Specifying a pulmonary rehabilitation service for patients with COPD

Service components

The key components required to provide an effective pulmonary rehabilitation service for patients with chronic obstructive pulmonary disease (COPD) are:

• ensuring appropriate referral of patients to the service
• developing a high-quality pulmonary rehabilitation service.

Appropriate referral of patients

Appropriate referral is an important step in managing the flow of patients into a rehabilitation service. The NICE clinical guideline CG12 on COPD states that “pulmonary rehabilitation should be offered to all patients who consider themselves functionally disabled by COPD (usually MRC [Medical Research Council] grade 3 and above). Pulmonary rehabilitation is not suitable for patients who are unable to walk, have unstable angina or who have had a recent myocardial infarction”.

The process for referral to the rehabilitation scheme should be agreed locally, and may be facilitated by a protocol for identifying eligible patients and allocating appointments to them for rehabilitation therapy. Most programmes require optimisation of medical therapy prior to, or as part of, enrolment. See Section 7.12.1 of the full clinical guideline on COPD and also the recent American Thoracic Society / European Respiratory Society statement on pulmonary rehabilitation.

Developing a high-quality pulmonary rehabilitation service

There are a variety of settings in which pulmonary rehabilitation services for patients with COPD can potentially be delivered. Traditionally, services were based in secondary care, but there is growing interest in developing services in community settings that make it easier for patients to attend. Alternatively, a rehabilitation service could be delivered in partnership between primary and secondary care, with the different teams being responsible for specific steps in referral, rehabilitation, and continuing care delivery.

Whichever model is chosen there are 3 core elements, defined in the full clinical guideline on COPD, which need to be considered:

• location: “for pulmonary rehabilitation programmes to be effective, and to improve concordance, they should be held at times that suit patients, and in buildings that are easy for patients to get to and have good access for people with disabilities”.
• content: “pulmonary rehabilitation programmes should include multi-component, multi-disciplinary interventions, which are tailored to the individual patient's needs. The rehabilitation process should incorporate a programme of physical training, disease education, nutritional, psychological and behavioural intervention”.
• duration of initial programme: the consensus of the Guideline Development Group is that outpatient programmes should contain a minimum of 6 weeks and a maximum of 12 weeks of physical exercise, disease education, psychological and social interventions. The evidence regarding prolonged supervised outpatient programmes showed only very modest benefits and such programmes were considered unrealistic. Commissioners should also be aware that the full guideline notes the benefits of pulmonary rehabilitation appear to wane with time, and that there is limited evidence of benefits in attending further rehabilitation programmes.

The NICE clinical guideline recommends that COPD care should be delivered by a multidisciplinary team. Commissioners may wish to consider the essential members of such a team and take into account the skill mix and competences of existing staff available locally.

See the recommendations relevant to pulmonary rehabilitation in the NICE clinical guideline CG12 on the management of chronic obstructive pulmonary disease in adults in primary and secondary care. link to NICE clinical guideline recommendations section in this guide

Local stakeholders, including service users, should be involved in determining what is needed from a pulmonary rehabilitation service in order to meet local needs. The service should be patient-centred and integrated with other elements of care for patients with COPD.

The service specification needs to consider:

• the expected number of patients (this should take into account how quickly changes in provision are likely to take place)
• location(s) of the service
• ease of access
• information requirements
• service monitoring criteria.

Useful sources of information may include:

• ‘Delivering the 18 week patient pathway: 18 week commissioning pathways'
• The ‘Map of medicine' provides an information resource that visually organises the latest evidence and best practice guidelines.
• The NICE ‘shared learning´ database offers examples of how organisations have implemented NICE guidance locally.