National COPD Audit Programme pulmonary rehabilitation clinical and organisational audit 2017
Source: data.gov.uk (2019-02-25)

This presents the data from the National Chronic Obstructive Pulmonary Disease (COPD) Audit Programme’s pulmonary rehabilitation clinical and organisational audit 2017. This comprised snapshot audits of the resources and organisation of PR services across England and Wales conducted between 3 January and 28 April 2017 and the process and clinical outcomes of treatment in patients with COPD assessed for PR between 3 January and 31 March 2017.

In his transparency and open data letter to Cabinet Ministers on 7 July 2011, the Prime Minister re-stated the commitment to make audit data available from the national audits within the National Clinical Audit and Patient Outcomes Programme.

The National COPD Audit Programme have made their data available for this purpose.

National COPD Audit Programme
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
April 2018
Prepared by:
In partnership with:

Commissioned by:

Working in wider partnership with:

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 34,000 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 COPD Audit Programme 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 has on healthcare quality in England and Wales. HQIP holds the contract to manage and develop
the NCA Programme, comprising more than 30 clinical audits that cover 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 audits, also funded by the Health Department of the Scottish Government, DHSSPS Northern Ireland
and the Channel Islands.
Citation for this document: 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

Copyright © Healthcare Quality Improvement Partnership 2018
ISBN 978-1-86016-708-9
eISBN 978-1-86016-709-6

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 #COPDAudit #COPDPRaudit #COPDPRbreathebetter #COPDauditQI

NATIONAL QI AIM
NATIONAL QI AIM
patients included in the
clinical audit from 184 services
(79% of all eligible patients)
Enrolment to PR within 90 days of receipt of
referral is a nationally agreed quality standard
services included in
organisational audit
(96% of all eligible organisations)
PARTICIPATION
ACCESS TO PR
7,476
187
1
GO!
Clinical outcomes from patients who
complete therapy remain excellent
GOOD NEWS!
ISWT
6MWT
Median Improvement
(metres)
0
10
20
30
40
50
60
MCID*
MCID*
Overall completion of PR programmes
has improved
*Minimal clinically important diﬀerence
OUTCOMES OF TREATMENT
3
68% of patients do not complete a
recommended practice exercise test
QUALITY OF PR SERVICES
2
59%
2015
62%
2017
Services should endeavour to enrol
85% of those referred for PR within
90 days
Services should aim for patient
completion rates of 70% or more
following assessment for PR
Services should ensure all exercise
assessments are performed to
accepted technical standards
Of the services that use
6MWT, only 6% use the
correct course length (30m)
2015
2017
60%
63%
60m
50m
2015
2017
DAYS
76
DAYS
75
NATIONAL QI AIM
Patients
enrolled
in 90
days
(Incremental Shuttle
Walking Test)
(Six Minute
Walk Test)

National COPD Audit Programme: Pulmonary rehabilitation combined organisational and clinical report 2017
Contents

How to use this report .......................................................................................................................... 6
Summary ............................................................................................................................................... 7
Results and quality improvement priorities ......................................................................................... 8
Participation ...................................................................................................................................... 8
Access to PR ...................................................................................................................................... 9
Quality of PR services ...................................................................................................................... 10
Outcomes of treatment .................................................................................................................. 12
QI case study ....................................................................................................................................... 14
Recommendations .............................................................................................................................. 15
Patients and carers/families ........................................................................................................... 15
PR programmes ............................................................................................................................... 15
Primary and secondary healthcare teams ...................................................................................... 15
System leaders (clinical commissioning groups/STPs) .................................................................... 15
Additional quality improvement opportunities .................................................................................. 16
For PR services ................................................................................................................................ 16
For primary and secondary healthcare teams ................................................................................ 16
For system leaders .......................................................................................................................... 16
Appendix A: BTS Summary of Quality Standards for Pulmonary Rehabilitation in Adults (2014) ...... 17
Appendix B: Document purpose ......................................................................................................... 18
Appendix C: References ...................................................................................................................... 19

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National COPD Audit Programme: Pulmonary rehabilitation combined organisational and clinical report 2017
How to use this report

This report outlines the summary findings of the second round of the pulmonary rehabilitation (PR)
component of the National Chronic Obstructive Pulmonary Disease (COPD) Audit Programme, which
comprises snapshot audits of:

• the resources and organisation of PR services across England and Wales conducted between
3 January and 28 April 2017
• the process and clinical outcomes of treatment in patients with COPD assessed for PR between
3 January and 31 March 2017.

The report summarises key findings, mapped to the appropriate 2014 British Thoracic Society (BTS)
Quality Standard (QS)1 where relevant, and priorities for quality improvement (QI) presented under
three broad categories:

• access to PR
• quality of PR services
• outcomes of treatment.

More detailed recommendations and QI opportunities are also provided for:

• patients and carers/families
• PR services
• primary and secondary care providers
• system leaders such as commissioners and sustainability and transformation partnerships
(STPs).

The full methodology and data analysis for these audits can be found in two online data reports,
www.rcplondon.ac.uk/an-exercise-in-improvement. All of the results highlighted in this report are
followed by references directing the reader to either the clinical audit analyses and results (CDAR) or
the organisational audit analyses and results (ODAR). Although these data are available to the
interested reader, it is not necessary to review them to appreciate the key messages. The data are
presented largely in tabular form, with explanatory notes throughout.

Direct comparisons with the 2015 audits2,3 are provided where possible and relevant.

Nationally benchmarked results for individual PR services have been provided within the online data
reports www.rcplondon.ac.uk/an-exercise-in-improvement. The indicators chosen are in support of
the recommendations made within this report in addition to aligning with national guidelines and
standards. These data will also be made publicly available on www.data.gov.uk, in line with the
government’s transparency agenda.

© Healthcare Quality Improvement Partnership 2018
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National COPD Audit Programme: Pulmonary rehabilitation combined organisational and clinical report 2017
Summary

Pulmonary rehabilitation (PR) is one of the most effective and high value interventions for people
suffering with COPD.4 In this report we present the second round of both clinical and organisational
PR audits, which follow the first rounds conducted in 2015.2,3 Both the current and 2015 audits
measured performance against the 2013 BTS clinical guidelines5 and quality standards1 (provided in
full in Appendix A).

The 2015 audits demonstrated the substantial and clinically important health benefits associated
with completion of PR, including a reduced risk of subsequent admission to hospital.6 However, they
also emphasised the key problem of under-referral and non-completion of PR. For example,
approximately 40% of patients assessed for PR did not go on to complete the treatment course.3
Deficiencies in some care processes were also identified in the 2015 audits, for example, the number
of patients that performed a practice exercise test at PR assessment was low (only 26% for the
incremental shuttle walk test (ISWT) and 24% for the 6-minute walk test), despite evidence that
outcomes are worse for patients who do not undertake one.3,7,8

The 2017 audit reiterates the successes of PR services in England and Wales in delivering
considerable health benefits such as improvements in exercise performance and health status, for
patients who complete treatment. It also highlights some key successes; rates of completion have
improved marginally to 62% in 2017 compared with 59% reported in 2015. There have also been
improvements in provision of written discharge exercise plans (84% in 2017 versus 65% in 2015), the
assessment of muscle strength (27% in 2017 versus 15% in 2015) and in the numbers of programmes
with a written standard operating procedure (84% in 2017 versus 67% in 2015). However, the
findings also highlight the need for improvement in care delivery and outcomes. Therefore, in this
report we recommend actions that PR services, primary care and hospital teams and system leaders
should take to address these needs. We also identify three national quality improvement targets
relating to waiting times for PR, conduct of exercise assessments and completion rates.

We believe that the improvement targets we have set are achievable by PR services with the support
of local system leadership. If these are achieved they will enhance access to treatment, improve the
quality of care and deliver significant benefits to patients and the NHS.

© Healthcare Quality Improvement Partnership 2018
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National COPD Audit Programme: Pulmonary rehabilitation combined organisational and clinical report 2017
Results and quality improvement priorities

Participation

All identified PR services in England and Wales were invited to participate in both the organisational
and clinical audits of PR. An interactive map of PR services in England and Wales was developed as
part of the PR service recruitment process.9 In keeping with the methodology for the 2015 audit,
individual patient consent was required to permit identifiable data to be uploaded to the audit.10

* In the 2017 audit, records were excluded as follows: 96 because they were duplicates, 61 because they were earlier dates
for PR, 3 because they were later dates for PR, and 8 because the record was almost entirely incomplete.
** In the 2015 audit, records were excluded as follows: 1,056 were duplicates for use in a reliability analysis, 17 because
they were triplicates, and 7 because they were later dates for PR.
187 services
participated in the
organisational audit
(224 participated in 2015)
195 services identified
(230 identified in 2015)
184 services
participated in the
clinical audit
(210 participated in 2015)
7,643 records were
exported from the web-
tool
(8,463 in 2015)
167 records excluded*
(1,080 records in 2015**)
7,476 patients were included in the
main analysis (median 32, IQR 19–
52, range 1–191 per service)
(7,413 patients were included in 2015
(median 27, IQR 15–45, range 1–208 per
service))
© Healthcare Quality Improvement Partnership 2018
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National COPD Audit Programme: Pulmonary rehabilitation combined organisational and clinical report 2017
Access to PR

To see the data analysis in full, please access the data analysis and results reports available at
www.rcplondon.ac.uk/an-exercise-in-improvement.

Key findings

• Waiting times for enrolment to PR from receipt of referral are similar to those reported in the
2015 audit and remain too long for such an effective and high value therapy:
o The median waiting time was 75 days, with 60% (4,213/6,965) of patients enrolled within
90 days in 2017, compared with 2015 when a median waiting time of 76 days was
reported with 63% (3,800/5,986) enrolled within 90 days (QS11). (CDAR, 1.9.1)
o There was an increase in the proportion of patients being enrolled to rolling programmes;
58% (4,116/7,051) in 2017, compared with 53% (3,357/6,319) in 2015. (CDAR, 1.10)
o Waiting times remained longer for cohort programmes (median of 89 days) compared
with those of rolling programmes (median of 66 days). (CDAR, 1.10.1)

• 29% of services did not offer early post-discharge PR for patients following discharge from
hospital for acute exacerbation of COPD (AECOPD). Possibly as a result, post-exacerbation PR
(vs PR for patients with stable COPD) remained a very small proportion of PR service caseloads
(3%) (QS31). (ODAR, 1.5)

• It is encouraging that the vast majority of services (92%, 172/187) accepted those patients
with more severe disability and self-reported breathlessness MRC grade 5* compared with
81% in 2015 (182/224) (QS11). A minority of services (5%, 9/187) continued not to accept
active smokers. (ODAR, 1.1, 1.2)

• The majority of services accepted patients with conditions other than COPD (eg asthma, lung
cancer, heart failure), however, a small number (5%, 9/187) continued not to (QS21). (ODAR, 1.4)

• Services estimated that 33% of referrals for 2015/16 did not attend an initial PR assessment.

• 19% (31/167) of services were operating under a fixed term of funding. In 60% (18/30) the
funding term was for 2 years or less. (ODAR, 4.2, 4.2.1)

• There was a reduction in the whole-time equivalent (WTE) staffing levels per service. A
median of 2.53 staff was reported for 187 services in 2017, compared with a median of 2.90
staff for 224 services in 2015. (ODAR, 5.3.2)
o 23% of PR service leads did not have protected management time within their jobs to
devote to service development and leadership. (ODAR, 5.2)

• Ratios of total referrals and total initial assessments per staff increased:
o Median total referrals per 1.0 WTE was 134, compared with 104 in 2015.
o Median total initial assessments per 1.0 WTE was 89, compared with 70 in 2015. (ODAR,
5.3.2)

*Medical Research Council breathlessness scale measuring perceived respiratory disability
© Healthcare Quality Improvement Partnership 2018
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National COPD Audit Programme: Pulmonary rehabilitation combined organisational and clinical report 2017

QI priority: Reduce waiting times for enrolment to PR (from receipt of referral) with
an achievement target of 85% of patients being enrolled within 90 days for each PR
programme.

How this priority was derived:

The BTS quality standard 1b states that people
referred for pulmonary rehabilitation should be
enrolled on PR within 3 months of receipt of
referral.1 The current audit indicates that
patients referred for PR often had to wait too
long for treatment. We note also the high risk of
admission to hospital among the population
assessed for PR (approximately 30% at 6
months). Reducing waiting times will lower the
risk of admission impeding uptake of the
referral. This is of potential high importance
given that the completion of PR was associated
with reduced subsequent risk of admission to
hospital.6

This aim may appear challenging for some
services, but the upper 25% of services for this
outcome enrolled 88% or more of referred
patients within 90 days. This is therefore an
achievable target for all programmes, which will
deliver substantial benefits to patients.6

Tips on how to achieve this:

Although cohort† programmes had similar
outcomes to rolling‡ programmes, they had
significantly longer waiting times. We therefore
suggest that services that solely run cohort
programmes and struggle with waiting times
consider a change to a rolling design (or to a
combination of the two) to deliver this objective.

Quality of PR services

To see the data analysis in full, please access the data analysis and results reports available at
www.rcplondon.ac.uk/an-exercise-in-improvement.

Key findings

• Conduct of exercise testing by the majority of programmes was not in line with accepted
standards (QS81):
o Numbers of patients that had a practice exercise test remained low (<50%). There was
however an improvement in the number of practice ISWTs performed; 39% (1,369/3,551)
in 2017 compared with 26% (1,004/3,811) in 2015. These figures did not improve for the
6-minute walk test (6MWT); 26% (822/3,181) in 2017, compared with 24% (668/2,835) in
2015. (CDAR, 2.11.1)
o Of those programmes using the 6MWT, only 6% (8/127) were using the recommended
walking course length of 30m or more. (ODAR, 2.7.2)
† A cohort programme is where all patients start and finish the programme at the same time.
‡ A rolling programme is a continuing cycle of sessions, with patients joining when there is a space and leaving after
completing a programme of sessions.
© Healthcare Quality Improvement Partnership 2018
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National COPD Audit Programme: Pulmonary rehabilitation combined organisational and clinical report 2017

• 10% (18/184) of services did not offer individually prescribed aerobic§ or resistance** training
and an additional 30% (55/184) estimated exercise intensity only from perceived exertion
score†† (QS51). (ODAR, 2.4.1)

• 84% (157/186) of services in 2017 reported routinely providing a written discharge exercise
plan, which is notably better than the 65% (145/224) reported in 2015. (ODAR, 3.5)
o Data analysed from the clinical audit supports this finding, with 81% (3,739/4,637) of
patients provided with a written exercise discharge plan, compared with 73%
(3,198/4,353) in the 2015 audit (QS71). (CDAR, 4.1.2)

• 27% (2,006/7,476) of patients had an assessment of muscle strength at baseline; this has
improved considerably since the 2015 audit, where only 15% (1,094/7,413) was reported.
(CDAR, 2.14)

• The recording of key clinical information such as body mass index (BMI) and spirometry did not
significantly change since the 2015 audit:
o BMI was reported for 70% (5,259/7,476) of patients in 2017, compared with 66%
(4,898/7,413) in 2015. (CDAR, 2.9)
o Spirometry was reported for 60% of patients in both 2017 and 2015 audits. (CDAR, 2.4 to 2.6)

• It is encouraging that more services had a standard operating procedure detailing local policies;
84% (157/187) in 2017, compared with 67% (150/224) in 2015 (QS101). (OADR, 6.1)

QI priority: Each PR service should ensure that all exercise assessments are performed
to recommended technical standards. This includes the routine conduct of practice walks
and the use of walking course lengths appropriate to the test used.

How this priority was derived:

Accurate measurement of baseline is critical for
exercise prescription and outcome assessment.
However, only a minority of programmes
undertook a practice test for the ISWT or the
6MWT. Data from the 2015 audit suggest that
overall outcomes of PR were better in
programmes that undertook practice walks
during testing.11 Importantly, if patients were
asked to undertake tests as part of their
treatment, it is expected that such tests would
be conducted according to recommended
standards. This will ensure such assessments are
reliable, ensure exercise training can be
accurately prescribed, and that outcome
assessments following PR are unbiased.

Tips on how to achieve this:

Space limitations may restrict walking course
lengths for the 6MWT. For programmes where
this is the case, consider a switching to using the
ISWT, which requires only a 10m course.
§ Aerobic training refers to endurance (or submaximal) whole body exercise most commonly performed using walking
(treadmill or corridor) or on an exercise bike.
** Resistance (or strength) training refers to the generation of force by specific muscle groups (either free weights or using
a multi-gym) with the aim of improving muscle strength.
†† This data cannot be directly compared with data from the 2015 audit as the question was rephrased in the 2017 audit.
© Healthcare Quality Improvement Partnership 2018
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National COPD Audit Programme: Pulmonary rehabilitation combined organisational and clinical report 2017

Outcomes of treatment

To see the data analysis in full, please access the data analysis and results reports available at
www.rcplondon.ac.uk/an-exercise-in-improvement.

Key findings

• Overall rates of completion of the PR programme have improved; 62% (4,637/7,476) of
patients completed in 2017, compared with 59% (4,353/7,413) in 2015. (CDAR, 4)

• Clinical outcomes of treatment (proportions meeting minimal clinically important differences
(MCID) for the relevant exercise capacity and health status measures) for patients who
complete therapy were excellent, as per those seen in clinical trials.12 The table below provides
more information. (CDAR, 4.3.2)

Patients (n)
Difference between initial
assessment and discharge,
median (IQR) change
Patients achieving the
MCID or higher (%)
Walk tests
ISWT (m)
2,324
60 (20, 100)
58% (>48 metres)
6MWT (m)
1,989
50 (20, 90)
68% (>30 metres)
St George’s Respiratory Questionnaire (SGRQ)
Total score
248
-5 (-13, 2)
54% (>4 points)
Chronic Respiratory Questionnaire (CRQ) average scores
Dyspnoea
1,801
0.8 (0, 1.6)
61% (>0.5 points)
Fatigue
1,768
0.7 (0, 1.5)
59% (>0.5 points)
Emotion
1,767
0.5 (0, 1.3)
53% (>0.5 points)
Mastery
1,767
0.5 (0, 1.5)
56% (>0.5 points)
COPD Assessment Test (CAT)
Total score
2,927
-2 (-6, 1)
56% (> 2 points)

• There was no significant difference in clinical outcomes between patients enrolled on cohort
programmes compared with rolling programmes. (CDAR, 4.6.4)

QI priority: PR programmes should achieve patient completion rates of 70% or more
following assessment for PR.

How this priority was derived:

There are substantial patient-centred benefits of
completing PR, namely a marked improvement
in exercise capacity and health status. However,
the audit highlights significant patient dropout
rates between referral for PR and the
assessment appointment, as well as between
assessment and completion (38%).

The 2015 PR outcomes report demonstrated
that PR completion was associated with lower

Tips on how to achieve this:

There are actions programmes can take to
influence completion rates. PR services should
review their completion rates in detail,
identifying and assessing factors resulting in
non-completion. For example, reducing waiting
times between assessment and enrolment to PR
(QI priority 1) could in turn assist with
achievement of this key priority.13
We suggest that PR services develop
systems/checklists to identify patients at high
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National COPD Audit Programme: Pulmonary rehabilitation combined organisational and clinical report 2017
hospital admission rates at 180 days.
Enhancement of completion rates therefore has
the potential for substantial health benefit to
patients and to the NHS.6

The upper quartile of completion rates for PR
programmes across the audit in 2017 was 75%
or higher, so this is an achievable target for all
programmes.

risk of exacerbation and hospital admission, for
example those with previous admissions, active
smokers, or with more advanced disease. PR
services should work in partnership with local
specialist and/or community COPD teams to
ensure evidence-based exacerbation prevention
strategies are implemented (for example,
ensuring correct diagnosis, optimising drug
treatment, managing comorbidities and
promoting smoking cessation and winter
vaccination) as these may also be effective in
enhancing PR completion rates.11

© Healthcare Quality Improvement Partnership 2018
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National COPD Audit Programme: Pulmonary rehabilitation combined organisational and clinical report 2017
QI case study

Below is an example of a small test of change14,15 implemented by BreathingSpace, Rotherham to
improve their patient completion rates (QI priority 3).

Developing a new patient information leaflet to raise
awareness of pulmonary rehabilitation

BreathingSpace, Rotherham

Background
Results from the 2015 PR audit showed
that BreathingSpace, Rotherham
reported that 11% of patients who
were assessed were then not enrolled
to PR. Therefore, to take steps to
reduce dropout rates BreathingSpace
utilised a communication tools quality
improvement methodology.

Aim
Evidence suggests that one of the reasons for non-
attendance and non-completion is uncertainty and a lack
of understanding of the benefits of PR.11,16

To increase patient uptake and completion of PR by
providing patients, their families and carers with clear,
comprehensive and consistent communication which is
focused on improving the quality of the care they receive.

Process
An outdated information leaflet was being used across the trust. It was recognised that the leaflet
lacked patient input and did not address the aspects of PR that patients felt were most important.

A patient focus group was conducted with those patients already engaged with PR to help
understand what they expected the leaflet to explain and to include any concerns that they had
prior to attending PR. It was recognised that some patients were unsure about what the term
‘rehabilitation’ would involve, so this was identified as a potential barrier to uptake. In addition to
the focus group, telephone interviews were conducted with patients who had been identified as
having either declined after the initial assessment or enrolled and not completed PR. Both these
methods helped to broaden the depth of information that was included in the leaflet.

Outcomes
The new patient information leaflet was distributed trust-wide. Its
success can be measured by the reduction in the percentage of
patients assessed for PR, who were then not enrolled on a
course. Results from the 2017 audit showed that only 2% of
patients fell into this category at BreathingSpace, Rotherham
(compared with 11% reported in the 2015 audit). Patients who
received the leaflet and healthcare professionals providing it were
asked to rate the value of its effectiveness. Results showed that
80% of patients rated the leaflet as ‘useful’ or ‘very useful’. 85% of
health and care professionals rated it as a useful tool to issue to
patients when introducing the idea of referral to PR. Governance
procedures have been put in place to routinely review and revise
the document. Copies of the outdated leaflet have now been
withdrawn.

© Healthcare Quality Improvement Partnership 2018
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National COPD Audit Programme: Pulmonary rehabilitation combined organisational and clinical report 2017
Recommendations
Patients and carers/families

• If your breathing is preventing you from undertaking normal physical tasks (such as walking on
flat ground), or if you have been admitted to hospital for a flare-up of your COPD, ask any
healthcare professional involved with your respiratory care to refer you to PR.

• You should expect to start PR treatment within 90 days of the service receiving your referral.
PR programmes

• All patients referred for PR should be enrolled to the programme within 90 days of receipt of
the referral (QI priority 1).
o PR services that solely run cohort programmes could consider switching to rolling
programmes (or using a combination of both) to reduce waiting times.

• Care processes should be reviewed to ensure that they meet BTS guidelines and quality
standards. Particular attention should be paid to ensure that:
o exercise testing at assessment is performed to accepted standards (QI priority 2)
o exercise training is accurately prescribed from an exercise test performed at assessment
o patients are provided with a written, individualised exercise plan at discharge from PR.

• Patients at high risk of exacerbation and hospital admission should be identified at assessment
for PR and evidence-based exacerbation prevention strategies implemented by developing
integration and referral pathways. Key interventions may include:
o ensuring correct diagnosis
o promoting smoking cessation and vaccination
o optimising drug therapy
o managing comorbidities.
Primary and secondary healthcare teams

• Practices should review COPD registers to ensure all eligible patients are offered PR and that
this offer is considered at each annual review.

• Hospital discharge teams should ensure that local discharge care bundles include the offer of
early post-discharge PR, accompanied by information about the benefits of PR.

• Hospital and community specialist COPD healthcare teams should work with PR programmes
to arrange review of individual patient exacerbation prevention measures.
System leaders (clinical commissioning groups/STPs)

• Should ensure that PR services receive funding of sufficient quantity and duration to enable
them to recruit and retain highly trained staff and develop processes to ensure that all
patients are enrolled to PR within 90 days of receipt of referral.

• Should ensure that there is an accessible PR service that can offer early post-discharge PR for
patients leaving hospital after an exacerbation of COPD.

• Prioritise measures to enhance referral and completion of PR, including developing integrated
referral pathways between PR services and other healthcare teams managing COPD.
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National COPD Audit Programme: Pulmonary rehabilitation combined organisational and clinical report 2017
Additional quality improvement opportunities

For PR services

• Record baseline exercise measures accurately (QI priority 2) and record exercise intensity
prescribed during PR, including how it is calculated. If resistance exercise training is undertaken,
record maximum strength and ensure it is measured at baseline, including how the resistance
training loads are calculated.

• Review discharge assessment processes and ensure the provision of a discharge exercise plan is
included and recorded.

• Develop referral pathways in collaboration with specialist hospital or community COPD teams in
order to facilitate engagement in implementing exacerbation prevention strategies.

For primary and secondary healthcare teams

• Review practice COPD registers to ensure that all patients with significant exercise limitation
(MRC grade 3 or worse) have had a proactive offer of PR. Record referral rates for PR on patient
records and set specific targets for improvement.

• Include referral to PR as part of your discharge care bundle for AECOPD and record these
referral rates. If patients choose to decline PR when leaving hospital, recommend that the offer
is made again later (during or following recovery) by healthcare teams that are taking over care
after discharge, and record that this recommendation has been made.

For system leaders

• Discuss resource needs directly with local programme leads and develop business plans to
deliver these resources. Support participation in ongoing audits to demonstrate that these
resources are meeting local and national QI objectives and delivering improvements in patient
care.

© Healthcare Quality Improvement Partnership 2018
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National COPD Audit Programme: Pulmonary rehabilitation combined organisational and clinical report 2017
Appendix A: BTS Summary of 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 exacerbations 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 process.

10

Pulmonary rehabilitation programmes produce an agreed standard operating procedure.

British Thoracic Society. BTS quality standards for pulmonary rehabilitation in adults. London: BTS, 2014.
www.brit-thoracic.org.uk/standards-of-care/quality-standards/bts-pulmonary-rehabilitation-quality-standards/
© Healthcare Quality Improvement Partnership 2018
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National COPD Audit Programme: Pulmonary rehabilitation combined organisational and clinical report 2017
Appendix B: Document purpose

Document
purpose
To disseminate the results of the national clinical and organisational audits of pulmonary
rehabilitation services in England and Wales 2017.
Title
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.
Authors
Steiner M, McMillan V, Lowe D, Saleem Khan M, Holzhauer-Barrie J, Mortier K, Riordan J,
Roberts CM
(on behalf of the National COPD Audit Programme: pulmonary rehabilitation workstream)
Publication
date
12 April 2018
Audience
Healthcare professionals, NHS managers, chief executives and board members, service
commissioners, policymakers, COPD patients, their families/carers, and the public.
Description
This is the fourth of the COPD pulmonary rehabilitation audit reports, and the first
reporting on data collected in 2017, published as part of the National COPD Audit
Programme.
This combined report details national data relating to the resources and organisation of
PR services across England and Wales in 2017 and the clinical outcomes of treatment in
patients with COPD assessed for PR between January and April 2017. It also documents
attainment against relevant pulmonary rehabilitation guidelines and quality standards as
published by the British Thoracic Society (BTS) in 2013 and 2014.
The report is relevant to anyone with an interest in COPD. It provides a comprehensive
picture of pulmonary rehabilitation services, and will enable lay people, as well as experts,
to understand how PR services function currently, and where change needs to occur.
The information, key findings and recommendations outlined in the report are designed
to provide readers with a basis for identifying areas in need of change and to facilitate
development of improvement programmes that are relevant not only to pulmonary
rehabilitation services, but also to commissioners and policymakers. There is no scheduled
review date for the report.
Supersedes
•
Steiner M, Holzhauer-Barrie J, Lowe D, Searle L, Skipper E, Welham S, Roberts CM.
Pulmonary Rehabilitation: Time to breathe better. National Chronic Obstructive
Pulmonary Disease (COPD) Audit Programme: Resources and organisation of
Pulmonary Rehabilitation services in England and Wales 2015. National organisational
audit report. London: RCP, November 2015.
www.rcplondon.ac.uk/projects/outputs/pulmonary-rehabilitation-time-breathe-
better
•
Steiner M, Holzhauer-Barrie J, Lowe D, Searle L, Skipper E, Welham S, Roberts CM.
Pulmonary Rehabilitation: Steps to breathe better. National Chronic Obstructive
Pulmonary Disease (COPD) Audit Programme: Clinical audit of Pulmonary
Rehabilitation services in England and Wales 2015. National clinical audit report.
London: RCP, February 2016. www.rcplondon.ac.uk/projects/outputs/pulmonary-
rehabilitation-steps-breathe-better
•
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. London: RCP, December
2017. www.rcplondon.ac.uk/projects/outputs/pulmonary-rehabilitation-beyond-
breathing-better
Contact
xxx@xxx.xx

© Healthcare Quality Improvement Partnership 2018
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National COPD Audit Programme: Pulmonary rehabilitation combined organisational and clinical report 2017
Appendix C: References

1 British Thoracic Society. BTS quality standards for pulmonary rehabilitation in adults. London: BTS, 2014.
www.brit-thoracic.org.uk/standards-of-care/quality-standards/bts-pulmonary-rehabilitation-quality-
standards/ [Accessed January 2018].

2 Steiner M, Holzhauer-Barrie J, Lowe D, Searle L, Skipper E, Welham S, Roberts CM. Pulmonary Rehabilitation:
Time to breathe better. National Chronic Obstructive Pulmonary Disease (COPD) Audit Programme: Resources
and organisation of Pulmonary Rehabilitation services in England and Wales 2015. National organisational
audit report. London: RCP, November 2015. www.rcplondon.ac.uk/projects/outputs/pulmonary-rehabilitation-
time-breathe-better [Accessed January 2018].

3 Steiner M, Holzhauer-Barrie J, Lowe D, Searle L, Skipper E, Welham S, Roberts CM. Pulmonary Rehabilitation:
Steps to breathe better. National Chronic Obstructive Pulmonary Disease (COPD) Audit Programme: Clinical
audit of Pulmonary Rehabilitation services in England and Wales 2015. National clinical audit report. London:
RCP, February 2016. www.rcplondon.ac.uk/projects/outputs/pulmonary-rehabilitation-steps-breathe-better
[Accessed January 2018].

4 British Thoracic Society Reports, Vol 4, Issue 2, 2012. IMPRESS Guide to the relative value of COPD
interventions. www.respiratoryfutures.org.uk/knowledge-portal/impress-documents/guide-to-the-relative-
value-of-copd-interventions/ [Accessed January 2018].

5 British Thoracic Society. BTS guideline for pulmonary rehabilitation in adults. London: BTS, 2013. www.brit-
thoracic.org.uk/standards-of-care/guidelines/bts-guideline-on-pulmonary-rehabilitation-in-adults/ [Accessed
January 2018].

6 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/pulmonary-
rehabilitation-beyond-breathing-better [Accessed January 2018].

7 Dyer F, Marriner P, Cheema K and Bott J. Is a practice incremental shuttle walk test really necessary? Chron
Respir Dis 2001;8(3):201–205. doi: 10.1177/1479972311415128
http://journals.sagepub.com/doi/pdf/10.1177/1479972311415128 [Accessed January 2018].

8 Griffiths TL, Burr ML, Campbell IA, et al. Results at 1 year of outpatient multidisciplinary pulmonary
rehabilitation: a randomised controlled trial. Lancet 2000;355:362–8
https://pdfs.semanticscholar.org/4059/328b782e144d96442633654bd88c0c07dc11.pdf [Accessed January
2018].

9 Pulmonary rehabilitation site locations map. www.nacap.org.uk/nacap/welcome.nsf/map.html [Accessed
January 2018]

10 Pulmonary rehabilitation workstream: audit resources. www.rcplondon.ac.uk/projects/outputs/pulmonary-
rehabilitation-workstream-audit-resources [Accessed January 2018].

11 Hakamy A, McKeever TM, Steiner MC, Roberts CM, Singh S.J and Bolton CE. The use of the practice walk
test in pulmonary rehabilitation program: National COPD Audit Pulmonary Rehabilitation Workstream. Int J
Chronic Obstr Pulm Dis 2017;12:2681–6. www.dovepress.com/the-use-of-the-practice-walk-test-in-pulmonary-
rehabilitation-program--peer-reviewed-article-COPD [Accessed November 2017].

12 Puhan MA, Gimeno-Santos E, Cates CJ, Troosters T. Pulmonary rehabilitation following exacerbations of
chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2016;12
http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD005305.pub4/full [Accessed September 2017].
© Healthcare Quality Improvement Partnership 2018
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National COPD Audit Programme: Pulmonary rehabilitation combined organisational and clinical report 2017

13 Keating A, Lee A, Holland AE. What prevents people with chronic obstructive pulmonary disease from
attending pulmonary rehabilitation? A systematic review. Chron Respir Dis 2011;8(2):89–99. doi:
10.1177/1479972310393756.

14 Institute for Quality Improvement. Science of improvement: Testing changes.
www.ihi.org/resources/Pages/HowtoImprove/ScienceofImprovementTestingChanges.aspx [Accessed
December 2017].

15 Royal College of Physicians. COPD audit: regional QI workshops.
www.rcplondon.ac.uk/projects/outputs/copd-audit-regional-qi-workshops [Accessed December 2017].

16 Lewis A, Bruton A, Donovan-Hall M. Uncertainty prior to pulmonary rehabilitation in primary care: A
phenomenological qualitative study in patients with chronic obstructive pulmonary disease. Chron Respir Dis
2014 Jun 30; 11(3): 173–180. Published online 30 June 2014. doi: 10.1177/1479972314539981.
© Healthcare Quality Improvement Partnership 2018
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For further information on the overall audit
programme or any of the workstreams, please
see our website or contact the national asthma
and COPD audit team directly:
National Asthma and Chronic Obstructive
Pulmonary Disease Audit Programme (NACAP)
formerly National COPD Audit Programme
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
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#COPDPRbreathebetter
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