C. Michael Roberts

British Thoracic Society guideline on pulmonary rehabilitation in adults: accredited by NICE

### The role of pulmonary rehabilitation ### Referral and assessment of patients for pulmonary rehabilitation #### Specific situations at assessment ##### Smoking

Differences in content and organisational aspects of pulmonary rehabilitation programmes

The aim was to study the overall content and organisational aspects of pulmonary rehabilitation programmes from a global perspective in order to get an initial appraisal on the degree of heterogeneity worldwide. A 12-question survey on content and organisational aspects was completed by representatives of pulmonary rehabilitation programmes that had previously participated in the European Respiratory Society (ERS) COPD Audit. Moreover, all ERS members affiliated with the ERS Rehabilitation and Chronic Care and/or Physiotherapists Scientific Groups, all members of the American Association of Cardiovascular and Pulmonary Rehabilitation, and all American Thoracic Society Pulmonary Rehabilitation Assembly members were asked to complete the survey via multiple e-mailings. The survey has been completed by representatives of 430 centres from 40 countries. The findings demonstrate large differences among pulmonary rehabilitation programmes across continents for all aspects that were surveyed, including the setting, the case mix of individuals with a chronic respiratory disease, composition of the pulmonary rehabilitation team, completion rates, methods of referral and types of reimbursement. The current findings stress the importance of future development of processes and performance metrics to monitor pulmonary rehabilitation programmes, to be able to start international benchmarking, and to provide recommendations for international standards based on evidence and best practice. Differences in aspects of pulmonary rehabilitation programmes suggest caution in generalisation of research findings http://ow.ly/qOJhl

European hospital adherence to GOLD recommendations for chronic obstructive pulmonary disease (COPD) exacerbation admissions

Understanding how European care of chronic obstructive pulmonary disease (COPD) admissions vary against guideline standards provides an opportunity to target appropriate quality improvement interventions. In 2010–2011 an audit of care against the 2010 ‘Global initiative for chronic Obstructive Lung Disease’ (GOLD) standards was performed in 16 018 patients from 384 hospitals in 13 countries. Clinicians prospectively identified consecutive COPD admissions over a period of 8 weeks, recording clinical care measures on a web-based data tool. Data were analysed comparing adherence to 10 key management recommendations. Adherence varied between hospitals and across countries. The lack of available spirometry results and variable use of oxygen and non-invasive ventilation (NIV) are high impact areas identified for improvement.

Variability of hospital resources for acute care of COPD patients: the European COPD Audit

Studies have suggested that larger hospitals have better resources and provide better care than smaller ones. This study aimed to explore the relationship between hospital size, resources, organisation of care and adherence to guidelines. The European COPD Audit was designed as a pilot study of clinical care and a survey of resources and organisation of care. Data were entered by clinicians to a multilingual web tool and analysed centrally. Participating hospitals were divided into tertiles on the basis of bed numbers and comparisons made of the resources, organisation of care and adherence to guidelines across the three size groups. 13 national societies provided data on 425 hospitals. The mean number of beds per tertile was 220 (lower), 479 (middle), and 989 (upper). Large hospitals were more likely to have resources and increased numbers of staff; hospital performance measures were related in a minority of indicators only. Adherence to guidelines also varied with hospital size, but the differences were small and inconsistent. There is a wide variation in the size, resources and organisation of care across Europe for hospitals providing chronic obstructive pulmonary disease care. While larger hospitals have more resources, this does not always equate to better accessibility or quality of care for patients. Although large hospitals are more likely to have more resources and staff, hospital performance does not differ greatly http://ow.ly/sfevS

Antibiotic Prescription for COPD Exacerbations Admitted to Hospital: European COPD Audit

Objective Appropriate use of antibiotics in the management of hospitalised patients with COPD exacerbations is defined within the GOLD strategy. This paper analyses the factors associated with antibiotic prescribing in patients to better understand how prescribing may be improved. Methods The European COPD audit was a study of clinical care in 384 hospitals from 13 European countries between 2010 and 2011 enrolling 16018 patients. Those admitted to hospital due to a clinician-made diagnosis of exacerbation of COPD at the time of discharge were audited. We defined antibiotic prescribing compliance as consistent with the GOLD 2010 recommendations. Two different multivariate models were used to evaluate factors associated with the prescription of antibiotics and the guideline-compliant prescriptions. Results Overall 86% of admissions were given antibiotics but only 61.4% cases met the GOLD recommendations. Antibiotics were more likely to be given in hospital and at discharge if received prior to admission. Antibiotic prescription was more likely in patients who met the GOLD recommendations and in those with radiological consolidation but there was also a significant use of antibiotics in patients who did not meet either criterion. Patients cared for on a Respiratory Ward were more likely to receive GOLD compliant antibiotic management. Conclusions The present study describes the audited in-hospital antibiotic prescription for COPD exacerbation across different European countries. In general, there is an apparent overuse of antibiotics likely to be associated with both patient and practice-related variables.

Socioeconomic deprivation and the outcome of pulmonary rehabilitation in England and Wales

Background Pulmonary rehabilitation (PR) improves exercise capacity and health status in patients with COPD, but many patients assessed for PR do not complete therapy. It is unknown whether socioeconomic deprivation associates with rates of completion of PR or the magnitude of clinical benefits bequeathed by PR. Methods PR services across England and Wales enrolled patients to the National PR audit in 2015. Deprivation was assessed using Index of Multiple Deprivation (IMD) derived from postcodes. Study outcomes were completion of therapy and change in measures of exercise performance and health status. Univariate and multivariate analyses investigated associations between IMD and these outcomes. Results 210 PR programmes enrolled 7413 patients. Compared with the general population, the PR sample lived in relatively deprived neighbourhoods. There was a statistically significant association between rates of completion of PR and quintile of deprivation (70% in the least and 50% in the most deprived quintiles). After baseline adjustments, the risk ratio (95% CI) for patients in the most deprived relative to the least deprived quintile was 0.79 (0.73 to 0.85), p<0.001. After baseline adjustments, IMD was not significantly associated with improvements in exercise performance and health status. Conclusions In a large national dataset, we have shown that patients living in more deprived areas are less likely to complete PR. However, deprivation was not associated with clinical outcomes in patients who complete therapy. Interventions targeted at enhancing referral, uptake and completion of PR among patients living in deprived areas could reduce morbidity and healthcare costs in such hard-to-reach populations.

The Effect of Incidental Consolidation on Management and Outcomes in COPD Exacerbations: Data from the European COPD Audit

Objective There is controversy regarding the significance of radiological consolidation in the context of COPD exacerbation (eCOPD). While some studies into eCOPD exclude these cases, consolidation is a common feature of eCOPD admissions in real practice. This study aims to address the question of whether consolidation in eCOPD is a distinct clinical phenotype with implications for management decisions and outcomes. Patients and Methods The European COPD Audit was carried out in 384 hospitals from 13 European countries between 2010 and 2011 to analyze guideline adherence in eCOPD. In this analysis, admissions were split according to the presence or not of consolidation on the admission chest radiograph. Groups were compared in terms of clinical and epidemiological features, existing treatment, clinical care utilized and mortality. Results 14,111 cases were included comprising 2,714 (19.2%) with consolidation and 11,397 (80.8%) without. The risk of radiographic consolidation increased with age, female gender, cardiovascular diseases, having had two or more admissions in the previous year, and sputum color change. Previous treatment with inhaled steroids was not associated. Patients with radiographic consolidation were significantly more likely to receive antibiotics, oxygen and non-invasive ventilation during the admission and had a lower survival from admission to 90-day follow-up. Conclusions Patients admitted for COPD exacerbation who have radiological consolidation have a more severe illness course, are treated more intensively by clinicians and have a poorer prognosis. We recommend that these patients be considered a distinct subset in COPD exacerbation.

Listening to the unmet needs of Europeans with COPD

![][1] Chronic obstructive pulmonary disease (COPD) is a significant cause of morbidity and mortality in Europe [1, 2], which has a major resource impact on both primary and secondary healthcare [3]. COPD has a huge impact on people with the condition, causing a gradual decline in functional ability and greater dependence upon health and social care support with both ageing and disease progression [4]. Patients with COPD are also likely to suffer with significant co-morbidities that further impair their quality of life and independent living [5]. Evidence is growing from audits in individual countries that COPD patient care varies widely between different hospitals and across Europe and is frequently not consistent with published guidelines [6–8]. There are many different service models and it remains unknown which deliver the best results for patients. In all likelihood, the care given to COPD patients can be improved if there is better understanding of care and service organisation factors in European hospitals that promote better outcomes. The recent European Respiratory Society (ERS) European COPD audit, conducted in 2010–2011, provides data on quality of care from over 400 hospitals in 13 countries [9]. This study confirmed that the quality of patient care varies not just between European countries in different health systems, but that there is even greater variability between hospitals within individual countries [10]. Discharge from hospital is a key moment for patients, and data on medications, oxygen and rehabilitation relating to discharge were collected in the audit. The scope of the audit did not, however, include out-of-hospital care or specifically the views and experiences of hospital care of COPD patients themselves. Therefore, an event was designed to address this deficiency with the following aims: 1. To better understand … [1]: /embed/graphic-1.gif

The European COPD Audit: brothers in arms

In March 2010, the European Respiratory Society funded a pilot audit programme of the process and outcomes of hospital care for patients admitted with exacerbations of COPD and on the organisation of care at hospital level. Originally it was intended to involve just five countries in this pilot scheme but such was the enthusiasm from national societies that 13 participated in the data collection programme. In March 2012, ERS published a document containing the results at national level for 19,021 cases entered into the audit database and subsequently site specific data has been distributed to each of the 422 hospitals that participated as shown in figure 1. Figure 1 Hospitals participating in the European COPD Audit. These data are unique in that they have been collected by clinicians prospectively identifying cases then recording in hospital care processes and patient outcomes at 90 days after admission date. In order to collect the data, many individuals had to use their time and skills but the success of the data collection is testimony to the enthusiasm of clinicians to better understand the quality of care delivered in their own institutions. The results are salutary and deserve our attention. In essence, they describe a standard of care with significant variation in adherence to guideline standards both within countries and between them. Arterial blood gases are taken on admission in only 12% cases in one country ranging to 96% in another whilst antibiotics are given to only 54% cases in country A yet 95% in country B. Unsurprisingly, outcomes vary equally widely with median length of stay at national level varying 5–15 days. At this stage in the data analysis, it is not possible to say why this occurs and there may be a number of explanations. There are certainly significant differences in case mix between …

The use of the practice walk test in pulmonary rehabilitation program: National COPD Audit Pulmonary Rehabilitation Workstream

Our aim was to evaluate the use and impact of the practice walk test on enrolment, completion, and clinical functional response to pulmonary rehabilitation (PR) using the 2015 UK National Chronic Obstructive Pulmonary Disease (COPD) Pulmonary Rehabilitation audit data. Patients were assessed according to whether a baseline practice walk test was performed or not. Study outcomes included use of the practice walk test, baseline and change in incremental shuttle walk test distance (ISWD) or 6-minute walk test distance (6MWD), and enrolment to and completion of PR program. Of 7,355 patients, only 1,666 (22.6%) had a baseline practice test. At baseline, the practice walk test group walked further as compared to the no practice walk test group: ISWD, 17.9 m [95% confidence interval (CI) 8.2–27.5 m] and 6MWD, 34.8 m (95% CI 24.7–44.9 m). The practice walk test group were 2.2 times (95% CI 1.8–2.6) more likely to enroll and 17% (95% CI 1.03–1.34) more likely to complete PR. Although the change in ISWD and 6MWD with PR was lower in the practice walk test group, they walked further at discharge assessment. Only 22.6% of the patients in the 2015 National PR audit had a practice walk test at assessment. Those who did had better enrolment, completion, and better baseline walking distance, from which the prescription is set.