Article Text

COPD discharge bundle and pulmonary rehabilitation referral and uptake following hospitalisation for acute exacerbation of COPD
  1. Ruth E Barker1,2,3,
  2. Samantha SC Kon1,3,
  3. Stuart F Clarke3,
  4. Jenni Wenneberg3,
  5. Claire M Nolan1,
  6. Suhani Patel1,
  7. Jessica A Walsh1,
  8. Oliver Polgar1,
  9. Matthew Maddocks4,
  10. Morag Farquhar5,
  11. Nicholas S Hopkinson2,
  12. Derek Bell6,
  13. Jadwiga A Wedzicha2,
  14. William D-C. Man1,2
  1. 1 Harefield Respiratory Research Group, Royal Brompton & Harefield Hospitals, Guy’s and St.Thomas’ NHS Foundation Trust, London, UK
  2. 2 National Heart and Lung Institute, Imperial College, London, UK
  3. 3 Hillingdon Integrated Respiratory Service, The Hillingdon Hospitals NHS Foundation Trust, London, UK
  4. 4 Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, Kings College London, London, UK
  5. 5 School of Health Sciences, University of East Anglia, Norwich, UK
  6. 6 National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care Northwest London, Imperial College London, London, UK
  1. Correspondence to Ruth E Barker, National Heart and Lung Institiute, Imperial College London, London, UK; r.barker18{at}


Pulmonary rehabilitation (PR) following hospitalisations for acute exacerbation of COPD (AECOPD) is associated with improved exercise capacity and quality of life, and reduced readmissions. However, referral for, and uptake of, post-hospitalisation PR are low. In this prospective cohort study of 291 consecutive hospitalisations for AECOPD, COPD discharge bundles delivered by PR practitioners compared with non-PR practitioners were associated with increased PR referral (60% vs 12%, p<0.001; adjusted OR: 14.46, 95% CI: 5.28 to 39.57) and uptake (40% vs 32%, p=0.001; adjusted OR: 8.60, 95% CI: 2.51 to 29.50). Closer integration between hospital and PR services may increase post-hospitalisation PR referral and uptake.

  • COPD exacerbations
  • pulmonary rehabilitation
  • respiratory infection

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There is an established evidence base supporting the benefits of pulmonary rehabilitation (PR) following hospitalisation for acute exacerbations of COPD (AECOPD), including improved exercise capacity and health-related quality of life, and reduced readmissions and mortality.1 2 However, PR referral and uptake rates are low. Previous data have shown that only 30% of eligible patients are referred for post-hospitalisation PR, with less than 10% completing a programme.3 Barriers to referral and uptake are complex and multi-factorial.4

The COPD discharge bundle (a structured package of evidence-based measures which should be delivered to all individuals) was introduced to facilitate implementation of evidence-based care following hospitalisation for an AECOPD and includes offering referral to PR.5 However, bundles can be challenging to implement and their impact unclear.6 7

The aim of this study was to determine predictors of referral for and uptake of post-hospitalisation PR. We hypothesised that delivery of a COPD discharge bundle by a PR practitioner would be associated with increased PR referral and uptake.


This prospective cohort study included consecutive hospital episodes for an AECOPD at Hillingdon Hospital, London, UK, from 1 April 2018 to 31 March 2019 and was considered service evaluation by the Health Research Authority. Patients admitted previously during the study period (and therefore already included in the data collection) were excluded.

Patients were classified according to three exposures (no COPD discharge bundle received; COPD discharge bundle received from a current PR practitioner; COPD discharge bundle received from a practitioner with no involvement in PR) and followed-up for 4 weeks after hospital discharge. All COPD discharge bundles (online supplemental figure E1) were delivered by a hospital-based multidisciplinary respiratory team with responsibility for early supported discharge, admission avoidance and community respiratory clinics. Two out of six team members were current PR practitioners, defined as someone also employed to deliver PR (assessments and/or supervision of classes) for a minimum 20% of their job plan. The research team played no involvement in exposure allocation (no randomisation, no influence on care team assignment). The clinical team delivering the bundle were blinded to the study objectives.

Supplemental material

The outcomes were referral for PR (defined as a referral received by PR service) and uptake of PR (defined as the proportion of those referred attending a PR assessment) within 4 weeks of hospital discharge.

Covariates were selected a priori as patient or hospital admission variables which have been shown to be predictors of non-referral and non-uptake of post-hospitalisation PR, including age, length of hospital stay and index of multiple deprivation (IMD) ( 9

The sample size calculations are available in the (online supplemental data). Outcomes were compared between the two COPD discharge bundle exposure groups using independent t-test (or Mann-Whitney for non-normally distributed data) or χ2 tests. Associations were investigated using logistic regression. Adjusted ORs with 95% CIs were estimated with p values<0.05 considered significant, with all clinically relevant covariates inputted into the model using the enter method.


Of 411 hospital episodes screened, 120 were excluded (24 were due to the patient being ineligible for PR and 96 as it was a readmission of a patient already included) (online supplemental figure E2). Baseline demographics of the 291 episodes included in the study were: 145 women, 146 men; 33% current smokers; age 72 (SD: 9) years, FEV1 38 (IQR: 26 to 52) per cent predicted; length of stay 3 (IQR: 2 to 7) days. Baseline demographics according to COPD discharge bundle exposure are shown in table 1.

Table 1

Baseline characteristics of cohort according to COPD discharge bundle exposure status

Of the 63 episodes where the COPD discharge bundle was not used, none were referred for PR. Significantly higher referral and uptakes rates were observed for those who received a COPD discharge bundle from a current PR practitioner (referral: 60% vs 12%, p<0.001; uptake: 40% vs 32%, p<0.001).

In adjusted multivariate logistic regression, COPD discharge bundle delivered by a current PR practitioner was a predictor of increased PR referral and uptake (table 2), with length of inpatient stay also an independent predictor for PR referral (table 2).

Table 2

Multivariate logistic regression for predictors of PR referral and uptake within 28 days of hospital discharge for those with completed bundles


In this prospective cohort study, provision of a COPD discharge bundle was an important factor in determining referral and uptake rates for post-hospitalisation PR. No resulting PR referrals or uptake occurred when a COPD discharge bundle was not delivered to the patient. Our data supports earlier observations that the introduction of COPD discharge bundles can generate increased referrals for post-hospitalisation PR.10

A novel aspect of our study examined whether the role of the practitioner delivering the bundle is influential. Intriguingly, we demonstrated that referral rates were significantly increased when the practitioner delivering the bundle also had responsibilities for delivering PR. Although this could simply represent referrer bias, we were reassured to also observe a higher PR uptake rate in those patients referred by current PR practitioners. After multivariate analysis, taking into account potential confounders such as patient demographics and hospital admission factors, the practitioner’s current involvement in delivering PR remained an independent predictor for both increased PR referral and uptake (table 2). We did not collect data on patient face-to-face exposure time with healthcare professionals but there was no difference between the COPD bundle groups in the proportion receiving specialist respiratory review within 24 hours of admission (table 1). Furthermore, respiratory outpatient review took place at 6 weeks post-discharge, and therefore did not influence the primary outcomes (uptake and referral within 28 days of discharge).

One explanation for our observation includes increased referrer knowledge about local referral pathways and processes. Referrer knowledge and attitudes may also influence the patient–referrer interaction, which in turn shape the patient’s understanding and demystify their expectations of PR. Knowledge is frequently identified as a barrier/enabler for PR referral and participation.11 We propose that further research is needed to test whether improving referrer knowledge and experience, perhaps through formal training or closer integration between hospital and PR practitioners, can increase referral and uptake for post-hospitalisation PR. This is particularly important given the paucity of effective interventions that address this area.9

A limitation was that this was a single-centre study with small number of practitioners involved, and therefore our results may not be generalisable. However, our results seem mechanistically plausible, and we are confident about the accuracy of the exposure data as the recruiting hospital was financially incentivised to keep rigorous audit records around bundle completion. Furthermore, as the recruiting hospital was served by a single PR service, collection of PR outcome data was simplified. Another limitation is that our study used routinely collected data as part of service evaluation and audit. It is possible that our findings could be explained by confounding factors not collected in our data set, with differences in patient knowledge, beliefs and attitudes between the exposure groups potentially relevant.11

In summary, we have demonstrated that COPD discharge bundles are associated with increased referral and uptake rates for post-hospitalisation PR. In particular, COPD discharge bundle delivered by a practitioner delivering PR within their workplan is an independent predictor of PR referral and uptake. Closer integration between clinical services could increase post-hospitalisation PR referral and uptake.

Ethics statements


We would like to express our gratitude to the patients for participating in this study. We would also like to thank the staff of the Hillingdon Integrated Respiratory Service for their support with data collection.


Supplementary materials

  • Supplementary Data

    This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.


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  • Contributors Concept and design of Study: REB, MM, MF, JAW, WM; Acquisition of Data: REB, SSCK, SFC, WM; Analysis of Data: REB and WM; Interpretation of Data: All authors; Drafting and revisions of Manuscript: All authors; Final approval of Manuscript: All authors; Guarantor: WM.

  • Funding This paper presents independent research funded by the National Institute for Health Research (NIHR) under its Clinical Doctoral Fellowship Programme (Fellowship Reference Number ICA-CDRF-2017-03-018). The funder had no role in the collection, analysis and interpretation of the data; the funder had no role in the writing of and decision to publish this report. The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care. REB is funded by a NIHR Clinical Doctoral Research Fellowship (ICA-CDRF-2017-03-018); CMN was funded by a NIHR Doctoral Research Fellowship (DRF-2014-07-089) and a NIHR Clinical Trials Fellowship (CTF-2017-06-005); MM is funded by a NIHR Career Development Fellowship (CDF-2017-10-009) and NIHR Applied Research Collaboration South London; MF is currently part-funded by the NIHR Applied Research Collaboration East of England programme.

  • Competing interests REB, SSCK, SFC, JW, CMN, SEJ, SP, JAW, MM, MF and NSH have no competing interests to report. WM reports personal fees from Jazz Pharmaceuticals, personal fees from Mundipharma, personal fees from Novartis, grants from Pfizer, non-financial support from GSK, grants from National Institute for Health Research, grants from British Lung Foundation, outside the submitted work.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.