The National Chronic Obstructive Pulmonary Disease (COPD) Audit Programme’s Pulmonary Rehabilitation (PR) Report reveals substantial health benefits received by patients who complete PR treatment yet many patients are not being referred, and many patients (40%) find it difficult to complete the PR programme.
COPD is the collective term for emphysema and chronic bronchitis, and it is mainly caused by smoking. People with COPD have breathing difficulties, which can affect the quality of their everyday life and prevent normal physical activity. PR is a combination of exercises to improve physical activity and fitness, together with advice and education about self-care: all of which help patients with COPD to cope with this long term medical condition.
The report also shows that over a third of patients (37%) in England and Wales are waiting longer than the 3 months recommended in the British Thoracic Society (BTS) quality standards.
The report entitled Pulmonary Rehabilitation: Steps to breathe better covers the second part of the COPD PR audit, reviewing the quality of care received by 7,413 patients across 210 PR services in the primary, secondary and community care sectors.
Overall, the report reveals many areas of good quality PR treatment for COPD patients, including widespread provision of walking (95%), cycle (70%) and aerobic and resistance exercise therapy (89%). However, not all patients are being provided with an ongoing individual exercise plan.
There remain significant variations in waiting times and quality of care when patients attend PR, and unacceptably long waits for treatment are more common when PR is given as part of a group because patients have to wait until the start of the next scheduled programme.
The report highlights the need for greater awareness of the benefits of PR in primary and secondary care. It also urges commissioners and providers to ensure that all patients receive an offer to start PR treatment within the recommended 3 months following their referral.
The key findings and recommendations are set against BTS quality standards for PR. The full COPD PR audit report can be found on the Pulmonary rehabilitation workstream page.
Other key findings
- There is widespread provision of walking (95%), cycle (70%) and aerobic and resistance exercise training (89%).
- Most patients (74%) were provided with a written, ongoing individualised exercise plan following discharge. However, this means that almost one-third (26%) of patients who attend a discharge assessment are not given an individualised plan.
- Significant numbers of patients who attend a PR assessment do not complete the treatment (40%).
- Patients that do complete PR, on average, show substantial improvements in quality of life and ability to exercise.
- Patients with a full range of self-reported exercise limitation were assessed and enrolled to PR. However, only 9% of patients who have the most severe disability were enrolled to PR.
Main recommendations for PR commissioners and providers
- Commissioners and providers should ensure that robust referral pathways for PR are in place and that PR programmes have sufficient capacity to assess and enrol all patients within 3 months of referral.
- PR programmes should examine their processes and ensure that they are performing exercise outcome measures to accepted standards, including exercise tests, where it is recommended.
- Referrers and patients should be provided with up-to-date and clear written information about the benefits of attending and completing PR.
- Programmes should ensure that they offer a sufficiently flexible service to encourage patients who are referred to PR to attend and complete the treatment (for example, flexibility about times and days of PR sessions and the availability of transport for patients who find travelling difficult).
Patients and commissioners can now begin to use these results in a practical way to understand the quality of their local services.
Professor Michael Steiner, national COPD audit clinical lead for pulmonary rehabilitation and a consultant respiratory physician, said:
The audit demonstrates the substantial health benefits received by people who complete PR. I hope the findings of this milestone PR clinical report and other PR audit reports will widen access to PR services and in turn, improve care for people with COPD. The enthusiasm with which the PR programmes have participated in the audit suggest the UK PR community is well placed to achieve this.
Dr Lisa Davies, chair of the British Thoracic Society, said:
The audit is an important step to really understanding the extent and quality of care in PR services across England and Wales. We are pleased to see that there is an overall adherence to the BTS standards. However, we hope and expect that action will be taken to increase referral rates of eligible patients and it will be crucial that PR services are sufficiently resourced to meet this demand, whilst individual waits for treatment are acceptable and in line with BTS standards.
The National COPD Audit Programme is commissioned by the Healthcare Quality Improvement Partnership (HQIP) as part of the National Clinical Audit and Patient Outcomes Programme (NCAPOP)*. The National COPD Audit Programme is led by the Royal College of Physicians (RCP), working closely with stakeholders, including the British Thoracic Society (BTS), the Primary Care Respiratory Society UK (PCRS-UK), the British Lung Foundation (BLF) and the Royal College of General Practitioners (RCGP).
For more information or to arrange an interview, please contact Joanna Morgan, communications manager, RCP Care Quality Improvement Department on 020 3075 1354.
The report will be available from 00.01 hours on Wednesday 10 February 2016 on the RCP website: www.rcplondon.ac.uk/COPD.
PR is an accepted standard of care for people with COPD and its lack of availability or a lack of referral to PR can affect the quality of care for patients. PR is one of the few therapies that has shown to reduce patients’ time spent in hospital and it is a cost-effective treatment for COPD. Therefore, PR programmes should be a high priority for national and local health policymakers.
Exercise programmes include a mixture of strength and aerobic exercise training. PR has been proven to reduce breathlessness and to help those who live with COPD to undertake everyday activities like walking or climbing stairs.
Chronic obstructive pulmonary disease (COPD) is a common and usually progressive disease and is a leading cause of mortality and morbidity globally: the World Health Organization estimates that
COPD is responsible for 5% of annual deaths globally. It causes progressive breathlessness with cough and wheeze, punctuated by exacerbations (flare-ups) that may lead to hospital admission. While 835,000 people in England have been diagnosed with the disease, a further 2 million people with COPD may be unidentified (Department of Health, 2010).
COPD is the fifth biggest killer in the UK and the only major cause of death that is on the increase. Respiratory disease is the third leading cause of death in England, with approximately 23,000 people dying from COPD each year (NHS Atlas of Variation in Healthcare for People with Respiratory Disease (September 2012).
More than six million people in England suffer with COPD or asthma. Respiratory disease is one of the principal reasons for emergency admission to hospital.
The National COPD Audit Programme brings together primary care, secondary care, PR and patient experience. This national audit programme comprises comprehensive multidisciplinary, collaborative working and aims to drive improvements in the quality of care and services provided for COPD patients in England and Wales. It is led by the RCP, working closely with a range of key stakeholders, including the BTS, the PCRS-UK, the BLF and the RCGP.
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 30,000 fellows and members worldwide, the RCP advises and works with government, patients, allied healthcare professionals and the public to improve health and healthcare.
The Clinical Effectiveness and Evaluation Unit (CEEU) of the RCP deliver projects that aim to improve healthcare in line with the best evidence for clinical practice: guideline development, national comparative clinical audit, the measurement of clinical and patient outcomes, and change management. All of our work is carried out in collaboration with relevant specialist societies, patient groups and NHS bodies.
The British Thoracic Society
The British Thoracic Society (BTS) was formed in 1982 by the amalgamation of the British Thoracic and Tuberculosis Association and the Thoracic Society, but their roots go back as far as the 1920s. BTS is a registered charity and a company limited by guarantee. The Society’s statutory objectives are: ‘the relief of sickness and the preservation and protection of public health by promoting the best standards of care for patients with respiratory and associated disorders, advancing knowledge about their causes, prevention and treatment and promoting the prevention of respiratory disorders’. Members include doctors, nurses, respiratory physiotherapists, scientists and other professionals with an interest in respiratory disease. In August 2015 BTS had 2,994 members. All members join because they share an interest in BTS’s main charitable objective, which is to improve the care of people with respiratory disorders.
*About HQIP, the National Clinical Audit Programme and how it is funded
The Healthcare Quality Improvement Partnership (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 National Clinical Audit Programme (NCA), 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. www.hqip.org.uk