Article Text

Download PDFPDF

Original article
Socioeconomic deprivation and the outcome of pulmonary rehabilitation in England and Wales
  1. Michael C Steiner1,
  2. Derek Lowe2,
  3. Katy Beckford3,
  4. John Blakey4,
  5. Charlotte E Bolton5,
  6. Sarah Elkin6,
  7. William D -C Man7,8,
  8. C Michael Roberts9,
  9. Louise Sewell10,
  10. Paul Walker11,
  11. Sally J Singh1
  1. 1Leicester Respiratory Biomedical Research Unit, Institute for Lung Health, University Hospitals of Leicester NHS Trust, Leicester, UK
  2. 2Clinical Effectiveness and Evaluation Unit, Royal College of Physicians of London, London, UK
  3. 3Berkshire Healthcare NHS Foundation Trust, Bracknell, UK
  4. 4Liverpool School of Tropical Medicine and Aintree University Hospital, Liverpool, UK
  5. 5Nottingham Respiratory Research Unit, School of Medicine, University of Nottingham, Nottingham, UK
  6. 6Imperial College NHS Trust and NHLI, Imperial College, London, UK
  7. 7NIHR Respiratory Biomedical Research Unit, Royal Brompton & Harefield NHS Foundation Trust and Imperial College, Harefield, UK
  8. 8Harefield Pulmonary Rehabilitation Unit, Harefield Hospital, Harefield, UK
  9. 9Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
  10. 10School of Health, CWG17, Coventry University, Coventry, UK
  11. 11Aintree University Hospital, Liverpool, UK
  1. Correspondence to Professor Michael Steiner, Leicester Respiratory Biomedical Unit, University Hospitals of Leicester NHS Trust, Glenfield Hospital, Groby Road, Leicester LE3 9QP, UK; michael.steiner{at}


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.

  • COPD epidemiology
  • Pulmonary Rehabilitation

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:

View Full Text

Statistics from


  • Twitter Follow Katy Beckford @KatyBeckford and Louise Sewell at @LouiseSewell_OT

  • Contributors All authors were members of the Pulmonary Rehabilitation (PR) Audit Group (led by MS), which designed the PR audit clinical and organisational datasets, provided oversight of the conduct of the audit and had access to the data. The manuscript concept was developed by MS, DL and SS. All authors contributed to the interpretation of the data and the writing of the manuscript.

  • Funding The National Clinical Audit is funded by NHS England, the Welsh Government and, with some individual audits, also funded by the Health Department of the Scottish Government, DHSSPS Northern Ireland and the Channel Islands. The authors are independent from HQIP and the audit funders who had no influence over the writing of the manuscript. This paper is supported by the National Institute for Health Research Leicester Respiratory Biomedical Research Unit. The views expressed are those of the author(s) and not necessarily those of the National Health Service (NHS), the National Institute for Health Research or the Department of Health. The British Thoracic Society managed the data collection under the auspices of Sally Welham and Laura Searle. We are grateful to all local pulmonary rehabilitation programmes that contributed data. We are also grateful to Pip Divall, Clinical Librarian at University Hospitals of Leicester NHS Trust for her assistance with systematic literature searches.

  • Competing interests Professor Steiner reports personal fees from Boehringer Ingelheim, non-financial support from Boehringer Ingelheim and GlaxoSmithKline (GSK), personal fees from Boehringer Ingelheim and GSK, grants from Medical Research Council (MRC) and East Midlands Collaboration for Leadership in Applied Health Research and Care (CLAHRC), outside the submitted work. Dr Bolton reports grants from MRC/Association of British Pharmaceutical Industry (ABPI) and GSK, personal fees from Chiesi, other support from GSK, outside the submitted work. Dr Blakey reports personal fees and non-financial support from GSK, personal fees and non-financial support from Napp, personal fees from Novartis and AstraZeneca, grants from Pfizer, outside the submitted work. Dr Man reports grants and other support from Pfizer, Boehringer Ingelheim, grants from National Institute for Health Research and Medical Research Council, outside the submitted work. Professor Singh reports personal fees from GSK, AstraZeneca and Novartis, grants from MRC/ABPI, National Institute for Health Research and East Midlands CLAHRC, outside the submitted work. PW reports personal fees from Chiesi and AstraZeneca, outside the submitted work.

  • Provenance and peer review Not commissioned; externally peer reviewed

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

Linked Articles