundation Trust 
| Patients     | Patients with    |
|--------------|------------------|
| enrolled for |                  |
| PR who       |                  |
| a discharge  |                  |
| assessment   |                  |
| subsequently | who received     |
| have a       | a written        |
| discharge    | individualised   |
| assessment   | exercise plan    |
Process items 
Outcome items 
| Start date within      | Patients     |
|------------------------|--------------|
| 90 days of             | undertaking  |
| receipt of             | practice     |
| board name             | Service name |
| Cases                  |              |
| audited                | referral*    |
| National QI aim        | 85%          |
| National result        | 2,792        |
| Shropshire Pulmonary   |              |
| Rehabilitation         |              |
| 30                     | 12           |
| Shropshire             |              |
| Community              |              |
| Health NHS Trust       |              |
| 15                     | 12           |
| Sirona Care &          |              |
| Health                 |              |
| South Gloucestershire  |              |
| Pulmonary              |              |
| Rehabilitation         |              |
| Solent NHS Trust       | <5           |
| Hampshire Pulmonary    |              |
| Rehabilitation         |              |
| Programme              |              |
| Solent NHS Trust       | <5           |
| Portsmouth Pulmonary   |              |
| Rehabilitation         |              |
| Programme              |              |
| Solent NHS Trust       |              |
| Southampton Integrated |              |
| COPD Team              |              |
| 60                     | 40           |
| 25                     | 19           |
| South Tyneside         |              |
| and Sunderland         |              |
| NHS Foundation         |              |
| Trust                  |              |
| South Tyneside         |              |
| Pulmonary              |              |
| Rehabilitation         |              |
| Programme (Acute)      |              |
| Patients     | Patients with    |
|--------------|------------------|
| enrolled for |                  |
| PR who       |                  |
| a discharge  |                  |
| assessment   |                  |
| subsequently | who received     |
| have a       | a written        |
| discharge    | individualised   |
| assessment   | exercise plan    |
| Start date within    | Patients     |
|----------------------|--------------|
| 90 days of           | undertaking  |
| receipt of           | practice     |
| board name           | Service name |
| Cases                |              |
| audited              | referral*    |
| National QI aim      | 85%          |
| National result      | 2,792        |
18 
10 
83% 
0 
7 
and Sunderland NHS Foundation 
Sunderland Community 
Pulmonary Rehabilitation Programme Physiotherapy Services 
9 
<5 
NHS Foundation 
enrolled for 
PR who 
assessment 
|            |                | subsequently    | who received    |
|------------|----------------|-----------------|-----------------|
| have a     | a written      | Improvement     | Improvement     |
| discharge  | individualised | in exercise     | in health       |
| assessment | exercise plan  | capacity        | status          |
Outcome items 
| Start date within      | Patients     |
|------------------------|--------------|
| 90 days of             | undertaking  |
| receipt of             | practice     |
| board name             | Service name |
| Cases                  |              |
| audited                | referral*    |
| National QI aim        | 85%          |
| National result        | 2,792        |
| 5                      | 5            |
| Southport and          |              |
| Ormskirk Hospital      |              |
| NHS Trust              |              |
| West Lancashire        |              |
| Pulmonary              |              |
| Rehabilitation         |              |
| Wandsworth Pulmonary   |              |
| Rehabilitation Service |              |
| 7                      | <5           |
| St George's            |              |
| University             |              |
| Hospitals NHS          |              |
| Foundation Trust       |              |
| 40                     | 19           |
| Stockport NHS          |              |
| Foundation Trust       |              |
| Stockport Pulmonary &  |              |
| Heart Failure          |              |
| Rehabilitation Service |              |
| COPD Coastal Service   | <5           |
| Sussex                 |              |
| Community NHS          |              |
| Foundation Trust       |              |
| 43                     | 28           |
| Sussex                 |              |
| Community NHS          |              |
| Foundation Trust       |              |
| Crawley Horsham and    |              |
| Mid Sussex COPD Adult  |              |
| Community Services     |              |
| 23                     | 17           |
| Sussex                 |              |
| Community NHS          |              |
| Foundation Trust       |              |
| Sussex Community       |              |
| Respiratory Service    |              |
| Brighton and Hove      |              |
| Patients     | Patients with    |
|--------------|------------------|
| enrolled for |                  |
| PR who       |                  |
| a discharge  |                  |
| assessment   |                  |
| subsequently | who received     |
| have a       | a written        |
| discharge    | individualised   |
| assessment   | exercise plan    |
Outcome items 
| Start date within       | Patients     |
|-------------------------|--------------|
| 90 days of              | undertaking  |
| receipt of              | practice     |
| board name              | Service name |
| Cases                   |              |
| audited                 | referral*    |
| National QI aim         | 85%          |
| National result         | 2,792        |
| 20                      | 12           |
| Sussex                  |              |
| Community NHS           |              |
| Foundation Trust        |              |
| The High Weald Lewis    |              |
| and Haven Community     |              |
| Respiratory Service     |              |
| 14                      | 0            |
| Tameside and Glossop    |              |
| Pulmonary               |              |
| Rehabilitation          |              |
| Tameside and            |              |
| Glossop                 |              |
| Integrated Care         |              |
| NHS Foundation          |              |
| Trust                   |              |
| 53                      | 39           |
| The Dudley Group        |              |
| NHS Foundation          |              |
| Trust                   |              |
| Dudley Pulmonary        |              |
| Rehabilitation          |              |
| Programme               |              |
| The Newcastle Hospitals |              |
| Respiratory Services    |              |
| 15                      | 7            |
| The Newcastle           |              |
| Upon Tyne               |              |
| Hospitals NHS           |              |
| Foundation Trust        |              |
Rotherham Breathing Space 
71 
30 
58% 
99% 
The Rotherham NHS Foundation Trust 
| Patients     | Patients with    |
|--------------|------------------|
| enrolled for |                  |
| PR who       |                  |
| a discharge  |                  |
| assessment   |                  |
| subsequently | who received     |
| have a       | a written        |
| discharge    | individualised   |
| assessment   | exercise plan    |
| Start date within    | Patients     |
|----------------------|--------------|
| 90 days of           | undertaking  |
| receipt of           | practice     |
| board name           | Service name |
| Cases                |              |
| audited              | referral*    |
| National QI aim      | 85%          |
| National result      | 2,792        |
- 
- 
- 
- 
- 
Hospital's Pulmonary Rehabilitation Service 
The Royal 
Bournemouth And Christchurch Hospitals NHS Foundation Trust 
Sutton Community Respiratory Service 
The Royal Marsden NHS Foundation Trust The Royal Wolverhampton NHS Trust 
Pulmonary Rehabilitation Service 
Torbay and South Devon NHS Foundation Trust 
Pulmonary Rehabilitation Programme 
University Hospital Southampton NHS Foundation 
| Patients     | Patients with    |
|--------------|------------------|
| enrolled for |                  |
| PR who       |                  |
| a discharge  |                  |
| assessment   |                  |
| subsequently | who received     |
| have a       | a written        |
| discharge    | individualised   |
| assessment   | exercise plan    |
Process items 
Outcome items 
| Start date within        | Patients     |
|--------------------------|--------------|
| 90 days of               | undertaking  |
| receipt of               | practice     |
| board name               | Service name |
| Cases                    |              |
| audited                  | referral*    |
| National QI aim          | 85%          |
| National result          | 2,792        |
| Solihull Community       |              |
| Respiratory Team         |              |
| 42                       | 16           |
| University               |              |
| Hospitals                |              |
| Birmingham NHS           |              |
| Foundation Trust         |              |
| 72                       | 14           |
| University               |              |
| Hospitals                |              |
| Birmingham NHS           |              |
| Foundation Trust         |              |
| University Hospitals     |              |
| Birmingham HGS           |              |
| Pulmonary                |              |
| Rehabilitation           |              |
| Programme                |              |
| Derby and Burton         |              |
| ImpACT+                  |              |
| 54                       | 13           |
| University               |              |
| Hospitals of             |              |
| Derby and Burton         |              |
| NHS Foundation           |              |
| Trust                    |              |
| 91                       | 13           |
| University               |              |
| Hospitals of             |              |
| Leicester NHS            |              |
| Trust                    |              |
| Glenfield and Leicester  |              |
| Hospitals Pulmonary      |              |
| Rehabilitation           |              |
| Programme                |              |
| Virgin Care Ltd          |              |
| Surrey Heath Respiratory |              |
| Care Team                |              |
| 14                       | <5           |
| Patients     | Patients with    |
|--------------|------------------|
| enrolled for |                  |
| PR who       |                  |
| a discharge  |                  |
| assessment   |                  |
| subsequently | who received     |
| have a       | a written        |
| discharge    | individualised   |
| assessment   | exercise plan    |
Outcome items 
| Start date within      | Patients     |
|------------------------|--------------|
| 90 days of             | undertaking  |
| receipt of             | practice     |
| board name             | Service name |
| Cases                  |              |
| audited                | referral*    |
| National QI aim        | 85%          |
| National result        | 2,792        |
| Virgin Care Ltd        | 24           |
| Virgin Care Community  |              |
| Respiratory Service -  |              |
| Bath and North East    |              |
| Somerset               |              |
| Walsall Pulmonary      |              |
| Rehabilitation Service |              |
| <5                     | <5           |
| Walsall                |              |
| Healthcare NHS         |              |
| Trust                  |              |
| 69                     | 40           |
| The Warrington &       |              |
| Halton Pulmonary       |              |
| Rehabilitation Service |              |
| Warrington and         |              |
| Halton Hospitals       |              |
| NHS Foundation         |              |
| Trust                  |              |
| West Suffolk NHS       |              |
| Foundation Trust       |              |
West Suffolk Pulmonary Rehabilitation Service 
44 
Western Sussex Hospitals NHS Foundation Trust 
Pulmonary Rehabilitation 
| Patients     | Patients with    |
|--------------|------------------|
| enrolled for |                  |
| PR who       |                  |
| a discharge  |                  |
| assessment   |                  |
| subsequently | who received     |
| have a       | a written        |
| discharge    | individualised   |
| assessment   | exercise plan    |
Outcome items 
| Start date within       | Patients     |
|-------------------------|--------------|
| 90 days of              | undertaking  |
| receipt of              | practice     |
| board name              | Service name |
| Cases                   |              |
| audited                 | referral*    |
| National QI aim         | 85%          |
| National result         | 2,792        |
| 34                      | 21           |
| Western Sussex          |              |
| Hospitals NHS           |              |
| Foundation Trust        |              |
| Worthing and            |              |
| Southlands Pulmonary    |              |
| Rehabilitation          |              |
| Programme               |              |
| 54                      | 42           |
| Whittington             |              |
| Health NHS Trust        |              |
| Whittington Health      |              |
| Pulmonary               |              |
| Rehabilitation          |              |
| Wiltshire Health        |              |
| and Care                |              |
| Wiltshire Community     |              |
| Respiratory Team        |              |
| 27                      | 11           |
| 56                      | 27           |
| Wirral COPD, Pulmonary  |              |
| Rehabilitation & Oxygen |              |
| Service                 |              |
| Wirral University       |              |
| Teaching Hospital       |              |
| NHS Foundation          |              |
| Trust                   |              |
| Worcestershire COPD     |              |
| Team                    |              |
| 58                      | 22           |
| Worcestershire          |              |
| Acute Hospitals         |              |
| NHS Trust               |              |
| Patients     | Patients with    |
|--------------|------------------|
| enrolled for |                  |
| PR who       |                  |
| a discharge  |                  |
| assessment   |                  |
| subsequently | who received     |
| have a       | a written        |
| discharge    | individualised   |
| assessment   | exercise plan    |
Outcome items 
| Start date within        | Patients     |
|--------------------------|--------------|
| 90 days of               | undertaking  |
| receipt of               | practice     |
| board name               | Service name |
| Cases                    |              |
| audited                  | referral*    |
| National QI aim          | 85%          |
| National result          | 2,792        |
| <5                       | 0            |
| Wrightington Wigan &     |              |
| Leigh tier 2 Respiratory |              |
| Services                 |              |
| Wrightington,            |              |
| Wigan and Leigh          |              |
| NHS Foundation           |              |
| Trust                    |              |
| 19                       | <5           |
| Wye Valley NHS           |              |
| Trust                    |              |
| Herefordshire            |              |
| Pulmonary                |              |
| Rehabilitation           |              |
| Programme                |              |
| <5                       | 0            |
| York Teaching            |              |
| Hospital NHS             |              |
| Foundation Trust         |              |
| York and Selby           |              |
| Pulmonary                |              |
| Rehabilitation           |              |
| Your Healthcare          | 16           |
| Your Healthcare          |              |
| Pulmonary                |              |
| Rehabilitation Service   |              |
NHS Grampian 
41 
12 
50% 
0 
0% 
Aberdeen City Health and Social Care Partnership pulmonary rehabilitation 
| Patients     | Patients with    |
|--------------|------------------|
| enrolled for |                  |
| PR who       |                  |
| a discharge  |                  |
| assessment   |                  |
| subsequently | who received     |
| have a       | a written        |
| discharge    | individualised   |
| assessment   | exercise plan    |
Process items 
Outcome items 
| Start date within        | Patients     |
|--------------------------|--------------|
| 90 days of               | undertaking  |
| receipt of               | practice     |
| board name               | Service name |
| Cases                    |              |
| audited                  | referral*    |
| National QI aim          | 85%          |
| National result          | 2,792        |
| NHS Grampian             | <5           |
| Aberdeenshire Health     |              |
| and Social Care          |              |
| Partnership pulmonary    |              |
| rehabilitation           |              |
| NHS Grampian             | 5            |
| Moray Health and Social  |              |
| Care Partnership         |              |
| pulmonary rehabilitation |              |
| 54                       | 36           |
| NHS Greater              |              |
| Glasgow, Clyde           |              |
| Greater Glasgow and      |              |
| Clyde Pulmonary          |              |
| Rehabilitation Service   |              |
| NHS Highland             |              |
| Lochaber Pulmonary       |              |
| Rehabilitation Service   |              |
| <5                       | -            |
| NHS Highland             |              |
| Raigmore Pulmonary       |              |
| Rehabilitation Service   |              |
| <5                       | 0            |
| NHS Lanarkshire          | 24           |
| Larnarkshire Self-       |              |
| Management and           |              |
| Pulmonary                |              |
| Rehabilitation           |              |
| Patients     | Patients with    |
|--------------|------------------|
| enrolled for |                  |
| PR who       |                  |
| a discharge  |                  |
| assessment   |                  |
| subsequently | who received     |
| have a       | a written        |
| discharge    | individualised   |
| assessment   | exercise plan    |
Process items 
Outcome items 
| Start date within      | Patients     |
|------------------------|--------------|
| 90 days of             | undertaking  |
| receipt of             | practice     |
| board name             | Service name |
| Cases                  |              |
| audited                | referral*    |
| National QI aim        | 85%          |
| National result        | 2,792        |
| NHS Lothian            | 29           |
| Lothian Community      |              |
| Pulmonary              |              |
| Rehabilitation Service |              |
| NHS Tayside            | 23           |
| Perth and Kinross      |              |
| Pulmonary              |              |
| Rehabilitation Service |              |
| Wales                  |              |
| Newport Pulmonary      |              |
| Rehabilitation         |              |
| 10                     | 6            |
| Aneurin Bevan          |              |
| University Local       |              |
| Health Board           |              |
| 6                      | 0            |
| Aneurin Bevan          |              |
| University Local       |              |
| Health Board           |              |
| Ysbyty Aneurin Bevan   |              |
| Pulmonary              |              |
| Rehabilitation         |              |
| 29                     | <5           |
| Betsi Cadwaladr        |              |
| University Local       |              |
| Health Board           |              |
| BCUHB - Centre         |              |
| Pulmonary              |              |
| Rehabilitation Service |              |
| Patients     | Patients with    |
|--------------|------------------|
| enrolled for |                  |
| PR who       |                  |
| a discharge  |                  |
| assessment   |                  |
| subsequently | who received     |
| have a       | a written        |
| discharge    | individualised   |
| assessment   | exercise plan    |
Process items 
Outcome items 
| Start date within      | Patients     |
|------------------------|--------------|
| 90 days of             | undertaking  |
| receipt of             | practice     |
| board name             | Service name |
| Cases                  |              |
| audited                | referral*    |
| National QI aim        | 85%          |
| National result        | 2,792        |
| BCUHB - East Pulmonary |              |
| Rehabilitation Service |              |
| 22                     | <5           |
| Betsi Cadwaladr        |              |
| University Local       |              |
| Health Board           |              |
| 26                     | 16           |
| Betsi Cadwaladr        |              |
| University Local       |              |
| Health Board           |              |
| BCUHB - West           |              |
| Pulmonary              |              |
| Rehabilitation Service |              |
| 9                      | <5           |
| Cardiff & Vale         |              |
| University Local       |              |
| Health Board           |              |
| University Hospital    |              |
| Llandough Pulmonary    |              |
| Rehabilitation Service |              |
Cwm Taf UHB Pulmonary Rehabilitation Service 
10 
Cwm Taf Morgannwg University Local Health Board 
11 
0 
Hywel Dda University Local Health Board 
Carmarthenshire Pulmonary Rehabilitation Programme 
| Patients     | Patients with    |
|--------------|------------------|
| enrolled for |                  |
| PR who       |                  |
| a discharge  |                  |
| assessment   |                  |
| subsequently | who received     |
| have a       | a written        |
| discharge    | individualised   |
| assessment   | exercise plan    |

Process items 
Outcome items 
| Start date within      | Patients     |
|------------------------|--------------|
| 90 days of             | undertaking  |
| receipt of             | practice     |
| board name             | Service name |
| Cases                  |              |
| audited                | referral*    |
| National QI aim        | 85%          |
| National result        | 2,792        |
| Powys Pulmonary        |              |
| Rehabilitation Service |              |
| 7                      | <5           |
| Powys Teaching         |              |
| Local Health           |              |
| Board                  |              |
| 32                     | 11           |
| Swansea Bay            |              |
| Local Health           |              |
| Board                  |              |
| Swansea Bay University |              |
| Health Board Pulmonary |              |
| Rehabilitation Service |              |

* This metric is only reported for non-AECOPD patients. Data is not directly comparable to the 2017 snapshot audit, as data was reported for all patients in 2017.9 

| Patients     | Patients with    |
|--------------|------------------|
| enrolled for |                  |
| PR who       |                  |
| a discharge  |                  |
| assessment   |                  |
| subsequently | who received     |
| have a       | a written        |
| discharge    | individualised   |
| assessment   | exercise plan    |

## 9.2 Non-Participating Services In England, Scotland And Wales

| Trust / health board / organisation                                       | Service                                                   |
|---------------------------------------------------------------------------|-----------------------------------------------------------|
| Bolton NHS Foundation Trust                                               | Bolton Pulmonary Rehabilitation Programme                 |
| Cross Plain Health Centre                                                 | Sarum Community Based Pulmonary Rehabilitation Team       |
| East London NHS Foundation Trust                                          | East London Pulmonary Rehabilitation Service              |
| Gloucestershire Hospitals NHS Foundation Trust                            | Gloucestershire Respiratory Team                          |
| Hywel Dda University Local Health Board                                   | Pembrokeshire Pulmonary Rehabilitation Programme          |
| Kettering General Hospital NHS Foundation Trust                           | Rocket Team Kettering General Hospital                    |
| Mid Yorkshire Hospitals NHS Trust                                         | North Kirklees Pulmonary Rehabilitation Programme         |
| Milton Keynes University Hospital NHS Foundation Trust                    | Milton Keynes Hospital Pulmonary Rehabilitation Programme |
| North East Hampshire and Farnham (NEH&F) Pulmonary Rehabilitation Service | BOC LTD                                                   |
| NHS Ayrshire and Arran                                                    | Ayrshire and Arran Pulmonary Rehabilitation Service       |
| NHS Borders                                                               | Borders Pulmonary Rehabilitation                          |
| NHS Dumfries and Galloway                                                 | Dumfries and Galloway Pulmonary Rehabilitation Service    |
| NHS Fife                                                                  | Integrated Care Team                                      |
| NHS Forth Valley                                                          | Forth Valley Pulmonary Rehabilitation Service             |
| NHS Highland                                                              | East Caithness Pulmonary Rehabilitation Service           |
| NHS Tayside                                                               | Dundee Pulmonary Rehabilitation Service                   |
| NHS Tayside                                                               | Angus Pulmonary Rehabilitation Service                    |
| NHS Western Isles                                                         | Western Isles Pulmonary rehabilitation                    |
| Royal Papworth Hospital NHS Foundation Trust                              | Papworth Hospital PR Programme                            |
| Swindon Borough Council (Unitary)                                         | Swindon Healthy Lives Pulmonary Rehabilitation Programme  |
| University Hospitals of Morecambe Bay NHs Foundation Trust                | South Lakes Community Respiratory Service                 |
| Warrington and Halton Hospitals NHS Foundation Trust                      | Halton Pulmonary Rehabilitation service                   |

## Appendix A: Methodology Back To Contents

NACAP's pulmonary rehabilitation (PR) continuous clinical audit is built upon the learning from the National COPD Audit Programme snapshot clinical audit.5 The structure of the dataset is similar to that used in 2017, however, it has been considerably streamlined to account for the change in methodology from snapshot (in 2017) to continuous audit which commenced in March 2019. This is the first report since the start of continuous data collection and presents the results of the cohort of patients assessed between 1 March and 31 May and discharged by 31 August 2019. All PR services in England, Scotland and Wales that treated patients with COPD (n=223) were eligible to participate in the audit. A total of 201 services (90.1%) participated in this period of the audit. A full list of participating hospitals, including those hospitals that did not enter any data for the audit period are listed in **Section 9**. The clinical audit operates on a patient consent model; eligible patients were required to provide written consent (using the forms available on the audit website www.rcplondon.ac.uk/projects/outputs/national-asthma-and-copd-audit-programme-nacappulmonary-rehabilitation-workstream) prior to their data being included in the audit. Data from patients that did not provide consent was not included in the audit. Participating PR services were required to enter clinical data into a secure online web tool. A total of 6,056 patient records have been included in this report.  

## Recruitment

There was a single recruitment process for both the PR clinical and organisational audits, which began in 2018, using the following channels: 

 partner and stakeholder channels (such as the British Thoracic Society's eBulletin, the British 
Lung Foundation's BreatheEasy networks, the Primary Care Respiratory Society UK's membership bulletin, and the Association of Respiratory Nurse Specialist's newsletter) 
 Twitter and the audit's own newsletter  communication with services that participated in the 2017 audit. 
 
To identify new services, or services where the management had changed, a Freedom of Information request was sent to all CCGs, asking them for the names and contact details of the PR services used by their healthcare providers. Where identified, these services were sent an approaching email asking them to participate in the audits. The reasons provided to participate were as follows: 

 the status of the audit as part of NHS Quality Accounts, and as a National Clinical Audit, meaning 
all providers of NHS care in England and Wales were required to participate. 
 to build on previous audit results and facilitate local improvement. 
 
Services were asked to complete a registration form, nominating an 'audit lead' and adding any other team members that would form part of the audit team. It was made clear to prospective participants that the 'audit lead' role took ultimate responsibility of the data entered for the service. 

Once a service had submitted their registration form, they were then sent a Caldicott Guardian letter and form to complete. Only after the Caldicott Guardian form was received by the audit team at the RCP was the service considered 'fully registered', and at that point, they were registered on the web tool. There were 229 PR services identified for participation in the audit, and we believe this to be a comprehensive picture of services in England, Scotland and Wales, but we cannot rule out the possibility that PR services exist that were not identified, and therefore did not participate in the audit. A total of 218 services are registered to participate in the audit, with 201 submitting data for this report. Reasons for non-participation included: 

 lack of local resource to complete the data collection and entry; and  no eligible patients during the audit period (ie services ran cohort (rather than rolling) 
programmes, and all their assessments took place prior to the audit period starting). 

## Information Governance And Patient Consent

The audit involved the collection of patient identifiable data for the purpose of linkage with data from other sources (such as Hospital Episode Statistics and Office for National Statistics data for readmission and mortality data), and the audit operated on a patient consent model on advisement from the Health Research Authority's Confidentiality Advisory Group (CAG 2-03(PR3)/2014). The rationale for this was the comparative low acuity of the patient cohort, combined with the fact that the patient interaction with their PR service is prolonged, both of which meant that seeking consent was viable. In addition, the 2015 and 2017 audits found that requesting patient consent proved to have no significant impact on the number of patients included (81% of patients approached gave consent). To support the process, a patient consent form, patient information leaflet as well as guidance for the staff involved, were made available on the project (www.rcplondon.ac.uk/nacap-pr-resources) and web tool webpages (beyond participants' logins). The forms and guidance were updated following the launch of NACAP in March 2018 and feedback from the 2015 and 2017 audits, in order to make the language clearer and to incorporate comments from external groups. The patient information leaflets, and consent form were ratified by NHS Digital Data Access Request Service (Information Governance section), the British Lung Foundation's patient think tank, as well as the Royal College of Physicians' Ethics Committee. Participating services were asked to approach all eligible patients for written consent. It was recommended this be done at their initial assessment and made clear that no data whatsoever should be entered onto the web tool until the patient had provided consent. Any delay in obtaining consent risked the patient dropping out of their PR programme before consent was obtained, in which case their data could not be used. 

## Audit Question Development And Pilot

To ensure PR care was audited against accepted standards, audit questions were mapped to the British Thoracic Society (BTS) PR quality standards. A specific effort was made to ensure that each question could be mapped to a quality standard, and conversely that each quality standard was represented within the audit datasets. 

The audit datasets were based on the 2017 equivalents. They were developed iteratively by the audit programme team and clinical lead, in consultation with the workstream group, in particular the representatives from the British Thoracic Society. 

The datasets and web tool were then tested (in a pilot) in November 2018. The pilot services were asked to contribute feedback on the web tool, the audit questions and help notes. These findings were discussed by the team and the workstream group, and the datasets were finalised. The clinical audit questions included demographic data about the patients being included, and also questions on: 

 the patient's referral process,  their assessment and assessment performance,  time from referral to start of PR, and 
 their discharge and discharge performance. 
 
The clinical datasets are available to download in full from our website: www.rcplondon.ac.uk/nacap-pr-resources 

## Data Entry

Services were required to enter data via the audit programme's bespoke web tool, created by Crown Informatics Ltd (available at www.copdaudit.org). Documentation to support participation in the audit was posted on the PR audit website and web tool, including audit instructions, data collection sheets, datasets with help notes, patient consent documentation, and copies of newsletters. Regular email updates and newsletters were sent to participants throughout the data collection period, with reminders of timelines and any answers to frequently asked questions. Towards the end of the clinical data entry period, reminders were sent to the services that had not entered many cases. Additionally, large numbers of draft records were queried.   

## Data Storage, Security, And Transfer

Data were collected on the audit's bespoke web tool. These data were stored and processed at a secure data centre, owned by Aimes Grid Services, located in Liverpool, UK. It operates to ISO 27001 certification (2015). The servers are owned and operated by Crown Informatics Ltd and are held in a secure locked rack, accessible to named individuals. All access is logged, managed and supervised. This data centre provides N3 aggregation in collaboration with NHS Digital. Data is stored in secured databases (software by IBM) and encrypted on disc (AES256 standard) and additionally in the database where required. Backups are encrypted at AES256, held in dual copies, and stored securely. Crown Informatics Ltd operate secure SSL at 256 bit, using SHA256 (SHA2) signatures and 4096 bit certificates.  Crown Informatics Ltd's certificate is an 'OV' certified by a respected global certifier (Starfield/GoDaddy).  In addition, 'Qualsys' using 'SSL Labs' have given the audit site an 'A' rating. At the end of the data collection period, the data was extracted from the web tool by the central audit team, using an 'extract' provision developed by Crown. It was then transferred securely (using the RCP Mimecast system) to the team at Imperial College London for analysis. The extract function did not include patient identifiers.  

## Technical And Email Support

The audit programme team at the RCP provided a helpdesk every working day during office hours, available on both telephone and email, so that participants could come directly to the team with any questions they had. 

## Data Cleaning And Analysis Methodology

The data were analysed at Imperial College London (National Heart & Lung Institute) in R version 
3.6.2. The patient's Index of Multiple Deprivation6 quintile was linked using the patient's lower layer super output area (LSOA). The dataset contained 8,324 records, of which 6,077 were assessed between 01/03/2019 and 31/05/2019. There were no data inconsistencies or assessment date/start date/discharge date order issues. After removing those with invalid NHS numbers (n=1) and duplicate records (n=20), 6,056 records remained suitable for analysis. New variables were created as follows: 
 'Days from referral to start date' created by subtracting the referral date from the start date  'Days from initial assessment to start date' created by subtracting the initial assessment date 

from the start date 
 'Days from start date to discharge date' created by subtracting the start date from the discharge 
date 
 'Start date offered within 90 days for non-AECOPD patients' created by categorising non-
AECOPD patients into <90 days and >=90 days from referral to start date 
 'Start date offered within 30 days for AECOPD patients' created by categorising AECOPD patients 
into <30 days and >=30 days from referral to start date 
 Difference in test values (ISWT, 6MWT, ESWT, CAT, CRQ domains) were calculated by subtracting 
the initial test result from the discharge test result 
 MCID variables for ISWT, 6MWT, CAT, and CRQ domains were then created by categorising the 
test value difference variables into those who achieved the MCID and those who didn't, with MCID achieved defined as: >=48 for ISWT, >=30 for 6MWT, <= –2 for CAT,  >=0.5 for CRQ domains. 
 
Summary statistics for patient N and % were created using the 'table' and 'prop.table' commands. Medians and interquartile ranges were calculated using the 'quantile' command. Odds ratio calculations and logistic regression was carried out using the 'glmer' command from the 'lme4' package in R. Kaplan–Meier curves were created using the 'survfit' command from the 'survival' package and the 'plot_survfit' command from the 'survsup' package in R. 

 

## Appendix B: Definitions Back To Contents

 **Service** means a pulmonary rehabilitation service with a shared pool of staff and central 
administration where referrals are received. A provider may run one or more services, and a service may operate at several sites. 
 **Programme** means the course of classes that the patient is referred to.  **Site** means the physical location where the pulmonary rehabilitation services are provided, eg a 
hospital gym or church hall. 
 **Date of assessment** is the date the patient attends an appointment to be assessed before 
beginning pulmonary rehabilitation sessions. If there was no separate assessment appointment, please enter the date of the first appointment/session. 
 **Date of first pulmonary rehabilitation session** is the first session that the patient attends with 
the pulmonary rehabilitation service. 

## Appendix C: Bts Quality Standards For Pulmonary Rehabilitation In Adults (2014) Back To Contents

| No.                                                                                       |
|-------------------------------------------------------------------------------------------|
| 1                                                                                         |
| Referral for pulmonary rehabilitation: a. People with COPD and self-reported exercise     |
| limitation (MRC dyspnoea 3–5) are offered pulmonary rehabilitation. b. If accepted,       |
| people referred for pulmonary rehabilitation are enrolled to commence within 3            |
| months of receipt of referral.                                                            |
|                                                                                           |
| 2                                                                                         |
| Pulmonary rehabilitation programmes accept and enrol patients with functional             |
| limitation due to other chronic respiratory diseases (for example bronchiectasis, ILD     |
| and asthma) or COPD MRC dyspnoea 2 if referred.                                           |
|                                                                                           |
| 3                                                                                         |
| Referral for pulmonary rehabilitation after hospitalisation for acute exacerbations of    |
| COPD: a. People admitted to hospital with acute exacerbation of COPD (AECOPD) are         |
| referred for pulmonary rehabilitation at discharge. b. People referred for pulmonary      |
| rehabilitation following admission with AECOPD are enrolled within 1 month of leaving     |
| hospital.                                                                                 |
|                                                                                           |
| 4                                                                                         |
| Pulmonary rehabilitation programmes are of at least 6 weeks duration and include a        |
| minimum of twice-weekly supervised sessions.                                              |
|                                                                                           |
| 5                                                                                         |
| Pulmonary rehabilitation programmes include supervised, individually tailored and         |
| prescribed, progressive exercise training including both aerobic and resistance training. |
|                                                                                           |
| 6                                                                                         |
| Pulmonary rehabilitation programmes include a defined, structured education               |
| programme.                                                                                |
|                                                                                           |
| 7                                                                                         |
| People completing pulmonary rehabilitation are provided with an individualised            |
| structured, written plan for ongoing exercise maintenance.                                |
|                                                                                           |
| 8                                                                                         |
| People attending pulmonary rehabilitation have the outcome of treatment assessed          |
| using as a minimum, measures of exercise capacity, dyspnoea and health status.            |
|                                                                                           |
| 9                                                                                         |
| Pulmonary rehabilitation programmes conduct an annual audit of individual outcomes        |
| and progress.                                                                             |
| 10                                                                                        |
| Pulmonary rehabilitation programmes produce an agreed standard operating                  |
| procedure.                                                                                |

 

## References

1. 
British Thoracic Society (BTS). Quality Standards for Pulmonary Rehabilitation in Adults 2014. 
London: BTS 2014. www.brit-thoracic.org.uk/quality-improvement/qualitystandards/pulmonary-rehabilitation/ [Accessed February 2020]. 
2. 
National Institute for Health and Care Excellence. Chronic obstructive pulmonary disease in adults. NICE Quality Standard 10 (QS5). London: NICE 2016. www.nice.org.uk/guidance/QS10 [Accessed February 2020]. 
3. 
Steiner M, McMillan V, Lowe D, Saleem Khan M, Holzhauer-Barrie J, Van Loo V, Roberts CM. Pulmonary rehabilitation: Beyond breathing better. National Chronic Obstructive Pulmonary 
Disease (COPD) Audit Programme: Outcomes from the clinical audit of pulmonary rehabilitation services in England 2015. National supplementary report. London: RCP, December 2017. www.rcplondon.ac.uk/projects/outputs/pulmonaryrehabilitationbeyond-breathing-better [Accessed January 2018]. 
4. 
National Institute for Health and Care Excellence. Smoking: supporting people to stop. NICE Quality Standard 43 (QS43). London: NICE 2013. **www.nice.org.uk/guidance/QS43** [Accessed February 2020]. 
5. 
Holland EA, Spruit A, Troosters T *et al.* An official European Respiratory Society/American Thoracic Society technical standard: field walking tests in chronic respiratory disease Eur Resp J 2014;44(6):1428–46.  
6. 
Singh SJ, Jones PW, Evans R, Morgan MDL. Minimum clinically important improvement for the incremental shuttle walking test. *Thorax* 2008;63:775–7. 
7. 
Gupta N, Pinto LM, Morogan A, Borbeau J. The COPD assessment test: a systematic review. Eur Resp J 2014;44(4):873–84.  
 
8. 
Chauvin A, Rupley L, Meyers K, Johnson K, Eason J. Outcomes in Cardiopulmonary Physical 
Therapy: Chronic Respiratory Disease Questionnaire (CRQ). *Cardiopulm Phys Ther J* 2008;19(2):61–7.  
 
9. 
Steiner M, McMillan V, Lowe D, Holzhauer-Barrie J, Mortier K, Riordan J, Roberts CM. Pulmonary rehabilitation: An exercise in improvement. National Chronic Obstructive Pulmonary Disease (COPD) Audit Programme: Clinical and organisational audits of pulmonary rehabilitation services in England and Wales 2017. National report. London: RCP, April 2018. www.rcplondon.ac.uk/projects/outputs/pulmonary-rehabilitation-exerciseimprovement-combined-clinical-and-organisational [Accessed July 2020]. 
National Asthma and COPD Audit Programme (NACAP)
Royal College of Physicians 11 St Andrews Place Regent's Park London NW1 4LE Tel: +44 (0)20 3075 1526 Email: pulmrehab@rcplondon.ac.uk

www.rcplondon.ac.uk/nacap
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