Pulmonary rehabilitation associated with lower hospital admission rates

The Pulmonary rehabilitation: Beyond breathing better report from the Royal College of Physicians (RCP) National Chronic Obstructive Pulmonary Disease (COPD) Audit Programme reveals that people who complete a full pulmonary rehabilitation programme are much less likely to be admitted to hospital than those who do not. 

The COPD pulmonary rehabilitation (PR) report demonstrates that 76% of people who completed their PR course avoided hospital admission within 6 months after their initial assessment, compared to 62.1% who did not. 

The report also reveals that people who were in hospital and who did not complete their PR course within 6 months after their initial assessment spent twice as long in hospital (9.6 days in 6 months) compared to those who were also admitted and did complete a course (4.8 days in 6 months).

COPD is the fifth biggest killer in the UK and the only major cause of death that is on the increase. It is responsible for 5% of annual deaths globally.

Pulmonary rehabilitation: Beyond breathing better covers the third part of the COPD PR audit, reviewing patients’ hospital admissions and mortality following assessment for PR for 7,135 people across 195 English PR services. It echoes the results from the previous audits: that PR gives substantial health benefits to those who complete treatment, however, many people do not complete their entire programme.
 
The report also found that mortality was higher in people who did not complete PR – within 3 months 1.6% of people had died compared to 0.1% who had completed PR treatment and within 6 months 3.2% of patients had died compared to 0.5% who had completed PR treatment.

The RCP has called for healthcare providers and commissioners to be aware of the substantial health benefits of completing PR, and the variety of reasons that may lead to patients not completing PR, including transport and access issues, as well as other illnesses.

The report states the need, therefore, for PR programmes to adapt their offering to increase convenience and acceptability of programmes. This includes:

  • offering flexible start dates
  • increasing the provision of rolling programmes
  • ensuring that the location at which PR is held is as accessible as possible, to as many people as possible.  

Main recommendations

  • 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 eligible people. 
  • Healthcare providers should work with patient support organisations and charities to make patients and the public aware of the benefits of attending and completing PR so to encourage patient referral.
  • Referrers and patients should be provided with up-to-date and clear written information about the benefits of attending and completing PR.
  • Commissioners should incentivise providers to enrol a higher proportion of patients discharged from hospital.

Professor Michael Steiner, national COPD audit clinical lead for pulmonary rehabilitation and a consultant respiratory physician, said:

The audit demonstrates substantial health benefits received by people who complete PR. We know that PR is the most effective treatment for the symptoms people experience with COPD, and that it improves their quality of life and it is safe. Completing PR can reduce demands on the NHS, by helping people to manage their condition and thereby reducing risk of hospital admission.

I hope the findings of this PR audit report will widen access to PR services, and improve care for people with COPD.

Dr Lisa Davies, consultant respiratory physician and chair of the British Thoracic Society’s board of trustees, said:

The results of this comprehensive audit show just how beneficial pulmonary rehabilitation can be to people living with COPD. The treatment is a real ‘win-win’ option – offering excellent clinical outcomes in terms of reduced hospital readmissions, shorter lengths of hospital stay and lower mortality rates, whilst also being a very efficient use of NHS resources.

We encourage all clinicians to ensure they're referring patients for pulmonary rehabilitation where appropriate – and we urge commissioners to make sure there is sufficient service capacity in place to meet demand. The benefits are clear for all to see – let’s make sure this highly effective treatment is always available where needed.

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 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), and led by the 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).

Notes to editors

For more information or to arrange an interview, please contact Joanna Morgan, communications manager, RCP Care Quality Improvement Department:

  • Tel: +44 (0)20 3075 1354. 

The key findings and recommendations are set against BTS quality standards for PR.

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 1.2 million people in the UK have been diagnosed with the disease, as many as two-thirds of people with COPD may return undiagnosed (British Lung Foundation, 2016). 

COPD is the fifth-biggest killer in the UK and the only major cause of death that is on the increase. In 2012, approximately 30,000 people in the UK died from COPD (British Lung Foundation, 2016). This represented 5.3% of the total number of UK deaths and 26.1% of deaths from lung disease. Respiratory disease is one of the principal reasons for emergency admission to hospital (British Lung Foundation, 2016).  

The National COPD Audit Programme brings together primary care, secondary care, pulmonary rehabilitation 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.

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 33,000 fellows and members worldwide, the RCP advises and works with government, patients, allied healthcare professionals and the public to improve health and healthcare.

British Thoracic Society

The British Thoracic Society is the UK’s professional body of respiratory specialists. The society seeks to improve standards of care for people who have respiratory diseases and to support and develop those who provide that care. A registered charity, it has over 3,400 members including doctors, nurses, respiratory physiotherapists, scientists and other professionals with a respiratory interest.

Healthcare Quality Improvement Partnership (HQIP) and the National Clinical Audit Programme

The National COPD Audit Programme is commissioned by the Healthcare Quality Improvement Partnership (HQIP) as part of the National Clinical Audit Programme (NCA). 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.