Comment
Pulmonary rehabilitation: the next steps Pulmonary rehabilitation is recognised as one of the most effective therapies available for people with chronic obstructive respiratory disease (COPD) and other respiratory disorders. Pulmonary rehabilitation addresses the key clinical problem of exercise limitation caused by breathlessness and fatigue and also provides a supportive environment in which patients can become active and engage in the management of their health problems. The scientific evidence for the benefit of pulmonary rehabilitation is uncontestable and its provision is now mandated in all national and international COPD treatment guidelines.1,2 The translation of scientific evidence and guidance documents into effective clinical practice is, however, not a given. Pulmonary rehabilitation is a complex intervention that includes exercise therapy, disease education, behaviour change, and psychological support. Although recent guidelines provide a definition of pulmonary rehabilitation,3,4 the precise content and delivery of the therapy is open to interpretation and the experimental conditions characterising randomised clinical trials might not apply in real-life clinical practice. Moreover, survey data suggest that the provision of pulmonary rehabilitation services is far from universal both within and between countries.5 These concerns have driven the development of the European Respiratory Society–American Thoracic Society policy statement on pulmonary rehabilitation6 which aims to bridge the large gap between the documented benefits of pulmonary rehabilitation and its practical implementation in real-world settings. In the UK, this issue has been addressed through a coherent sequence of quality improvement measures in which updated evidence-based guidance on the provision of pulmonary rehabilitation (published in 2013)3 was followed by the development of pulmonary rehabilitation quality standards7 (indicators of high-quality care) and subsequently by a nationally commissioned audit of pulmonary rehabilitation services that measured clinical process with outcomes assessed against these standards. The report of this audit of clinical outcomes of pulmonary rehabilitation8 was published this month and links to an earlier report of the resources and organisation of pulmonary rehabilitation services published in 2015.9 Both reports are part of the England and Wales national COPD audit programme, which also includes data about acute
hospital care and primary care services. The pulmonary rehabilitation clinical report presents data from more than 7000 patients assessed for rehabilitation over a 3-month period by 210 different pulmonary rehabilitation programmes (91% of all services across England and Wales) and as such represents one of the largest audit datasets for pulmonary rehabilitation outcomes worldwide. What do the findings tell us about the state of pulmonary rehabilitation provision in England and Wales and about the challenges involved in implementing high-quality pulmonary rehabilitation services worldwide? The audit suggests that a widespread desire exists among pulmonary rehabilitation programmes and practitioners to measure and improve the service they provide, since participation was enthusiastic and virtually all services routinely used
Lancet Respir Med 2016 Published Online February 10, 2016 http://dx.doi.org/10.1016/ S2213-2600(16)00008-4
For every 100 patients that completed either the 6MWT or the ISWT, both on initial assessment and discharge, the following responses were recorded: 63 improved after pulmonary rehabilitation by more than the MCID* 20 improved after pulmonary rehabilitation but by less than the MCID 17 had no change or a reduction
For every 100 patients that had a health status test (either CAT, SGRQ, or CRQ) both upon initial assessment and discharge, the following differences were recorded: 61 improved after pulmonary rehabilitation by more than the MCID† 13 improved after pulmonary rehabilitation but by less than the MCID 26 had no change or a worse score
Figure: Clinical response rates for patients completing pulmonary rehabilitation in the National Pulmonary Rehabilitation Audit for England and Wales8 6MWT=6-Minute Walk Test. ISWT=Incremental Shuttle Walk Test. MCID=minimum clinically important difference. CAT=COPD Assessment Test. SGRQ=St George’s Respiratory Questionnaire. CRQ=Chronic Respiratory Questionnaire. *For the ISWT the MCID is 48 m and for the 6MWT the MCID is 30 m. †For the SGRQ the MCID was taken as a reduction in 4 points in the total score, for the CRQ the MCID was an increase in 0·5 points in the average of the four domain scores, and for the CAT the MCID was a reduction in 2 points.
www.thelancet.com/respiratory Published online February 10, 2016 http://dx.doi.org/10.1016/S2213-2600(16)00008-4
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objective clinical measurement to assess individual patient outcomes. Although the processes of care were, for the most part, robust and evidence based, the audit report outlines areas where this could be improved (eg, accurate prescription of exercise training and provision of ongoing exercise plans). Some programmes were operating in an environment of funding insecurity, which hampered staff recruitment and service development. The data about clinical outcomes are striking in confirming the substantial and clinically important benefits bequeathed by pulmonary rehabilitation to patients who complete the treatment. The size of these benefits is in line with those seen in clinical trials, with most patients achieving changes in exercise performance and health status above accepted thresholds for important change in the outcome assessments used (figure). However, the audit is also in line with published data10,11 indicating that substantial numbers of patients referred for pulmonary rehabilitation either do not attend an initial assessment (31% of those referred) or do not complete treatment (40% of those assessed). Moreover, when compared with the number of eligible patients with COPD (self-reported exercise limitation, Medical Research Council Dyspnoea Scale grade 3 or worse) estimated from primary care databases, it is clear that many patients who might benefit from pulmonary rehabilitation are not being referred at all. The audit identifies areas in which pulmonary rehabilitation programmes can improve their processes of care and can be a powerful driver for service improvement. However, it also delivers a message to the wider respiratory health-care community. Referral for pulmonary rehabilitation needs to move to the top of the agenda in discussions of treatment options with patients with COPD and other chronic respiratory diseases and routes of referral need to be streamlined and straightforward. There is also a message to patients and patient groups. Pulmonary rehabilitation is demanding on patients’ time and effort but the audit confirms just how effective it can be if individuals adhere to the rehabilitation course. Evidence from clinical trials tells us that pulmonary rehabilitation delivers health benefits and can be cost effective, and this large-scale real-life clinical audit confirms that similar effect sizes can be delivered at scale. Of equal importance are the findings that potentially undermine the effectiveness of pulmonary rehabilitation as a more widely provided health-care intervention. Low patient uptake of the intervention and high dropout 2
rates, coupled with the implied substantial underreferral at source, point to a major failure in the health system. The call to researchers and health policy makers internationally is to develop a more sophisticated understanding of the patient and health-care factors that determine access to pulmonary rehabilitation. The goal is to identify the potential interventions that can enhance referral and completion rates to levels that would truly make pulmonary rehabilitation the cornerstone of COPD management at a national and international level. *Michael C Steiner, C Michael Roberts Centre for Exercise and Rehabilitation Science and The Institute for Lung Health, Leicester Respiratory Biomedical Research Unit, Glenfield Hospital, University Hospitals of Leicester NHS Trust, Groby Road, Leicester, LE3 9QP, UK (MCS); School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK (MCS); Institute of Health Sciences Education, Queen Mary University of London, Barts Health NHS Trust, London, UK (CMR); UCLPartners, AHSN, London, UK (CMR); and Clinical Effectiveness Unit, Royal College of Physicians of London, London, UK (CMR) [email protected] MCS has received support from the Royal College of Physicians. CMR declares no competing interests. 1
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Vestbo J, Hurd SS, Agustí AG, et al. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary. Am J Respir Crit Care Med 2013; 187: 347–65. National Institute for Health and Care Excellence. Management of chronic obstructive pulmonary disease in adults in primary and secondary care (partial update). NICE Clinical Guidelines, no. 101. London: Royal College of Physicians, 2010. Bolton CE, Bevan-Smith EF, Blakey JD, et al. British Thoracic Society guideline on pulmonary rehabilitation in adults. Thorax 2013; 68 (suppl 2): ii1–30. Spruit MA, Singh SJ, Garvey C, et al. An official American Thoracic Society/ European Respiratory Society statement: key concepts and advances in pulmonary rehabilitation. Am J Respir Crit Care Med 2013; 188: e13–64. Spruit MA, Pitta F, Garvey C, et al. Differences in content and organisational aspects of pulmonary rehabilitation programmes. Eur Respir J 2014; 43: 1326–37. Rochester CL, Vogiatzis I, Holland AE, et al. An Official American Thoracic Society/European Respiratory Society policy statement: enhancing implementation, use, and delivery of pulmonary rehabilitation. Am J Respir Crit Care Med 2015; 192: 1373–86. British Thoracic Society. Quality standards for pulmonary rehabilitation in adults. 2014. British Thoracic Society. https://www.brit-thoracic.org.uk/ document-library/clinical-information/pulmonary-rehabilitation/btsquality-standards-for-pulmonary-rehabilitation-in-adults/ (accessed Jan 27, 2016). Steiner MC, Holzhauer-Barrie J, Lowe D, et al. Pulmonary rehabilitation: steps to breathe better. National Chronic Obstructive Pulmonary Disease (COPD) Audit Programme: resources and organisation of pulmonary rehabilitation services in England and Wales 2015. London: Royal College of Physicians, 2016. Steiner MC, Roberts CM, Lowe D, et al. 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. London: Royal College of Physicians, 2015. 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: 89–99. Jones SE, Green SA, Clark AL, et al. Pulmonary rehabilitation following hospitalisation for acute exacerbation of COPD: referrals, uptake and adherence. Thorax 2014; 69: 181–82.
www.thelancet.com/respiratory Published online February 10, 2016 http://dx.doi.org/10.1016/S2213-2600(16)00008-4
Pulmonary rehabilitation: the next steps Pulmonary rehabilitation is recognised as one of the most effective therapies available for people with chronic obstructive respiratory disease (COPD) and other respiratory disorders. Pulmonary rehabilitation addresses the key clinical problem of exercise limitation caused by breathlessness and fatigue and also provides a supportive environment in which patients can become active and engage in the management of their health problems. The scientific evidence for the benefit of pulmonary rehabilitation is uncontestable and its provision is now mandated in all national and international COPD treatment guidelines.1,2 The translation of scientific evidence and guidance documents into effective clinical practice is, however, not a given. Pulmonary rehabilitation is a complex intervention that includes exercise therapy, disease education, behaviour change, and psychological support. Although recent guidelines provide a definition of pulmonary rehabilitation,3,4 the precise content and delivery of the therapy is open to interpretation and the experimental conditions characterising randomised clinical trials might not apply in real-life clinical practice. Moreover, survey data suggest that the provision of pulmonary rehabilitation services is far from universal both within and between countries.5 These concerns have driven the development of the European Respiratory Society–American Thoracic Society policy statement on pulmonary rehabilitation6 which aims to bridge the large gap between the documented benefits of pulmonary rehabilitation and its practical implementation in real-world settings. In the UK, this issue has been addressed through a coherent sequence of quality improvement measures in which updated evidence-based guidance on the provision of pulmonary rehabilitation (published in 2013)3 was followed by the development of pulmonary rehabilitation quality standards7 (indicators of high-quality care) and subsequently by a nationally commissioned audit of pulmonary rehabilitation services that measured clinical process with outcomes assessed against these standards. The report of this audit of clinical outcomes of pulmonary rehabilitation8 was published this month and links to an earlier report of the resources and organisation of pulmonary rehabilitation services published in 2015.9 Both reports are part of the England and Wales national COPD audit programme, which also includes data about acute
hospital care and primary care services. The pulmonary rehabilitation clinical report presents data from more than 7000 patients assessed for rehabilitation over a 3-month period by 210 different pulmonary rehabilitation programmes (91% of all services across England and Wales) and as such represents one of the largest audit datasets for pulmonary rehabilitation outcomes worldwide. What do the findings tell us about the state of pulmonary rehabilitation provision in England and Wales and about the challenges involved in implementing high-quality pulmonary rehabilitation services worldwide? The audit suggests that a widespread desire exists among pulmonary rehabilitation programmes and practitioners to measure and improve the service they provide, since participation was enthusiastic and virtually all services routinely used
Lancet Respir Med 2016 Published Online February 10, 2016 http://dx.doi.org/10.1016/ S2213-2600(16)00008-4
For every 100 patients that completed either the 6MWT or the ISWT, both on initial assessment and discharge, the following responses were recorded: 63 improved after pulmonary rehabilitation by more than the MCID* 20 improved after pulmonary rehabilitation but by less than the MCID 17 had no change or a reduction
For every 100 patients that had a health status test (either CAT, SGRQ, or CRQ) both upon initial assessment and discharge, the following differences were recorded: 61 improved after pulmonary rehabilitation by more than the MCID† 13 improved after pulmonary rehabilitation but by less than the MCID 26 had no change or a worse score
Figure: Clinical response rates for patients completing pulmonary rehabilitation in the National Pulmonary Rehabilitation Audit for England and Wales8 6MWT=6-Minute Walk Test. ISWT=Incremental Shuttle Walk Test. MCID=minimum clinically important difference. CAT=COPD Assessment Test. SGRQ=St George’s Respiratory Questionnaire. CRQ=Chronic Respiratory Questionnaire. *For the ISWT the MCID is 48 m and for the 6MWT the MCID is 30 m. †For the SGRQ the MCID was taken as a reduction in 4 points in the total score, for the CRQ the MCID was an increase in 0·5 points in the average of the four domain scores, and for the CAT the MCID was a reduction in 2 points.
www.thelancet.com/respiratory Published online February 10, 2016 http://dx.doi.org/10.1016/S2213-2600(16)00008-4
1
Comment
objective clinical measurement to assess individual patient outcomes. Although the processes of care were, for the most part, robust and evidence based, the audit report outlines areas where this could be improved (eg, accurate prescription of exercise training and provision of ongoing exercise plans). Some programmes were operating in an environment of funding insecurity, which hampered staff recruitment and service development. The data about clinical outcomes are striking in confirming the substantial and clinically important benefits bequeathed by pulmonary rehabilitation to patients who complete the treatment. The size of these benefits is in line with those seen in clinical trials, with most patients achieving changes in exercise performance and health status above accepted thresholds for important change in the outcome assessments used (figure). However, the audit is also in line with published data10,11 indicating that substantial numbers of patients referred for pulmonary rehabilitation either do not attend an initial assessment (31% of those referred) or do not complete treatment (40% of those assessed). Moreover, when compared with the number of eligible patients with COPD (self-reported exercise limitation, Medical Research Council Dyspnoea Scale grade 3 or worse) estimated from primary care databases, it is clear that many patients who might benefit from pulmonary rehabilitation are not being referred at all. The audit identifies areas in which pulmonary rehabilitation programmes can improve their processes of care and can be a powerful driver for service improvement. However, it also delivers a message to the wider respiratory health-care community. Referral for pulmonary rehabilitation needs to move to the top of the agenda in discussions of treatment options with patients with COPD and other chronic respiratory diseases and routes of referral need to be streamlined and straightforward. There is also a message to patients and patient groups. Pulmonary rehabilitation is demanding on patients’ time and effort but the audit confirms just how effective it can be if individuals adhere to the rehabilitation course. Evidence from clinical trials tells us that pulmonary rehabilitation delivers health benefits and can be cost effective, and this large-scale real-life clinical audit confirms that similar effect sizes can be delivered at scale. Of equal importance are the findings that potentially undermine the effectiveness of pulmonary rehabilitation as a more widely provided health-care intervention. Low patient uptake of the intervention and high dropout 2
rates, coupled with the implied substantial underreferral at source, point to a major failure in the health system. The call to researchers and health policy makers internationally is to develop a more sophisticated understanding of the patient and health-care factors that determine access to pulmonary rehabilitation. The goal is to identify the potential interventions that can enhance referral and completion rates to levels that would truly make pulmonary rehabilitation the cornerstone of COPD management at a national and international level. *Michael C Steiner, C Michael Roberts Centre for Exercise and Rehabilitation Science and The Institute for Lung Health, Leicester Respiratory Biomedical Research Unit, Glenfield Hospital, University Hospitals of Leicester NHS Trust, Groby Road, Leicester, LE3 9QP, UK (MCS); School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK (MCS); Institute of Health Sciences Education, Queen Mary University of London, Barts Health NHS Trust, London, UK (CMR); UCLPartners, AHSN, London, UK (CMR); and Clinical Effectiveness Unit, Royal College of Physicians of London, London, UK (CMR) [email protected] MCS has received support from the Royal College of Physicians. CMR declares no competing interests. 1
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Vestbo J, Hurd SS, Agustí AG, et al. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary. Am J Respir Crit Care Med 2013; 187: 347–65. National Institute for Health and Care Excellence. Management of chronic obstructive pulmonary disease in adults in primary and secondary care (partial update). NICE Clinical Guidelines, no. 101. London: Royal College of Physicians, 2010. Bolton CE, Bevan-Smith EF, Blakey JD, et al. British Thoracic Society guideline on pulmonary rehabilitation in adults. Thorax 2013; 68 (suppl 2): ii1–30. Spruit MA, Singh SJ, Garvey C, et al. An official American Thoracic Society/ European Respiratory Society statement: key concepts and advances in pulmonary rehabilitation. Am J Respir Crit Care Med 2013; 188: e13–64. Spruit MA, Pitta F, Garvey C, et al. Differences in content and organisational aspects of pulmonary rehabilitation programmes. Eur Respir J 2014; 43: 1326–37. Rochester CL, Vogiatzis I, Holland AE, et al. An Official American Thoracic Society/European Respiratory Society policy statement: enhancing implementation, use, and delivery of pulmonary rehabilitation. Am J Respir Crit Care Med 2015; 192: 1373–86. British Thoracic Society. Quality standards for pulmonary rehabilitation in adults. 2014. British Thoracic Society. https://www.brit-thoracic.org.uk/ document-library/clinical-information/pulmonary-rehabilitation/btsquality-standards-for-pulmonary-rehabilitation-in-adults/ (accessed Jan 27, 2016). Steiner MC, Holzhauer-Barrie J, Lowe D, et al. Pulmonary rehabilitation: steps to breathe better. National Chronic Obstructive Pulmonary Disease (COPD) Audit Programme: resources and organisation of pulmonary rehabilitation services in England and Wales 2015. London: Royal College of Physicians, 2016. Steiner MC, Roberts CM, Lowe D, et al. 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. London: Royal College of Physicians, 2015. 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: 89–99. Jones SE, Green SA, Clark AL, et al. Pulmonary rehabilitation following hospitalisation for acute exacerbation of COPD: referrals, uptake and adherence. Thorax 2014; 69: 181–82.
www.thelancet.com/respiratory Published online February 10, 2016 http://dx.doi.org/10.1016/S2213-2600(16)00008-4
