Who Is More Likely to Receive Referrals for Pulmonary Rehabilitation for COPD?

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While patients with severe chronic obstructive pulmonary disease (COPD) are receiving referrals for pulmonary rehabilitation (PR), female patients and other groups are less likely to receive them.

According to a recent Welsh study, women, current smokers, older patients, and patients with a low socioeconomic status (SES) with chronic obstructive pulmonary disease (COPD) were found to have low rates of receiving a referral for pulmonary rehabilitation (PR).

The cross-sectional analysis published in the International Journal of Chronic Obstructive Pulmonary Disease also revealed that patients with COPD who have certain comorbidities, such as diabetes and asthma, or had 4 or more prescriptions for analgesics or other drugs used for pain had low odds of receiving a PR referral.

Past research has found that access to PR programs can improve dyspnea, fatigue, quality of life, and exercise capacity in patients with COPD. PR can also reduce the need for hospital visits. A prior study, for example, found that in the United Kingdom, less than 10% of patients with COPD eligible for PR received a referral from their physician.

The authors of the current study said in Wales, 50% of eligible patients were referred to a PR program in 2017, meaning that half of the COPD population eligible for PR are missing out on the potential benefits.

Investigators evaluated the records of 82,696 patients, who were entered into the 2017 primary care COPD audit database for the United Kingdom, who had received care for COPD by the audit date of March 31, 2017

Of interest to the researchers: how many patients were referred to PR in the 3 years leading up to the audit date, starting on April 4, 2014.

While referrals are recommended in the United Kingdom for those who have frequent COPD exacerbations or moderate symptom severity and above as indicated by a Medical Research Council (MRC) grade of 3 or more, the PR decision is left up to the provider.

Out of the total,, 16% (13,297) received a referral from a primary care provider for PR.

Women were found to have 7% lower odds of getting a PR referral than men (odds ratio [OR], 0.93; 95% CI, 0.89-0.98; P = .0031). Similarly, a sensitivity analysis showed that women were also 8% less likely to be considered for PR than men (OR, 0.92; 95% CI, 0.88-0.95; P <.0001). Researchers said that there does not seem to be an obvious reason for these lower odds.

“It is possible an unconscious bias against women exists in treatment of COPD as well as diagnosis,” said the authors.

In comparison with patients under 60 years old, patients 70 years or older were less likely to be referred to PR but did have higher odds of PR consideration, suggesting that older people may be more likely to decline, be unsuitable for, or not live near a PR program (P <.0001).


“It is possible older people are less likely to be referred due to their increased comorbidity and frailty,” the researchers wrote.

Welsh individuals who were among the 20% most deprived socioeconomically, relative to the 50% least deprived patients, had lower odds of PR referral (P <.0061). Investigators suggested that this may be because patients with a lower SES may be more likely to refuse PR, not have access to an available PR program, or have “poorer engagement” with primary care, the authors said.

Ex-smokers were found to have 41% higher odds of receiving a PR referral than current smokers (OR, 1.41; 95% CI, 1.34-1.49; P <.0001). Consideration for PR was not significantly different between smokers and former smokers, which investigators noted may suggest that current smokers are more likely to refuse PR.

“The finding that ex-smokers were more likely to be referred than current or never smokers is potentially concerning as current smokers can benefit from pulmonary rehabilitation in parallel with smoking cessation treatment,” wrote investigators.

Besides former smokers, other patients with COPD who were more likely to receive a PR referral were those who had bronchiectasis, depression, any MRC recorded in the last year, higher MRC grade, more exacerbations in the last year, had higher levels of inhaled therapy, or had an influenza vaccination.

Investigators noted that “these results are encouraging as they seem to indicate that people with more severe symptoms are being appropriately prioritized,” however, it is still concerning that women, smokers, and patients with a lower SES are less likely to receive a PR referral.

Patients with COPD who also had diabetes had 10% lower odds to have a PR referral than those who did not have diabetes (OR, 0.90; 95% CI, 0.85–0.95, P <.0001). Patients with other comorbidities including asthma (OR, 0.91; 95% CI, 0.87–0.95; P <.0001) and a painful condition (OR, 0.89; 95% CI, 0.84–0.95; P<.0003) had 9% and 11% lower odds of referral, respectively.

The authors said that it was “disappointing to find that people with comorbid asthma were less likely to be referred” because evidence has shown PR to be beneficial for patients with asthma and therefore, referral should be encouraged.


Stone PW, Hickman K, Steiner MC, Roberts CM, Quint JK, Singh SJ. Predictors of Referral to Pulmonary Rehabilitation from UK Primary Care. Int J Chron Obstruct Pulmon Dis. 2020;15: 2941-2952. doi: 10.2147/COPD.S273336