Pulmonary rehabilitation (PR) clinical and organisational audit 2019 report
Source: data.gov.uk (2020-12-30)

National Asthma and COPD Audit Programme (NACAP): Pulmonary rehabilitation clinical and organisational audit 2019 report. The pulmonary rehabilitation (PR) combined clinical and organisational audit report is the second report published post launch of continuous data collection on 1 March 2019.

The report presents information on:

- over 12,000 patients who were assessed for pulmonary rehabilitation between 1 June – 30 November 2019, and
- the structure and organisational of PR services between July and September 2019.

Data includes national and country level performance:

- for key clinical process measures such as waiting times for PR, initially assessments and walking tests, discharge assessments and completion rates for PR. In addition, data on outcomes measures for improvements in exercise capacity and health status are also presented, and
- on organisational factors such as service provision (education sessions, written exercise plans etc) and staff levels.

In association with:
Commissioned by:
National Asthma and Chronic Obstructive 
Pulmonary Disease Audit Programme (NACAP)
Pulmonary rehabilitation clinical 
and organisational audits 2019
Clinical (patients assessed for PR between June and November 2019)
and organisational audits of pulmonary rehabilitation services in 
England, Scotland and Wales 2019.
Pulmonary rehabilitation 2019 
audit report
Published December 2020

National Asthma and COPD Audit Programme: pulmonary rehabilitation clinical and organisational audit report 2019  
© Healthcare Quality Improvement Partnership 2020 
2 
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 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: clinical and organisational audit report 2019 
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; and 
head of pulmonary/cardiac rehabilitation and consultant clinical scientist, University Hospitals of Leicester 
Ms Susan Latchem, programme manager, NACAP, CQID, RCP 
Ms Rachael Andrews, deputy programme manager, NACAP, CQID, RCP 
Ms Neena Garnavos, project manager, Pulmonary Rehabilitation Services Accreditation Programme (PRSAS), CQID, RCP 
Ms Natasha Long, programme coordinator, NACAP, 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 
Professor Jennifer Quint, professor of 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; managing director of academic science partnership, 
UCLPartners, professor in medical education for clinical practice, Institute of Population Health Sciences, Queen Mary 
University London and deputy director of NIHR North Thames Applied Research Collaboration. 
Citation for this document: Singh S, Latchem S, Andrews R, Garnavos N, Long N, Stone P, Adamson A, Quint J, Roberts CM. 
National Asthma and Chronic Obstructive Pulmonary Disease Audit Programme (NACAP). Pulmonary rehabilitation audit 
report 2019. Combined clinical and organisational audit of pulmonary rehabilitation services in England, Scotland and 
Wales. London: RCP, 2020. 
Copyright 
Copyright © Healthcare Quality Improvement Partnership 2020 
ISBN: 978-1-86016-819-2| eISBN: 978-1-86016-820-8 
 
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 
 
 
 

National Asthma and COPD Audit Programme: pulmonary rehabilitation clinical and organisational audit report 2019  
© Healthcare Quality Improvement Partnership 2020 
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Contents 
 
Report at a glance ................................................................................................................................... 4 
How to use this report ............................................................................................................................ 6 
Foreword by Sally Singh, pulmonary rehabilitation audit clinical lead ................................................... 9 
Recommendations ................................................................................................................................ 10 
Section 1: Audit participation ............................................................................................................... 12 
Section 2: General information about the patients included in the 2019 PR clinical audit ................. 13 
Section 3: Access to pulmonary rehabilitation services ....................................................................... 14 
Section 4: Quality of pulmonary rehabilitation services ....................................................................... 19 
Section 5: Discharge assessment and outcomes .................................................................................. 23 
Section 6: Staffing ................................................................................................................................. 26 
Section 7: Closing remarks .................................................................................................................... 27 
Appendix A: BTS Quality Standards for Pulmonary Rehabilitation in Adults (2014) ............................ 28 
References ............................................................................................................................................ 29 
 
 
 

National QI priority*
Start date of PR
 
of patients with stable COPD referred for 
pulmonary rehabilitation (PR) started PR 
within 90 days of referral.
54%
90 
days
Ensure 
85% 
of patients with stable COPD referred for PR 
start it within 90 days of receipt of referral. 
* All national QI priorities align with the quality standards for PR 
   
Report at a glance
Access to pulmonary rehabilitation (PR)
National QI priority*
Practice walk tests
 
Technical standards
National QI priority*
Ensure all PR services 
have an agreed SOP.
Ensure all walk tests are performed 
to accepted technical standards 
and all patients undertake a 
practice walk test at their 
initial PR assessment.
Of those completing an incremental shuttle walk test (ISWT) 
or 6-minute walk test (6MWT) at initial assessment: 
47%
of patients performed 
a practice walk test.
Quality of pulmonary rehabilitation (PR) services
of PR services are meeting the technical standards 
for conducting the 6MWT along a 30-metre course.
13% 
Standard Operating Procedure (SOP)
 
Only
of PR services have an SOP.
84% 

*  All national QI priorities align with the quality standards for PR 
† As measured using the minimal clinically important difference (MCID) for incremental shuttle walk test (ISWT) or 6-minute walk test (6MWT)
‡  As measured using the MCID for COPD assessment test (CAT)
   
Discharge assessment
 
Outcomes of PR
65% 
of patients experienced an improvement 
in exercise capacity.†
56% 
of patients experienced an improvement 
in health status.‡
Discharge assessment and outcomes
of patients assessed between 1 June and 
30 November 2019 had a discharge assessment. 
67% 
National QI priority*
Ensure 
70% 
of patients enrolled for PR go 
on to have a discharge assessment.

National Asthma and COPD Audit Programme: pulmonary rehabilitation clinical and organisational audit report 2019  
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How to use this report 
1. Scope and data collection 
The pulmonary rehabilitation (PR) audit, a component of the National Asthma and COPD Audit 
Programme (NACAP), is a continuous clinical audit with a biennial (in alternate years) organisational 
audit component, launched in March 2019 in England, Scotland and Wales. All services who treat 
patients for chronic obstructive pulmonary disease (COPD) are eligible to participate. These audits 
capture the process of treatment in patients who are treated by, and the structure and resources of, 
PR services.  
 
This report, which is the first combined clinical and organisational report following the launch of 
continuous data collection, presents data describing:  
 patients assessed for PR between 1 June and 30 November 2019 (n=12,127),* and 
 the structure and resourcing of PR services between 1 July – 30 September 2019.  
 
Contributing to the overarching national quality improvement (QI) objectives of the NACAP, it serves 
to empower stakeholders to use audit data to facilitate improvements in the quality of care. The 
clinical audit works under a consent model, so only data from patients who consented to be part of 
the audit have been reported. 
 
The report highlights areas for QI that were identified in 2019. Providers and commissioners should 
consider how these can be delivered locally for the benefit of patients and the healthcare system. A 
selection of case studies, provided by participating PR services, are included in the report to 
showcase good practice. In addition, tips to achieving the QI priorities are included in the relevant 
sections of the report. For more information about the delivery of QI within the NACAP please view 
the programme’s QI strategy available at: www.rcplondon.ac.uk/nacap-quality-improvement-
resources.   
The combined PR clinical and organisational 2019 audit report provides a suite of outputs designed 
for various audiences, shown on page 7. These can be all found at www.rcplondon.ac.uk/nacap-PR-
2019.  
 
 
* This cohort 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. 
 

National Asthma and COPD Audit Programme: pulmonary rehabilitation clinical and organisational audit report 2019 
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2. Indicators included
Key process and organisation measures included in this report are: being referred to PR, waiting 
times to start of PR, walk tests, discharge assessment and PR services having a standard operating 
procedure. The outcome measures included in this report are improvement in exercise capacity and 
health status. 
This report brings together the key findings, recommendations and national QI priorities from the 
2019 PR clinical and organisational audits. Separate data analysis and methodology reports are 
available for both the clinical and organisational audits at: www.rcplondon.ac.uk/nacap-PR-2019. 
These provide the following information: 
 the full data analysis, presented with England, Scotland and Wales results, as well as combined 
results for all three countries denoted as ‘All’ in tables and figures, with explanatory notes 
throughout 
 nationally benchmarked clinical audit results for participating services, using variables based on 
national guidelines and standards (clinical audit only) 
 appendices, including the methodology for the audit. 
It is not necessary to review the full analysis to appreciate the key messages available in this short 
report. 
The clinical and organisational results together are designed to provide a picture of the care and 
service organisation provided to the cohort of patients with COPD assessed for PR who were 

National Asthma and COPD Audit Programme: pulmonary rehabilitation clinical and organisational audit report 2019 
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included in the audit, as well as their outcomes at discharge assessment. With each round of 
reporting, the NACAP aims to provide an increasingly comprehensive picture of PR care and service 
provision provided across the country as case ascertainment builds over the length of the 
continuous audit and changes over time become more apparent. Comparisons with previous audit 
reports have not been given in this report for two reasons: 
1.
datasets (both clinical and organisational) for the PR audit underwent considerable review
and streamlining prior to their launch under NACAP making comparison difficult and
potentially misleading, and,
2.
the patient cohort included in the PR interim report (published in July 2020) was very small
therefore making comparisons with it limited. Comparisons to the interim report have been
presented, where appropriate, in the accompanying clinical audit data and methodology
report but they have not been emphasised in this report.
However, with the move to continuous data collection, comparisons with previous audit rounds and 
therefore trend analysis and changes over time will become more extensive and robust.  
Alongside the publication of this report, PR services will also be provided with site-level reports, 
presenting their own service-level data against both the national and devolved nation average. 
These reports are provided directly to the PR service responsible for participation in the NACAP PR 
audits via the NACAP web tool (www.nacap.org.uk). Run charts for key clinical dataset metrics are 
also accessible for authorised service web tool users to access; these display audit data in real time 
at provider- and national-level to support local QI. In addition, service-level audit data will be made 
publicly available on the NACAP web pages (www.rcplondon.ac.uk/nacap-PR-2019) and 
www.data.gov.uk, in line with the government’s transparency agenda. Copies of our datasets, our 
good practice repository and all other resources can be found via our website: 
www.rcplondon.ac.uk/nacap-pr-resources.  
3. Report structure
National breakdowns are given for England, Scotland and Wales are presented, as well as ‘All’ 
figures.  
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, voluntary organisations and service 
users. A separate report has been produced for patients and the public and is available at: 
www.rcplondon.ac.uk/nacap-PR-2019. Where an area of care or service provision has been 
highlighted as a patient priority (something of particular importance to patients) by the NACAP 
patient panel this is shown with the patient priority icon displayed below.  
References to the appropriate British Thoracic Society (BTS) Quality Standards (Appendix A) are 
provided at the beginning of each section.

National Asthma and COPD Audit Programme: pulmonary rehabilitation clinical and organisational audit report 2019  
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Foreword by Sally Singh, pulmonary rehabilitation 
audit clinical lead  
Welcome to the first National Asthma and COPD Audit Programme (NACAP) 
pulmonary rehabilitation (PR) combined clinical and organisational audit report. It 
presents data entered for over 12,000 patients assessed for PR between 1 June – 
30 November 2019, and the structure and resourcing of PR services between 1 July 
– 30 September 2019. 
 
Most PR services are participating in this national continuous clinical and snapshot 
organisational audits (87.7%), with well over half (63.2%) providing a complete 
organisational audit dataset and being included in the final analysis for report. Of course, the valuable 
insights gained from this report would not be possible without this high level of engagement and support 
from PR services up and down the UK. We owe a huge thank you to the services for recognising the 
importance of the national audit in improving patient care. The data provided is important to our 
understanding of the practice of PR, with respect to both the process and the clinical outcomes.  
 
There is a great deal for PR services to be proud of, notably the impact of rehabilitation for the 
participant; the clinical outcomes show that a high proportion of patients achieve important gains in 
exercise performance (64.8%) and/or health status (55.5%). Equally, referrals to PR seem to be 
appropriate with only a small percentage (8.4%) of patients not proceeding to a PR programme.  
 
Of course, the audit data identifies areas for improvement. Completion of rehabilitation remains stable 
(66.7%). However, those living within the most deprived areas of England, Scotland and Wales are still less 
likely to attend their discharge assessment than those living in the least deprived areas. This limits our overall 
understanding of the clinical impact on these groups and this inequality is an ongoing challenge for PR services 
that collectively we must strive to even out and share best practice. 
 
There are still delays in patients accessing PR in a timely manner, with only 53.9% of patients with stable 
COPD commencing a PR programme within the 90-day (from receipt of referral) target. The quality 
standards indicate that patients with a Medical Research Council (MRC) grade 3–5 should be offered PR 
and, by and large, this is the case with the exception in England where 12.6% of services reported not 
offering programmes to MRC grade 5. Access to PR for the post-hospitalisation population remains low.  
 
Not surprisingly, the majority of PR services patients were enrolled onto were centre-based (97.9%). We might 
anticipate a change in the future but in this audit period there were very few cases of home-based 
rehabilitation (1.6%).  
 
We do not believe that the COVID-19 pandemic has affected this report, or the data contained within it, as the 
dataset was closed for this report on 10 April 2020 and therefore only includes patients who completed their 
PR programme by this point. It should be noted that during the COVID-19 pandemic, PR services have been 
severely challenged, and it is likely that future models of PR will not be exclusively based on directly supervised 
groups in rehabilitation centre. To date, the audit reports very little appetite for alternative models; we 
anticipate this is likely to change in the future.  
 
We hope this data will provide valuable insights into the provision and outcomes of PR and support services to 
continue to improve the standard of the PR programmes offered to patients.  

National Asthma and COPD Audit Programme: pulmonary rehabilitation clinical and organisational audit report 2019 
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Recommendations 
This section brings together recommendations and national QI priorities from both the PR clinical and organisational 2019 audits. The reference numbers given 
for these are split between recommendations (CA1/OA1) and national QI priorities (C1/O1). The same reference numbers are used for the recommendations / 
QI priorities in the full data analysis and methodology reports for each audit. Supporting standards/guidelines for recommendations, where applicable, are also 
presented in the full data analysis and methodology reports.  
Clinical audit recommendations (CA) 
Organisational audit recommendations (OA) 
Audience 
National 
CA1.  National organisations, service providers, commissioners and 
patient charities should work together to optimise timely referral 
to and start of PR for those with both stable COPD and following an 
admission to hospital with an acute exacerbation of COPD 
(AECOPD).  
- 
PR services 
National QI priority C1: Start PR within 90 days of receipt of 
referral for 85% of patients referred for PR with stable COPD. 
National QI priority C2: Perform all walk tests to accepted 
technical standards, including ensuring all patients undertake a 
practice walk test at their initial PR assessment. 
National QI priority C3: Complete PR programmes and discharge 
assessments for 70% of patients enrolled for PR. 
National QI priority O1: Offer PR to all patients 
with a COPD self-reported exercise limitation 
(Medical Research Council (MRC) grade 3–5).  
National QI priority O2: Assess outcomes of treatment 
for all patients attending PR as a minimum, measures of 
exercise capacity and health status. Ensure that measures 
are assessed in line with recommended guidance at the 
initial and discharge assessment. 
National QI priority O3: Ensure all PR services have an 
agreed standard operating procedure (SOP). 
CA2.  Work with secondary care providers to identify all suitable patients 
for PR following an admission for AECOPD. The pathway should be 
integrated for all PR to start within 30 days for these patients. 
OA1.  Involve lay people and patients / carers representatives 
  in service planning and development. 
C1 
C2 
C3 
O1
O2 
O3 

National Asthma and COPD Audit Programme: pulmonary rehabilitation clinical and organisational audit report 2019 
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Clinical audit recommendations (CA) 
Organisational audit recommendations (OA) 
Audience 
Commissioners, health 
boards, sustainability and 
transformation 
partnerships, integrated 
care systems  
CA3.  Work with your PR services to ensure that patients are seen in a 
timely manner (QI priority: starting PR within 90 days of receipt of 
referral). 
OA2.   Provide an adequate funding model for PR services to 
minimise service disruption and ensure service 
sustainability. 
CA4/OA3. 
Have a local resource plan in place to facilitate and encourage your local PR services to participate in the NACAP PR audit. 
CA5.  Provide adequate training and awareness for all staff of national, 
and where relevant, international guidance,8 ie BTS quality 
standards for pulmonary rehabilitation in adults (2014).1 
OA4.   Provide adequate clinical lead management time to 
coordinate and manage/develop services. 
OA5.   Work with your PR services to provide COPD patients 
who require it with transport to and from PR 
programmes in order to facilitate equity of access. 
Primary and secondary 
care providers 
CA6.  Assess all COPD patients for suitability for referral to PR 
(patient-reported MRC grades 3–5). 
CA7.  Provide all staff working with patients with COPD with information 
on the benefits of PR. 
OA6.   Offer PR to all patients with patient-reported 
MRC grades 3–5. 
For patients living with 
COPD and their families 
and carers 
CA8/OA7. 
Ask for information on PR when you visit your GP / practice nurse and discuss whether a referral to your local PR service may be 
beneficial to you. 
CA9.  Make sure arrangements are made to refer you to your local PR 
service, if you are admitted to hospital with a worsening of your 
COPD. 
OA8.   Consider being a patient representative as part of the 
PR service team, if you have experience of COPD and 
PR. 

National Asthma and COPD Audit Programme: pulmonary rehabilitation clinical and organisational audit report 2019  
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Section 1:  
Audit participation  
Back to contents 
Key findings 
NACAP PR clinical audit 
 
A high proportion (87.7%) of PR services are participating in the PR continuous clinical audit. 
 
Very few services either did not register (4.4%) or registered but did not submit any data (8.0%). 
 
NACAP PR organisational audit 
 
63.2% of PR services fully completed the PR organisational audit for 2019 and were included in the final 
analysis. A further 56 (24.6%) services also submitted partial information. In addition, 94 services out of 
the 144 (65%) included in the final data analysis also provided updated case ascertainment and workforce 
planning information in May to June 2020.  
 
Case ascertainment data is available in the organisational audit data and methodology report. These are not available here 
as they should be reviewed and interpreted in the context of the additional information available within that report.  
 
 
 
 
 
 
227 services were identified for 
the clinical audit 
228* for the organisational audit 
199 (87.7%) PR services  
participated in the clinical audit 
144 (63.2%)** PR services    
provided full organisational audit 
records 
178 (91.3%) in England 
10 (55.6%) in Scotland 
11 (100%) in Wales 
12,127 records were included  
in the main analysis 
11,630 for England 
174 for Scotland 
323 for Wales 
132 (67.3%) in England 
4 (21.1%) in Scotland 
8 (72.7%) in Wales 
* Two services who participated individually in the organisational audit have since merged to participate as a combined service for the clinical audit. 
** A further 56 services submitted partial information bringing the total participation rate to 200 services (87.7%). 
94/144 (65%) services provided 
updated workforce planning and case 
ascertainment data in May – June 
2020 

National Asthma and COPD Audit Programme: pulmonary rehabilitation clinical and organisational audit report 2019 
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Section 2:  
General information about COPD patients 
included in the 2019 PR clinical audit 
Back to contents 
Median age 
at referral to 
PR 
 71 years 
 69 years 
 71 years 
  71 years 
Key standards 
NICE 2013 QS43 [QS1]:3 People are asked by their healthcare practitioner if they smoke, and 
those who smoke are offered advice on how to stop.   
Key findings 
 
The median age at referral was 71 years (interquartile range (IQR) 64–76). 
 
More males (52.8%) were assessed for PR than females (47.1%). 
 
The majority (82.5%) of patients referred for PR were white British. 
 
In total, 12,127 patients were assessed for PR between 1 June and 30 November 2019. 
 
Patients within the most deprived areas (quintile 1) in England (25.3%) and Wales (24.9%) represented a 
higher proportion of those assessed for PR. However, patients in quintile 2 represented the higher 
proportion of those assessed for PR in Scotland (30.0%). 
Of patients assessed for PR: 
 
a large proportion were either ex-smokers (68.8%) or current smokers (21.7%) 
 
the majority had an MRC score of either 3 (35.7%) or 4 (31.1%) 
 
49.7% had a measure of FEV1/FVC ratio and 61.4% had a measure of FEV1 
 
35.7% had a history of cardiovascular disease and 35.6% a history of lower limb or 
lower back musculoskeletal disorders 
 
19.9% had a history of mental illness. 

National Asthma and COPD Audit Programme: pulmonary rehabilitation clinical and organisational audit report 2019 
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Section 3: 
Access to pulmonary rehabilitation services 
Back to contents 
Median time 
from referral 
to start of 
PR* 
 83 days 
 106 days 
         154 days 
         84 days 
*For patients with stable COPD 
Key standards 
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 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 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. 
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. 
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. 
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. 

National Asthma and COPD Audit Programme: pulmonary rehabilitation clinical and organisational audit report 2019 
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Key findings 
Referral to PR for COPD patients 
 
Overall, the highest proportion of patients (66.8%) were referred from primary care or the community 
with stable COPD. 
 
5.2% of patients (632) were referred after admission to hospital for an acute exacerbation of COPD 
(AECOPD). 
 
Not all services in England offered PR for MRC grade 3–5. In particular, MRC grade 5 was not offered PR 
in 12.9% of services in England.   
 
All (100.0%) services offered PR to current smokers. 
 
Most services (78.5%) would offer a second course of PR to patients if they had completed a course over 
a year ago. 
 
After the initial assessment, 91.6% of patients were enrolled onto a PR programme. This shows that 
referrals are being appropriately made by primary and secondary care. 
Data on referrals and access to PR for all patients (including non-COPD) is available in the full organisational audit data 
and methodology report. These are not available here as they should be reviewed and interpreted in the context of the 
additional information available within that report. 
Waiting times for COPD patients 
 
Overall, 53.9% of patients with stable COPD commenced PR within 90 days of receipt of referral. 
Waiting times were longest in Wales (median 154 days). 
 
12.8% of patients referred after admission to hospital for an AECOPD started PR within 30 days 
of referral. 
Location and duration of services 
 
The majority (97.9%*) of patients enrolled entered into a centre-based PR programme. 
 
1.6%* of patients received home-based PR, largely supported with supervised sessions in the home. 
 
34.0% of PR services offered a home-based programme. 
− 
Of these, 61.2% offered supervised PR sessions in the patient’s home. 
 
66.5% of PR programmes were rolling programmes. 
 
Nearly all (99.3%) PR services met the standard for centred-based PR programmes to be at least 6 weeks 
in duration. 
*This does not include patients who received both centre and home-based PR (0.5%).
Equity of access 
 
The majority (65.3%) of PR services did not offer transport to support patients access to the service. 
Contracting 
 
22.2% of PR services had at least some part of their service on a fixed-term contract. 

National Asthma and COPD Audit Programme: pulmonary rehabilitation clinical and organisational audit report 2019 
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National QI priority O1: Offer PR to all patients with a COPD self-reported 
exercise limitation (Medical Research Council grade 3–5) (BTS quality 
standards for pulmonary rehabilitation in adults (2014). Standard 
1a).1 
Rationale  
The BTS quality standard for PR in adults (2014) 1a 
states that people with chronic obstructive 
pulmonary disease (COPD) with a self-reported 
exercise limitation MRC grade 3–5 are offered PR. 
This audit reported that 12.9% of services in England 
did not offer PR to patients with MRC grades 3–5.  
Tips to achieve this priority 
 
Ensure that the service offers rehabilitation to 
all eligible patients by considering local referral 
pathways and working with primary, secondary 
and community care providers to optimise 
systems to support referral. 
 
Consider accessibility for people with COPD and 
a self-reported exercise limitation of MRC grade 
5. 
 
Consider offering assistance with travel to PR 
centre for initial assessment. 
National QI priority C1: Start PR within 90 days of receipt of referral for 85% of patients 
referred for PR with stable COPD. (BTS quality standards for pulmonary 
rehabilitation in adults (2014). Standard 1b).1 
Rationale  
The BTS quality standard for PR in adults (2014) 1b 
states that people with stable COPD who are 
referred for PR should start it within 3 months of 
receipt of referral. This audit reported 53.9% 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.8 Therefore ensuring patients start PR 
within 90 days is of the utmost importance. 
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. 
For example, consider running rolling 
programmes rather than cohort. 
O1 
C1 

National Asthma and COPD Audit Programme: pulmonary rehabilitation clinical and organisational audit report 2019 
© Healthcare Quality Improvement Partnership 2020 
17 
Case study: Whittington Health Pulmonary Rehabilitation (PR) service 
 
Issues around referral to treatment times and large did not attend 
rates at initial assessment and commencing the programme 
were identified in 2017.    
 
Following this concurrent service/quality improvement (QI) 
projects to support and improve these issues were run in 
order to address these issues.  
The service is now run as follows: 
 
Daily triaging of new referrals which ensures good quality 
referrals, with correct diagnosis and meeting referral 
criteria.  Those that don’t are deferred and discharged with 
recommendations to gain the correct diagnosis or missing 
information. Once this information      
is received the new referral is added, triaged and an appointment 
offered 
accordingly. 
 
Patients are contacted (by phone) within 2 days of receipt of referral to discuss referral and 
accepted/discharged as necessary. The PR programme and the commitment required are fully 
explained. If the patient cannot be reached, an answerphone message is left, and text message 
sent prompting the patient to call back. If the call is not returned within 5 days and/or if the 
patient is still not reachable, the referral is discharged with an opt-in letter for 3 months.   
 
All rehabilitation assistants completing the telephone calls have received motivational interview 
training to support the calls and exploring barriers to attending PR, eg transport options and 
beliefs surrounding exercise and breathlessness. 
 
If the invitation for PR is accepted, the next available appointment is offered at the venue where 
waiting times are lowest. It is explained to the patient that they may attend the programme at any 
centre they wish but the wait for starting PR may be longer. Exceptions are made if there are 
mobility/transport issues. This means that all patients can be booked onto a PR programme at any 
venue with capacity within 6 weeks. 
 
Patients who cannot commit to the programme are offered a similar opt-in letter to those that we 
have been unable to reach. When they are ready to engage, they are asked to contact the PR 
service directly and are offered the soonest available appointment. 
 
If the patient does not attend their appointment, contact is made at the time of the missed 
appointment and next soonest offered. If we are unable to contact the patient the referral is then 
discharged with an opt-in letter. A new referral is then opened if the patient contacts the service.  
 
Ad hoc clinic appointments can be added throughout week if there is capacity at any of the sites, 
which does not clash with another service.  
 
Patients receive reminder telephone calls and text messages the day prior to their assessment; 
this is in addition to the same being received before their initial session to reduce missed 
appointments. 
 
To support better patient communication and understanding of PR and it’s benefits we have: 
 
changed the wording in our letters to be more lay focused and using lay explanations.  These 
include testimonials and encouraging language to prompt patients to engage when they are 
ready,  
 
rebranded the Breathe Better, Do More PR group to support the above as patient feedback 
feels this more accurately describes the main functional benefit of attendance, and 
 
updated all our websites to reflect this change in attitude with up to date information on the 
team and service. 
100% of patients with 
stable COPD referred to 
Whittington Health 
Pulmonary 
Rehabilitation service 
started PR within 90 
days of receipt of 
referral. 

National Asthma and COPD Audit Programme: pulmonary rehabilitation clinical and organisational audit report 2019 
© Healthcare Quality Improvement Partnership 2020 
18 
Case study: Northumbria Healthcare Rehabilitation Service 
•
A pulmonary rehabilitation (PR) screening assessment was
implemented for all patients admitted to Northumbria
Specialist Emergency Care hospital respiratory ward with
AECOPD for more than
24 hours.
•
Screening assessments are undertaken by the respiratory
physiotherapy team who also lead the Northumbria
Healthcare PR Service.
•
Inpatients admitted with AECOPD are identified each morning
using the electronic patient records and added to the
physiotherapy clinical caseload for the day. These criteria are applicable 7 days a week so that
patients admitted at weekends are not excluded.
•
Band 5 physiotherapists are provided with training on PR while on rotation so that they
understand the benefits and importance of referral to PR. This helps staff having informed and
motivating conversations with patients about PR.
•
The screening assessment includes checking patient’s suitability for PR and referral onto the PR
service.
•
If patients are severely unwell on admission to hospital, eg requiring non-invasive ventilation
(NIV), then the screening assessment for PR is delayed until towards the end of the patient’s
admission. This gives the physiotherapist screening the patient the opportunity to have a more
detailed conversation with the patient about their quality of life, goal setting and benefits of PR.
•
This focused approach has improved the referral rate to PR post-AECOPD admission.
15.9% of patients who 
had an initial PR 
assessment at 
Northumbria Healthcare 
Pulmonary Rehabilitation 
Service were referred 
following an AECOPD. 

National Asthma and COPD Audit Programme: pulmonary rehabilitation clinical and organisational audit report 2019 
© Healthcare Quality Improvement Partnership 2020 
19 
Section 4: 
Quality of pulmonary rehabilitation services 
Back to contents 
PR services 
with a 
standard 
operating 
procedure 
 85.6% 
 100% 
 50% 
 84.0% 
Key standards 
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 6]: 1 Pulmonary 
rehabilitation programmes include a defined, structured education programme. 
BTS quality standards for pulmonary rehabilitation in adults (2014) [Standard 7]: 1 
People completing pulmonary rehabilitation are provided with an individualised structured, written plan for 
ongoing exercise maintenance. 
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 10]: 1 Pulmonary 
rehabilitation programmes produce an agreed standard operating procedure (SOP). 
Technical standard: field walking tests in chronic respiratory disease5

National Asthma and COPD Audit Programme: pulmonary rehabilitation clinical and organisational audit report 2019 
© Healthcare Quality Improvement Partnership 2020 
20 
Key findings 
Walk tests for COPD patients 
Of patients assessed for PR: 
 
41.6% completed an incremental shuttle walk test (ISWT) and 42.3% a 6-minute walk test (6MWT); 
7.6% of patients completed neither test.  
 
60.6% of those completing an ISWT and 29.7% of those completing a 6MWT test performed a practice 
walk test at assessment. 
 
86.7% of PR services were not adhering the technical standards for the conduct of the 6MWT, which is 
to use a 30-metre course.4 
Aerobic and resistance training 
 
Nearly all (95.8%) PR services are individually prescribing aerobic training. 
− 
Of these, 85.4% of services reported using the Borg breathlessness of perceived exertion scale for 
prescribing aerobic training. 
 
All PR services (100.0%) offered resistance training. 
− 
Of these, 93.7% individually prescribed resistance training. 
− 
77.8% of services reported using the Borg breathlessness of perceived exertion scale for prescribing 
resistance training. 
Face-to-face education sessions 
 
The median number of hours of education sessions scheduled during a centre-based PR programme was 
12 (6–12) hours. This was lower in Scotland at 2.5 (1.5–4.5) hours. 
 
All PR services (100.0%) offered face-to-face education sessions.  
 
Physiotherapists and registered nurses made considerable contributions delivering face-to-face 
education sessions. 
Written plans for on-going exercise maintenance 
 
Most PR services (82.6%) provided patients with a written plan for ongoing exercise maintenance. 
Standard operating procedure 
 
16.0% of PR services did not have an SOP. 

National Asthma and COPD Audit Programme: pulmonary rehabilitation clinical and organisational audit report 2019 
© Healthcare Quality Improvement Partnership 2020 
21 
National QI priority C2: Perform all walk tests to accepted technical standards, including 
ensuring all patients undertake a practice walk test at their initial PR assessment. (BTS 
quality standards for pulmonary rehabilitation in adults (2014). Standards 8 and 
9)1 
Rationale  
Accurate measurement of baseline is critical for 
exercise prescription and outcome assessment. 
However, 60.6% of patients who performed an ISWT 
and only 29.7% 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 
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. 
 
To support correct conducting of walk tests, PR 
services should consider joining the pulmonary 
rehabilitation services accreditation scheme 
(www.prsas.org/).   
National QI priority O3: Ensure all PR services have an agreed standard operating 
procedure (SOP)  
(BTS quality standards for pulmonary rehabilitation in adults (2014). Standard 
10).1
Rationale  
The BTS quality standard for PR in adults (2014) 10 
states that PR programmes produce an agreed SOP. 
This audit reported 16.0% of services did not have an 
SOP. 
Tips to achieve this priority 
 
Ensure that the services have an SOP that 
relates specifically to the rehabilitation service 
(this may include existing documents 
addressing broader issues by the host 
organisation). 
 
Collaborate with other rehabilitation services to 
share best practice. 
 
Use forums such as Respiratory Futures for 
example of best practice 
(www.respiratoryfutures.org.uk). 
C2 
O3 

National Asthma and COPD Audit Programme: pulmonary rehabilitation clinical and organisational audit report 2019 
© Healthcare Quality Improvement Partnership 2020 
22 
Case study: Birmingham Community Healthcare (BCHC) Community 
Respiratory Service 
•
All patients are allocated 90 minutes for an initial
assessment.
•
Patients are guided to the venue and the process of the
initial assessment is explained. This allows time for
recovery, if required, following the walk into the
assessment clinic.
•
After consent is gained, patients are taken to the Incremental
Shuttle Walking Test (ISWT) area (never more than a few metres
away) and remain seated while initial observations are recorded.
•
A clinician walks alongside the patient for the first minute, ensuring the patient understands there
should be no talking except for expressing concerns or uncomfortable symptoms induced by
exercise.
•
To allow for a rest period (>30 minutes), PR staff will then complete other objective
measurements (height, weight, BMI), subjective questionnaires (CRQ/KBILD, CAT/ACT, LINQ and
PHQ9, GAD (if indicated)) and a full detailed medical history is collected.
•
Patients are then invited to repeat the ISWT independently.
•
Before attending a 90-minute pre-assessment appointment, all patients are invited to a ‘Prehab’
meeting. The prehab meeting provides information on what is involved in the commitment to
attend PR and provides an opportunity for any questions or concerns to be addressed prior to
their initial assessment. Patients then have a much greater understanding of the pre-assessment
process before they arrive at their appointment, can book a time and date for pre-assessment that
suits them and can make an informed decision whether to take up the offer of PR.
•
Clinic time assessments are run concurrently where two PR clinicians (one qualified and one L4-
trained PR rehab assistant) are present to enable two assessments to be completed within the 90-
minute appointment.
•
All venues are large enough to complete both subjective and objective assessment within the
same clinical area with a walking area of greater than 10 metres.
100% of patients at 
BCHC Community 
Respiratory Service 
had a practice walk 
test for ISWT. 

National Asthma and COPD Audit Programme: pulmonary rehabilitation clinical and organisational audit report 2019 
© Healthcare Quality Improvement Partnership 2020 
23 
Section 5: 
Discharge assessment and outcomes for COPD 
patients 
Back to contents 
Patients who 
had a 
discharge 
assessment 
performed 
        66.4% 
        63.5% 
        76.%% 
         66.7% 
Key standards 
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. 
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. 

National Asthma and COPD Audit Programme: pulmonary rehabilitation clinical and organisational audit report 2019 
© Healthcare Quality Improvement Partnership 2020 
24 
Key findings 
Discharge assessment completed on COPD patients 
Of patients assessed for PR between 1 June and 30 November 2019, and enrolled: 
 
66.7% had a discharge assessment  
 
for patients with a history of cardiovascular disease (OR = 0.81 (95% CI = 0.74–0.89)) and depression 
(OR = 0.73 (95% CI = 0.63–0.83)) there was reduced likelihood of completing a discharge assessment 
 
those in the most deprived areas of England, Scotland and Wales were less likely to attend their 
discharge assessment compared with those in the least deprived areas 
 
81.0% of patients received an individualised discharge plan. 
Outcomes recorded for COPD patients 
Of patients completing a discharge assessment: 
 
for those with an MRC score reported at initial and discharge assessment, 39.5% reported an improved 
score 
 
70.5% who performed the 6MWT achieved improvements in exercise capacity and 60.4% who 
performed the ISWT achieved improvements4, 5 
 
55.5% who completed the COPD assessment test (CAT) achieved improvements in health status and 
58.5% who completed the dyspnoea domain of the chronic respiratory questionnaire (CRQ) achieved 
improvements.6, 7
National QI priority C3: Complete PR programmes and discharge assessments for 70% of 
patients enrolled for PR. (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.29  
Tips to achieve this priority 
 
Incorporate a process to contact patients who 
have stopped attending to encourage 
reengagement and completion. 
 
Involve patients who have previously 
completed a rehabilitation programme to 
encourage participation and support 
completion. 
 
Ensure the patient receives clear information 
about the rehabilitation programme and the 
required commitment.  
C3 

National Asthma and COPD Audit Programme: pulmonary rehabilitation clinical and organisational audit report 2019 
© Healthcare Quality Improvement Partnership 2020 
25 
National QI priority O2: Assess outcomes of treatment for all patients attending PR as a 
minimum, measures of exercise capacity and health status. Ensure that measures are 
assessed in line with recommended guidance at the initial and discharge assessment (BTS 
quality standards for pulmonary rehabilitation in adults (2014). Standard 8).1 
Rationale  
The BTS quality standard for PR in adults (2014) 8 
states that people attending PR have the outcome of 
treatment assessed using as a minimum, measures of 
exercise capacity and health status. Ensure that 
measures are assessed in line with recommended 
guidance at the initial and discharge assessment. This 
audit reported 86.7% of PR services were not 
adhering to the technical standards for the conduct 
of the 6MWT, which is to use a  
30-metre course. 
Tips to achieve this priority 
 
Ensure there is adequate space to conduct a 
6MWT (30-metre course).  
 
Use an alternative test (ISWT) if there is 
insufficient space to complete the 6MWT in 
line with recommended guidance. 
O2 

National Asthma and COPD Audit Programme: pulmonary rehabilitation clinical and organisational audit report 2019 
© Healthcare Quality Improvement Partnership 2020 
26 
Section 6: 
Staffing 
Back to contents 
PR services 
with funding 
for a named 
clinical lead 
        95.5% 
        50.0% 
        87.5% 
       93.8% 
Key findings 
 
Nearly all (93.8%) PR services had funding for a named clinical lead. Of these posts, 91.7% were filled.  
 
Around two thirds (90/135, 62.5%) of PR services had a physiotherapist in the named clinical lead role. 
 
31.9% of services collaborated with lay people and/or patient representatives.  
 
Over three quarters (77.1%) of PR services did not have audit support provided. 

National Asthma and COPD Audit Programme: pulmonary rehabilitation clinical and organisational audit report 2019 
© Healthcare Quality Improvement Partnership 2020 
27 
Section 7: 
Closing remarks 
Back to contents 
Although this report covers a patient cohort largely not effected by the COVID-19 pandemic, many 
PR services began to reduce their service and/or close their doors in response to COVID-19 and to 
ensure the safety of their patients, very soon after it.  
Where possible during the first COVID-19 lockdown period (spring–summer 2020) patients were 
offered care from PR services, many adapting the way they work to incorporate 
virtual/web/telephone-based packages so that they could continue to support patients. Many 
services were unfortunately unable to conduct walk tests (ISWT and 6MWT) as part of the baseline 
assessment due to the need to physically assess and measure the patient’s performance on these.  
The NACAP supported services wherever it could during this time. The web tool remained open for 
all possible data entry and the PR dataset was adapted to ensure that patient records could be 
entered and completed in the absence of a walk test. The dataset was fortunately already in a 
position to capture alternative modes of delivery beyond centre-based. Verbal consent audit 
guidance was also produced and made publicly available to facilitate patient consent being obtained 
by services via virtual/web/telephone PR assessments.  
We hope that with these efforts, and the continued dedication of the PR services we work with, 
some information can be gleaned from the care of COPD patients treated by PR services during the 
COVID-19 pandemic. Slowly, services which had to close are now beginning to reopen after a 
significant period of disruption and change and we hope that the information included within this 
report, as well as on the NACAP on the web tool, will help them plan what their service should look 
like post-COVID-19. However, we also recognise that for a time capacity will be reduced, with the 
infection control procedures that need to be adopted. 
Like many other healthcare services, PR services (and NACAP with them) wait to see what the post-
COVID-19 world holds for them. Will this stimulate the need for alternative home-based 
rehabilitation options to be offered alongside centre-based PR (which currently accounts for 97.9% 
of PR)? Time will tell. Until then, NACAP will continue to work with, and support, PR services in 
providing the best care and service provision possible.  

National Asthma and COPD Audit Programme: pulmonary rehabilitation clinical and organisational audit report 2019 
© Healthcare Quality Improvement Partnership 2020 
28 
Appendix A: BTS Quality Standards for Pulmonary 
Rehabilitation in Adults (2014) 
No. 
Quality statement 
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. 

National Asthma and COPD Audit Programme: pulmonary rehabilitation clinical and organisational audit report 2019 
© Healthcare Quality Improvement Partnership 2020 
29 
References 
1 
British Thoracic Society (BTS). Quality Standards for Pulmonary Rehabilitation in Adults 2014. 
London: BTS, 2014 www.brit-thoracic.org.uk/quality-improvement/quality-
standards/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 
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]. 
4 
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 Dec;44(6):1428–46.  
5 
Singh SJ, Jones PW, Evans R et al. Minimum clinically important improvement for the 
incremental shuttle walking test. Thorax 2008;63:775–7. 
6 
Gupta N, Pinto LM, Morogan A et al. The COPD assessment test: a systematic review. Eur 
Resp J 2014 Oct;44(4):873–84.  
7 
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.  
8 
Steiner M, McMillan V, Lowe D et al. 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, 2017. 
www.rcplondon.ac.uk/projects/outputs/pulmonaryrehabilitation-beyond-breathing-
better [Accessed January 2018]. 

NACAP
National Asthma and COPD 
Audit Programme (NACAP)
Royal College of Physicians
11 St Andrews Place
Regent’s Park
London NW1 4LE
Tel: xx-xxxx-xxxx
Email: xxx@xxx.xx
www.rcplondon.ac.uk/nacap
@NACAPaudit
#pulmrehab
#PR