Effectiveness, Attendance, and Completion of an Integrated, System-Wide Pulmonary Rehabilitation Service for COPD: Prospective Observational Study

Figures & data

Figure 1.  Recruitment pathway of all PR referrals received April 2008 –March 2010. Percentages based on eligible referrals (n = 1114).

Table 1.  Characteristics of attenders at assessment for pulmonary rehabilitation (Adjusted odds ratios for association with attendance)

Characteristic	Attended assessment n (% of all referred)	Adjusted odds ratios^† (95% CI) n = 1084
Age (years)
0–54	83 (60)	1
55–64	225 (77)	2.17 (1.38–3.44)^a
65–74	276 (78)	2.24 (1.43–3.5)^a
75+	228 (69)	1.49 (0.96–2.3)
Gender
Female	382 (71)	1
Male	430 (74)	0.92 (0.7–1.22)
Referrer
Consultant respiratory physician	168 (80)	1
In-patient COPD multidisciplinary team	96 (63)	0.45 (0.28–0.73)^a
In-patient physiotherapist	60 (61)	0.43 (0.25–0.75)^a
GP	110 (78)	0.94 (0.55–1.61)
Practice nurse	180 (76)	0.78 (0.49–1.24)
Community COPD clinic	181 (72)	0.63 (0.4–0.98)^a
Other	17 (71)	0.67 (0.26–1.75)
Deprivation quintiles (IMD)
6.86–27.1	137 (72)	1
27.2–34.4	174 (80)	1.3 (0.81-2.06)
34.5–39.01	153 (69)	0.8 (0.52–1.23)
39.02–43.4	164 (77)	1.18 (0.75–1.84)
43.41–60.41	162 (67)	0.76 (0.49–1.16)

a = significant effect.

†Adjusted for other variables in the table.

Pseudo R2 (33) for multiple logistic regression = 0.064. Describes how well (6.4%) the model performs when compared to a perfect prediction model (33).

Table 2.  Characteristics of patients who completed a pulmonary rehabilitation course and of those who dropped out

Characteristic	Attended Assessment n = 812		Unadjusted odds ratio (95% CI)	p-value^a
	Drop Out^b n = 371(%)	Completer n = 441 (%)
Age:
up to 54 years	44 (11.9)	39 (8.8)	1
55 to 64 years	113 (30.5)	112 (25.4)	1.12 (0.08–1.85)	0.66
65 to 74 years	108 (29.1)	168 (38.1)	1.76 (1.07–2.88)	0.026
75 years +	106 (28.6)	122 (27.7)	1.3 (0.79–2.15)	0.309
Sex:
Male (%)	182 (49.1)	248 (56.2)	1.33 (1.01–1.76)	0.04
Source of referral:
Consultant respiratory physician	71 (19.1)	97 (22.0)	1
In-patient COPD team	44 (11.9)	52 (11.8)	0.87 (0.52–1.43)	0.574
In-patient physiotherapist	32 (8.6)	28 (6.3)	0.64 (0.35–1.16)	0.14
GP	65 (17.5)	45 (10.2)	0.51 (0.31–0.83)	0.006^c
Practice nurse	69 (18.6)	111 (25.2)	1.17 (0.77–1.81)	0.46
Community COPD clinic	80 (21.6)	101 (22.9)	0.92 (0.61–1.41)	0.72
Other	10 (2.7)	7 (1.6)	0.51 (0.77–1.81)	0.2
IMD score of deprivation:
Quintiles:
6.86–28.1	63(17.2)	97 (22.5)	1
28.11–35.02	75 (20.4)	92 (21.3)	0.8 (0.51–1.24)	0.31
35.03–39.57	60 (16.3)	92 (21.3)	0.99 (0.63–1.57)	0.99
39.58–43.85	90 (24.5)	78 (18.1)	0.56 (0.36–0.87)	0.01 c
43.86–60.41	79 (21.5)	72 (16.7)	0.59 (0.38–0.93)	0.02
Ethnicity:	n = 282	n = 409
White British & Irish	255 (90.4)	347 (84.8)	1
White Other	3 (1.1)	21 (5.1)	5.14 (1.52–17.43)	0.009 c,e
Black	16 (5.7)	31 (7.6)	1.42 (0.76–2.66)	0.27
Asian sub-continent^d	7 (2.5)	6 (1.5)	0.63 (0.21–1.9)	0.41
Other	1 (0.4)	4 (1.0)	2.94 (0.33–26.46)	0.34
MRC Dyspnoea:	n = 308	n = 426
1 and 2	46 (14.9)	93 (21.8)	1
3	102 (33.1)	168 (39.4)	0.78 (0.51–1.18)	0.24
4	128 (41.6)	140 (32.9)	0.52 (0.34–0.78)	0.002^c
5	30 (9.7)	16 (3.8)	0.25 (0.13–0.5)	<0.001^c
Gold Stage n (%)	n = 222	n = 285
I	16 (7.2)	27 (9.5)	1
II	85 (38.3)	113 (39.6)	1.02 (0.6–1.75)	0.95
III	88 (39.6)	106 (37.2)	1.13 (0.65–1.94)	0.67
IV	33 (14.9)	39 (13.7)	1.43 (0.66–3.09)	0.37
Baseline ISWT:	n = 252	n = 390
Quartiles:
0–130 m	83 (32.9)	82 (21.0)	1
131–220 m	75 (29.8)	92 (23.6)	1.24 (0.8–1.91)	0.33
221–340 m	44 (17.5)	108 (27.7)	2.48 (1.56–3.95)	<0.001^c
341–1020 m	50 (19.8)	108 (27.7)	2.19 (1.39–3.44)	0.001^c
CRQ Dyspnoea:	n = 278	n = 406
Mean (SD)	2.54 (1.14)	2.74 (1.20)	1.16 (1.02–1.33)	0.029
CRQ Emotion:	n = 281	n = 407
Mean (SD)	3.69 (1.39)	4.21 (1.40)	1.31 (1.17–1.47)	<0.001^c
CRQ Fatigue:	n = 282	n = 406
Mean (SD)	3.01 (1.29)	3.44 (1.37)	1.27 (1.13–1.43)	<0.001^c
CRQ Mastery:	n = 283	n = 407
Mean (SD)	3.83 (1.49)	4.33 (1.41)	1.27 (1.14–1.42)	<0.001^c
HADS Anxiety: n (%)	n = 285	n = 403
#7	113 (36.9)	204 (50.6)	1
8–10	66 (23.2)	93 (23.1)	0.78 (0.52–1.15)	0.21
#11	106 (37.2)	106 (26.3)	0.55 (0.39–0.79)	0.001^c
HADS Depression: n (%)	n = 283	n = 403
#7 =	131 (46.3)	246 (61.0)	1	0.045
8–10	67 (23.7)	85 (21.1)	0.68 (0.46–0.99)	<0.001^c
#11	85 (30.0)	72 (17.9)	0.45 (0.31–0.66)
Programme type: n (%)	n = 371	n = 441
Cohort recruitment	113 (30.5)	133 (30.2)	1
Rolling recruitment	258 (69.5)	308 (69.8)	1.01 (0.75–1.37)	0.93

aThe large number of tests of association increases the risk of finding a significant association by chance. We have therefore increased the threshold for significance by only accepting p-values of 0.01 or less.

bDrop out = patient declined at assessment, did not start PR course or started but did not complete course.

c= significant result.

dAsian sub-continent = Bangladesh, Bhutan, India, Nepal, Pakistani, Sri Lanka.

^eThe importance of the significant finding with respect to White Other subjects is doubtful because the group consisted of only 3 participants. (Unadjusted odds ratios for association with completion).

Table 3.  Characteristics of patients who completed pulmonary rehabilitation compared with those who dropped out (adjusted)

Characteristic		Adjusted odds ratio for completion of the course^a (95% CI) n = 657
Referrer
Consultant respiratory physician		1
In-patient COPD multidisciplinary team		0.87 (0.48–1.57)
Hospital physiotherapist		0.55 (0.27–1.15)
GP		0.42 (0.24–0.74) b
Practice nurse		0.89 (0.54–1.48)
Community COPD clinic		0.82 (0.49–1.35)
Other		0.55 (0.15–2.07)
MRC dyspnoea score
	1 or 2	1
	3	0.88 (0.55–1.41)
	4	0.61 (0.37–0.97)^b
	5	0.39 (0.16–0.93)^b
Depression score (HADS)
(Not depressed)	0–7	1
(Risk of depression)	8–10	0.77 (0.51–1.18)
(Depressed)	#11	0.56 (0.37–0.85)^b
Deprivation quintiles (IMD)
IMD score	6.86–28.1	1
	28.11–35.02	0.72 (0.43–1.2)
	35.03–39.57	1.0 (0.59–1.7)
	39.58–43.85	0.56 (0.33–0.94)^b
	43.86–60.41	0.57 (0.34–0.85)^b

aAdjusted for other variables in table and age and sex.

bSignificant effect.

Pseudo R2 (McFadden 1974) for multiple logistic regression = 0.103. Describes how well (10.3%) the model performs when compared to a perfect prediction model (33).

Table 4.  Changes over time in exercise tolerance, health-related quality-of-life, and anxiety and depression scores. (Rolling and cohort programmes shown separately)

	All completers		Rolling		Cohort
	n	Mean change (CI)	n	Mean change (CI)	n	Mean change (CI)
ISWT (m)	311	68.3 (59.3–77.4)	205	74.2 (63.5–85.0)	106	56.9 (40.3–73.2)
CRQ Dyspnoea	329	0.94 (0.80–1.07)	214	0.99 (0.82–1.15)	115	0.84 (0.60–1.09)
CRQ Emotion	334	0.64 (0.52–0.76)	218	0.66 (0.50–0.82)	116	0.61 (0.41–0.81)
CRQ Fatigue	333	0.7 (0.58–0.83)	217	0.74 (0.57–0.90)	116	0.64 (0.44–0.84)
CRQ Mastery	333	0.71 (0.58–0.84)	217	0.71 (0.54–0.87)	116	0.71 (0.49–0.92)
HADS Anxiety	327	0.9 (0.5–1.2)	212	0.9 (0.5–1.3)	115	0.8 (0.2–1.3)
HADS Depression	328	1.1 (0.8–1.4)	212	1.4 (0.9–1.8)	116	0.6 (0.1–1.0)

Minimally clinically important differences: ISWT 0.47m; CRQ-SR all domains 0.5; HADS anxiety 1.32, depression 1.4.

All p values < 0.001 with the exception of change in the Anxiety (p = 0.009) and Depression (p = 0.02) scores for cohort programmes.