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New report highlights quality improvement priorities for pulmonary rehabilitation

Tuesday, April 17, 2018

Claire Nolan is a British Lung Foundation Research Scientist and a NIHR Clinical Trials Fellow based at the Royal Brompton and Harefield NHS Foundation Trust and the Pragmatic Clinical Trials Unit at Queen Mary, University of London. Her background is as a pulmonary rehabilitation (PR) physiotherapist and she is also a member of the BTS PR Quality Improvement Advisory Group and regular contributor to the Respiratory Futures PR forum.

 

Here Claire discusses the new report from the 2017 national pulmonary rehab audits.

Hi Claire, welcome to Respiratory Futures and thank you for speaking to us about the latest report from the National COPD Audit Programme: Pulmonary rehabilitation: An exercise in improvement, which presents findings from the 2017 national PR audits.

What has changed since the first audits in 2015 and where can services look to make further improvements?  

Hi, thank you for asking me to contribute. The first national PR audit in 2015 found widespread good practice and delivery of health benefits for patients: the majority of patients who completed PR showed significant improvements in exercise capacity and health status, and patients who completed were also found to have lower mortality rates and fewer hospital admissions in the following months.  

One way of improving enrolment is to offer a rolling programme as this format was found to be more able to meet the 90 day target than cohort programmes.
Claire Nolan

The 2015 audit also highlighted areas for improvement, particularly in relation to waiting times and exercise prescription, and while some improvements were seen in 2017, many services are not meeting all the requirements of the BTS PR Guidelines and Quality Standards. The 2017 audit has therefore identified three quality improvement priorities for services to target.  

What does the report recommend in terms of access to PR?

Improvement in waiting times was one of the key recommendations from the first audit and remains an area for improvement: disappointingly only 60% of patients started PR within 90 days (compared with 63% in 2015). PR services are therefore encouraged to work towards 85% of patients being enrolled within 90 days of referral.

One way of improving enrolment within this timeframe is to offer a rolling programme as this format was found to be more able to meet the 90 day target than cohort programmes. Services that offer cohort programmes may want to consider moving to a rolling format (or offering both types) to help achieve this target. Reducing waiting times by ensuring enrolment of patients in a PR programme within 90 days is important as it may reduce the risk of patients becoming hospitalised or unwell whilst waiting to start PR. This in turn may improve the uptake of PR.

How does the report discuss quality of services?

As we all know the baseline assessment and exercise prescription are crucial elements of the exercise component of PR. As such it is important that the assessment measures are all performed to accepted technical standards. A key area for improvement is performance of a practice walk for the incremental shuttle walk test (ISWT) and six minute walk test (6MWT). A practice walk helps to ensure valid baseline measurement for accurate prescription of aerobic exercise and comparison with the post-PR test.

There was good news regarding completion rates which have risen from 59% in 2015 to 62% in 2017.
Claire Nolan

The 2015 audit also found an association between completion of practice walks and better outcomes. Although there was some improvement in the number of practice ISWTs (from 26% in 2015 to 39% in 2017), the number of practice 6MWTs remained low (24% in 2015 compared with 26% in 2017), and overall 68% of patients did not complete a recommended practice exercise test in 2017.

Another important area that services should review is the distance required for each field walk test: the six minute walk test should be performed on a 30 metre course whereas the incremental shuttle walk test on a 10 metre course. Information on the conduct of exercise tests is available on the Respiratory Futures PR programme here

What about outcomes of treatment?

There was good news regarding completion rates which have risen from 59% in 2015 to 62% in 2017. Additionally, as was seen in the first audit, the majority of patients who complete PR achieve clinically significant improvements in exercise capacity and health status. The 2015 audit also showed an association between completion of PR and lower hospital admission rates at 180 days.

The Respiratory Futures PR forum has been set up to allow those working in PR to share information.

In order to build on this improvement, PR services are encouraged to aim for completion rates of at least 70% PR. This figure was chosen as the top 25% of programmes achieve completion rates of 75% or higher. Strategies that may help improve completion rates include:

  • Identifying patients at risk of exacerbation and working with other teams to make sure that comorbidities are addressed, drug therapy is optimised and winter vaccinations are up to date.
  • Current smoking appears to be associated with non-completion so making sure any smokers have access to smoking cessation support could also be of benefit.

What's next?

This latest report from the national PR audits provides a great opportunity for PR services to assess how they are performing and where they might want to focus efforts on service improvement. The Respiratory Futures PR forum has been set up to allow those working in PR to share information.

If you have any questions on how to improve the service you offer patients or alternatively, if your service has successfully introduced changes in response to either round of the audit we would love to hear from you on the PR forum so that others can benefit from your work: http://www.respiratoryfutures.org.uk/pulmonaryrehabforum/

Thank you for joining us, Claire.

Further reading:

Visit the Pulmonary rehabilitation programme page and join the dedicated forum to discuss useful articles and resources, share ideas and questions, and promote events.

Pulmonary rehabilitation: An exercise in improvement – combined clinical and organisational audit 2017: https://www.rcplondon.ac.uk/projects/outputs/pulmonary-rehabilitation-exercise-improvement-combined-clinical-and-organisational

Reports from the 2015 audit: https://www.rcplondon.ac.uk/projects/national-copd-audit-programme-pulmonary-rehabilitation-workstream-2013-18