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The efficacy of pulmonary rehabilitation has been established for people with COPD such that the addition of further controlled clinical trials comparing pulmonary rehabilitation with usual care is considered unnecessary.1 ,2 How well the degree of health benefit reported within clinical trials of pulmonary rehabilitation translates into real-life settings is more difficult to ascertain. In real-world clinical environments, the effectiveness of pulmonary rehabilitation for people with COPD is likely to be confounded by heterogeneity in national healthcare systems, structure and staffing of rehabilitation programmes and participant characteristics of those referred to, accessing and completing pulmonary rehabilitation. While pragmatic clinical trials might provide local intelligence on pulmonary rehabilitation effectiveness, census-level surveys of clinical outcomes and sociodemographic data or pulmonary rehabilitation registries, such as those established in the USA3 and proposed in Australia4 permit associations between service provision, demographic characteristics and clinical outcomes to be explored at the population level.
The value of such population-level approaches is evident in the paper by Steiner and colleagues5 published in Thorax. Using data from the 2015 National COPD Clinical Audit Programme (England and Wales), Steiner and colleagues present an analysis of uptake and performance of participants across 230 pulmonary rehabilitation services,6 including over 7000 participants with COPD.7 Steiner and colleagues have reported that completion (defined as attending a discharge assessment) of pulmonary rehabilitation is lower in those with greater levels of socioeconomic deprivation. Where programmes are not ‘completed’, the optimal benefits of rehabilitation in terms of quality of life, breathlessness and exercise capacity are not expected to be gained. This is consistent with the results shown in other population-based studies where people with COPD and lower socioeconomic status attain poorer outcomes across the board, including greater mortality, more hospitalisations, less use …
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