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In their paper the members of the BTS Standards of Care Subcommittee on Pulmonary Rehabilitation provide a clear statement on the current status of pulmonary rehabilitation in the UK.1 Funding for pulmonary rehabilitation has lagged behind cardiac rehabilitation even though the evidence base is stronger and patients are usually more disabled. Let us hope that the government, which places so much weight on evidence based medicine, will agree with your statement that there are now strong arguments for widespread development of pulmonary rehabilitation services.
The key consideration for new services is accessibility. In this, location and frequency of attendance may be critical. Local community based services have the advantage over hospital programmes in being closer to the patients, reducing time and costs for transport. They may be better placed for providing ongoing support after the programme has finished, both in terms of social contact between the group and follow up programmes. It is not easy to demonstrate whether these factors are important in practice, but our patients tell us that they strongly influence both recruitment and drop out rate. Simple things like parking at hospitals may prove insuperable obstacles to patients with severe COPD.
On the surface it would seem that the more often the rehabilitation is performed, the more likely there is to be a positive outcome. Based on hospital programmes, the committee states that “at least three exercise sessions per week are necessary for sustained improvement, two of which should be supervised”. Reducing the number of sessions in the programme may make it more accessible, especially when it is difficult to attend either through morbidity, social factors, or being at work. Home based programmes with minimal supervised exercise showed good outcomes in the Netherlands.2 Our own group has been running a once weekly programme, initially in general practice3 and now based in the community. Over 50 patients have enrolled so far, and the shuttle test and health status scores show good clinically important gains.
Reducing the frequency of the programme may also have some resource and cost advantages.4 Even when money is found, staff—especially physiotherapists—may be in short supply. Once weekly programmes may be more feasible and appropriate for the community; they should not be discouraged until more results are published.
As small community based programmes proliferate with both non-specialist rehabilitation teams and different schemes, the quality of the service must be assessed. The guidelines should make a clear statement as to the most practical and important outcome measures to be recorded. Only with common yardsticks can the different interventions be compared and standards maintained.
On behalf of the BTS Standards of Care Subcommittee on Pulmonary Rehabilitation we thank Dr Jones for his supportive comments. We would obviously agree that provision for pulmonary rehabilitation has fallen behind that for patients with similar disability from cardiac disease. One of the purposes of the BTS statement is to provide support for the argument for greater resources. We would also agree with Dr Jones that accessibility for rehabilitation is a key component for success and must ultimately take place in a community setting to cater for the potentially large numbers of disabled patients. However, as rehabilitation moves into the community, it will be very important to maintain standards and monitor outcomes to ensure that the process remains effective.
It is encouraging that pilot projects have now begun in the community and we look forward to seeing high grade evidence which can be incorporated in future BTS statements. At present the effectiveness of home based and low session frequency rehabilitation is uncertain. The original Dutch experience quoted by Dr Jones is a little ambiguous.1–3 When the original papers are read carefully, it is clear that two supervised exercise sessions per week are conducted within the physiotherapist's home rather than the patient's own home. In fact, other attempts at genuine home based rehabilitation in patients with severe COPD have not been so successful.4 At present also there is inadequate evidence to support the effectiveness of once weekly supervised exercise programmes.5 One further difficulty associated with poor service provision is that many research projects are conducted from a background of clinical inexperience because of the necessity to obtain research funding to start a programme!
Finally, we would support Dr Jones in his plea for standardisation of process and outcomes. We believe that the BTS statement did give a clear indication as to what outcomes of functional performance and health status might be sensitive and appropriate. The British Thoracic Society and the British Lung Foundation have plans to set up a register of rehabilitation programmes in the UK to assist with this process.