Setting the stage for more acceptable pulmonary rehabilitation post-acute exacerbation of

COPD.

Tania Janaudis-Ferreira1,2,3, Catherine M. Tansey1, Samantha L. Harrison4, Cecile Elisabeth

Beaurepaire1, Donna Goodridge5, Jean Bourbeau3, Marcel Baltzan6.

1. School of Physical and Occupational Therapy, McGill University, Montreal, Quebec,

Canada.

2. Centre for Health Outcomes Research (CORE), Research Institute of the McGill

University Health Centre, Montreal, Canada.

3. Respiratory Epidemiology and Clinical Research Unit, Research Institute, McGill

University Health Center Montreal, QC, Canada.

4. School of Health and Social Care, Teesside University, Middlesbrough, United Kingdom.

5. College of Medicine, University of Saskatchewan, Saskatoon, Canada

6. Mount Sinai Hospital Centre, Montreal, QC, Canada

Corresponding Author, Contact Information:

Tania Janaudis-Ferreira

5252 de Maisonneuve Blvd. W., room # 3E01, Montreal, Quebec, Canada, H4A 3J1

Tania.janaudis-ferreira@mcgill.ca

Telephone: 514-398-5325

Fax: 514-398-8193

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ABSTRACT

Introduction: Current international guidelines for prevention of acute exacerbation of chronic

obstructive pulmonary disease (AECOPD) recommend enrolment and participation in a

pulmonary rehabilitation (PR) program within 4 weeks of hospital discharge. However, there is

poor uptake of these programs as well as low adherence and completion rates. The objective of

this study was to explore the views of patients and healthcare professionals (HCPs) on PR

following AECOPD and how participation could be enhanced.

Methods: A qualitative study was undertaken, and data were analyzed using Deductive Thematic

Analysis. Thirteen patients who had experienced an AECOPD in the previous 6 months and 11

HCPs experienced in the management of COPD participated in face-to-face semi-structured

interviews. Patients and HCPs were recruited from both rehabilitation and acute hospital settings.

Results: Four main themes were identified. 1) Uncertainty about timing of PR: Most HCPs

endorsed the professional guidelines that advocate for PR programs to begin within 4 weeks of an

AECOPD. Patients, however, varied drastically in their view of the ideal timing to start a PR

program; anywhere from before an exacerbation (perhaps preventing one) and up to 6-8 weeks

post-exacerbation. 2) Tailored and flexible manner to deliver PR programs with a gradual start:

Patients and HCPs talked about individually tailored programs with a gradual introduction of

exercise and teaching sessions. Some HCPs advocated allowing patients to pick and choose

which elements would help them the most. 3) Education for all: Patients would like HCPs to be

more informed and informative about the PR programs available in their neighbourhoods and

HCPs focused on how they could educate patients about their disease and how better to manage

it. And 4) Logistical, disease-related and psychological barriers: Barriers to PR were discussed

by both HCPs and patients. These fell into two categories: a) delivery issues (i.e., transportation

and location of PR); and b) patient specific issues (too sick or too well, high levels of anxiety).

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Conclusions: Our findings lay the foundation for the development of a flexible stepped-care

approach to delivering PR post-AECOPD which should be tailored according to the needs and

preferences of the individual.

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INTRODUCTION

Chronic obstructive pulmonary disease (COPD) is a major public health concern, the

fourth leading cause of mortality worldwide and has a higher readmission rate than other chronic

conditions such as angina, heart failure, diabetes or hypertension.1 Acute exacerbations of COPD

(AECOPD) are common2 and responsible for a stepwise decline in lung function3,4 and have

negative consequences on health-related quality of life (HRQL), symptoms of dyspnea, anxiety,

depression, exercise tolerance and levels of physical activity that may take several weeks to

return to their pre-exacerbation state, if they ever do.5,6 Poor physical performance post-

AECOPD is associated with increased risk of readmission to hospital.6,7 Exercise-based

interventions have the potential to not only improve exercise capacity and HRQL, but to reduce

healthcare utilization, especially early hospital readmission.8

Although most research concerning the effects of pulmonary rehabilitation (PR) has been

focused on individuals with stable COPD, in recent years several studies have examined the

effects of PR post-AECOPD. A recent Cochrane review published in 20168 demonstrated that PR

post- AECOPD improves HRQL and exercise capacity and reduces hospital admission. This

review also stated that PR following AECOPD might decrease mortality in patients with COPD,

however, these data were based on one study with a small sample size.8 As a result of this

increase in evidence about the benefits of PR post-AECOPD, current guidelines9-11 included a

recommendation about participation in PR post-AECOPD 3-4 weeks after hospital discharge.

Despite the guidelines’ recommendation, studies of PR in the early days post-AECOPD have

demonstrated poor uptake, adherence and completion rates.12-14 Harrison et al.14 in a prospective

observational study demonstrated that the acceptance of a referral to PR following and AECOPD

was low (55%) with 41% starting PR after accepting a referral and only 9% completing the

program within six months post-AECOPD.

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Recent studies have identified barriers to participation in physical activity or PR following

an AECOPD.15,16 The identified barriers were related to health (e.g. co-morbidities, COPD

symptoms), environment (e.g. lack of access to transport, limited finances and a lack of support

from family members and friends) and personal factors (e.g. lack of time, lack of knowledge

about PR, feelings of fatigue, perception of being too ill, feelings of worthlessness, depression,

fear of exercise-induced dyspnea, and previous negative experiences related to hospital setting).

Although barriers to participation in physical activity or PR following AECOPD have been

previously identified,15,16 it is still unclear how patients and healthcare professionals (HCPs)

would like rehabilitation programs post-AECOPD to be delivered.

This study had two main objectives. First, we aimed to explore the views of individuals

with COPD and HCPs on the delivery of PR post-AECOPD and whether they deem it timely,

appropriate, and effective. Second, we wanted to investigate how patients and HCPs think

participation in PR post-AECOPD could be enhanced, and particularly, how they would like to

see PR delivered in terms of location, timing and frequency, and content of the program. The

information generated from this study will lay the foundation for the development of a more

acceptable rehabilitation intervention for patients following an AECOPD.

METHODS

Study design

We undertook a qualitative study at two hospitals in Montreal: a rehabilitation hospital

(Mount Sinai Hospital Centre) and an acute hospital (The Montreal Chest Institute of the McGill

University Health Centre). We conducted semi-structured interviews with patients who had had a

recent episode of AECOPD as well as with HCPs who were experienced in the management and

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treatment of COPD. Deductive thematic analysis17 was used since it is independent of theory and

epistemology and provides a flexible and pragmatic approach to collecting and analyzing

narrative accounts in a rich and detailed way. We followed Braun & Clarke’s17 six-phase guide to

doing thematic analysis. These phases include: 1) familiarization with data, 2) generation of

initial codes, 3) search for themes, 4) review of themes, 5) definition and names of themes, and 6)

production of the report. Details and nuances of these steps and how we followed them is

included in the data analysis section below. Approval was obtained from the research ethics

boards of the two hospitals and all participants provided written informed consent. The reporting

of this qualitative study has followed the “Consolidate Criteria for Reporting Qualitative

Research (COREQ)”.18

Study population

Individuals with COPD

We recruited individuals who had a clinical diagnosis of COPD (confirmed by

spirometry) and at least one recent (last 6 months) exacerbation of their COPD with or without

hospitalization. A purposeful sampling strategy was used to gain a diverse range of views from

individuals with COPD. Specifically, we recruited patients who had recently been enrolled in an

inpatient or outpatient PR program as well as those who were being seen in an active respiratory

clinic but were not referred to PR or who decided not to participate in PR after their AECOPD

(Mont Sinai Hospital). We also recruited patients hospitalized for AECOPD in an acute

respiratory care inpatient unit (Montreal Chest Institute). We recruited patients with different

ages, gender and stage of COPD. Individuals were excluded if they had a primary respiratory

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diagnosis other than COPD or an inability to communicate because of language skills, a hearing

or a cognitive impairment (diagnosed or according to the healthcare team’s judgment).

Healthcare Professionals

We used a purposeful sampling strategy to identify experienced HCPs with different

professional backgrounds who were involved in some aspect of the management of COPD. We

defined “experienced HCPs” as those who have at least two years of clinical experience caring

for individuals with COPD. We recruited some HCPs that worked in a rehabilitation setting

(Mont Sinai Hospital) and some from an acute care setting (inpatient or outpatient clinic of the

Montreal Chest Institute) and with various types of positions (leadership vs. frontline staff).

Data collection

Demographics

For participating patients, we documented demographic data such as sex, age, symptom

severity (measured by the Modified Medical Research Council (MMRC) and forced expiratory

volume in one second (FEV1) from the last 6 months, smoking history, number of years

diagnosed with COPD as well as number of previous AECOPD. We also documented whether

participating patients had been previously referred to PR, had completed or were enrolled in an

in- or outpatient PR program at the time of the interview. For participating HCPs, we collected

information on sex, age, location of employment (acute vs. rehabilitation hospital), professions

and years of experience.

Semi-structured interviews

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A female research assistant (CEB) with a PhD who was not part of the clinical team

conducted the interviews with participating patients and HCPs in English or French (based on

participants’ preference) between July 2016 and April 2017. All interviews were audiotaped.

Semi-structured interviews using open-ended questions were used based on an interview guide

that was informed by pre-identified issues based on the literature and on the investigators’

clinical and research experience. The interview guide focused on how to overcome these issues

and more specifically on how patients and HCPs think PR post-AECOPD should be delivered

and how they think participation can be enhanced. (Interview guides are attached in the

appendix). Patient interviews lasted between 9 and 40 minutes (mean 18 minutes) while

interviews with HCP were between 11 and 28 minutes (mean 20 minutes). A professional

transcriptionist transcribed the interviews verbatim. QSR NVivo (version 9) was used to aid the

analytic process. Recruitment was considered complete once data saturation occurred, meaning

no new themes were emerging from the interviews.19

Data analysis

The data were analyzed using Deductive Thematic Analysis (DTA) as described by Braun

and Clarke.17 DTA adopts a framework approach, which is applied when there are pre-identified

issues the researcher wishes to investigate whilst still maintaining flexibility to allow new themes

to be uncovered. Interviews from patients and HCPs were coded at the same time as they became

available from the transcriber. The analysis was guided by the researchers’ previous clinical and

research experience in the care of individuals with COPD and the delivery of PR and followed

the six-step procedure of Braun and Clark:17 1) two researchers (TJF; CT) familiarized

themselves with the data prior to developing a preliminary list of codes; 2) one researcher (CT)

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organized units of text under each code, creating additional codes if new issues were identified;

Two researchers (TJF; SH) also independently coded two interviews (one from a patient and the

other one from a HCP). 3) Then two researchers (TJF; CT) searched the codes generated from all

sources for overarching, broader ‘candidate themes’; 4) two researchers (TJF; CT) then reviewed

all the data extracts coded under each theme to consider if the themes were coherent, consistent,

distinctive and the data extracts appropriate; 5) Appropriate definition and names of the themes

were then generated and 6) before the production of the report, thematic mapping was used to

check that the themes worked in relation to the entire data set and final analysis consisted of

using selected extracts, and relating them back to the research questions and to the literature. As

part of the report writing, we broadened the analysis into interpretation.17 We asked questions

like ‘What does this theme mean’ and ‘what are the implications of this theme?’ Two patient

interviews were done in French and translated to English. The English versions were used for

analysis. No HCP interview was done in French. Initially themes were generated separately for

patients and HCP, but since they were converging, at the end of step 3 analysis was finalized on

both data sets together.

RESULTSWe recruited 16 patients and 12 HCPs. Three patients were removed from the study

because it was discovered during the interviews that two patients had never suffered an

exacerbation and another patient clearly demonstrated that she was confused about the study

purpose despite having read and signed the consent form. One HCP was removed from the study

because during the interview she confirmed that she did not have the required 2 years or more of

experience caring for COPD patients. Therefore, we present data from interviews of 13 patients

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(10 males, 3 females) and 11 HCPs. The characteristics of the participants are presented in Table

1 (patients) and Table 2 (HCPs).

Interviews

Four main themes were identified from the combined data set of both patients and HCP

and included: 1) Uncertainty about timing of PR; 2) Tailored and flexible PR programs with a

gradual start; 3) Education for all and 4) Logistical, disease-related and psychological barriers.

1. Uncertainty about timing of PR

Most HCPs endorsed the professional guidelines that advocate for PR programs to begin

within 4 weeks of an AECOPD. “In my experience the sooner they get started, the sooner they

are able to master their condition and help themselves (HCP#1). “It’s also, to my knowledge,

been well established that Pulmonary Rehabilitation should be started fairly soon after

exacerbation” (HCP#5). Patients, however, varied drastically in their view of the ideal timing to

start a PR program; anywhere from before an AECOPD (perhaps preventing one) and up to 6-8

weeks post-exacerbation. “Honestly there, before going to the hospital” (P#1). “No, not right

after because you’re still trying to get yourself back to normal. Maybe a month or so. You know,

get their routine back into order and then start” (P#6). In particular, some patients who had not

participated in a PR program thought that they might need some time to recuperated at home

before starting the program, while those who had participated in PR advocated starting as soon as

possible.

2. Tailored and flexible manner to deliver PR programs with a gradual start

HCPs talked about individually tailored and flexible PR programs post-AECOPD (in

terms of content and setting) with a gradual introduction of exercise and teaching sessions. Some

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HCPs advocated allowing patients to pick and choose which elements would help them the most

post-AECOPD. “I think the patient should be involved in deciding or at least have a say in

terms of how they’ll exercise …So it’s a bit more self-directed” (HCP#1). “It would be

something that would be relatively low intensity to start with, and focused on education and

lifestyle change, and was community or home base that was easily accessible” (HCP#9). Patients

also suggested that PR post-AECOPD should have a stepped-care approach: “No, I feel that

originally it should be one on one. And then graduate, you’d go into a group session, maybe not

too big” (P#5). “I would like to have the [psychological] support and education first [before

starting an exercise program]” (P#11).

One patient suggested that HCPs should take into account patient comorbidities when

evaluating patients and designing rehabilitation programs post-AECOPD. “Somebody that can

tell me what to do based on the fact that in addition to the lung I have a back problem” (P#10).

HCPs and patients discussed that PR programs should be tailored to patients’ level of

functioning (both low and high levels of functioning). “And then we need something in between

that’s for people even more debilitated with functional limitations” (HCP#13). “Well one I don’t

think I need it, because I do my own exercise. And I do get out, I do get fresh air, and I usually

walk for close to an hour in the morning” (P#5). Patients who had participated in PR and those

who never had participated agreed that flexibility and individual tailoring were important

characteristics of a PR program.

3. Education for all

Both HCPs and patients considered “education” as an important factor to enhance

knowledge about PR and possibly enhance participation post-AECOPD. HCPs focused on how

they could educate patients about their disease and how better to manage it. “Knowledge is

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power. The more that they know about their disease and how to control their symptoms can be a

powerful thing” (HCP#13). Patients, however, would like HCPs to be more informed and

informative about the PR programs available in their neighbourhoods. “I think we should talk

more, people in the health field should be more aware of this program” (P#1). “The CLSC

[French short version of “Local Centre of Community Services”) should be made aware that

these programs are going to happen” (P#9). In particular, patients who had not participated in a

PR program felt HCPs were not effectively communicating about the logistics of programs

available in the neighbourhoods close to where they lived. One patient said, “I am not aware

enough about the program. (P#5)”

4. Logistical, disease-related and psychological barriers

Patients and HCPs discussed barriers to participation in PR post-AECOPD. These

barriers fell into two categories: a) delivery issues (i.e., transportation and location of PR); and b)

patient specific issues (too sick, high levels of anxiety). “They’re functionally at a lower level, to

expect them to go and attend an outpatient program consistently for weeks, doesn’t end up

working well. They don’t have the ability” (HCP#8). “OK now if I’m very ill and I don’t have

transportation and I can’t come by public transportation…” (P#3). “The location would be a

factor, uh, the costs, the parking is not cheap, so if you come four times a week it’s 40 bucks.

That’s a lot” (P#5). “I’m not strong enough. I can’t, I even have a hard time to get to the door”

(P#13).

HCPs discussed strategies to mitigate these barriers which included neighbourhood

programs with transport provided, home-based or tele-rehabilitation and provision of anxiety

reducing strategies. “Health coaching or home rehab, something that was relatively low resource

and could overcome that sort of logistical barriers so that most patients could participate in

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some way or another. … community, satellite, home, whatever it is, you know, telephone based”

(HCP#9). “In an ideal world, I think psychological or social work [services need to be used

more] because a lot of these people have anxiety, depression, other comorbidities and other

social issues that prevent them from doing what they have to do and respecting their limitations.

Whether it’s family issues and yeah, I mean either social work or psych [could help] with

that” (HCP #2). “As a psychologist I have to say exercise often can help people better manage

mood or anxiety” (HCP #5). Patients who had and had not participated in a PR program agreed

that these barriers exist and can be restricting.

DISCUSSION

Although barriers to participation in physical activity or PR following AECOPD have

been previously identified,15,16 this study is the first to collect the views of patients with COPD

and HCPs on the delivery of PR post-AECOPD and their suggestions on how participation could

be enhanced. We identified four main themes: 1) Uncertainty about timing of PR; 2) Tailored and

flexible PR programs with a gradual start; 3) Education for all and 4) Logistical, disease-related

and psychological barriers and pointed out three strategies that could help enhance participation

in PR post-AECOPD (Figure 1).

Patients and HCPs disagreed about timing to initiate PR post-AECOPD but shared similar

views about how PR should be delivered (tailored to patients’ needs and barriers, flexible in

terms of type of exercise and setting, and delivery with a gradual start). Both patients and HCPs

emphasized the importance of education (e.g. disease-specific education, what PR is, its benefits,

programs available) and the need to address logistical, disease-related and patient-related barriers

to enhance participation in PR post-AECOPD. Interestingly, there were no major differences

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between the thoughts of patients who had participated in PR and those who had not, although

those who had not participated in PR did voice that they needed more time to recuperate at home

before starting a PR program, while those who had participated in PR advocated starting as soon

as possible. These findings suggest that if patients can be convinced to participate in early PR,

they will appreciate the opportunity and acknowledge the benefits of PR. However, the reality is

that many patients still do not accept the referral. In addition, patients who had not participated in

PR expressed more emphathically that they did not receive as much information about PR as they

would have liked suggesting that better education about the program at the time of referral is

essential. It is noteworthy that both patients who had participated in PR and those who never had

participated, agreed that flexibility and individual tailoring were important factors that could

enhance participation in PR post-AECOPD. Our findings lay the foundation for a more

acceptable manner in which PR post-AECOPD can be delivered.

The disagreement between some patients and HCPs about timing of PR post-AECOPD is

noteworthy. It reflects an important contradiction that is also observed in the literature and

suggests that it is time for HCPs and researchers to consider what matters to patients (in a world

where patient-centered care is now being prioritized). While international clinical guidelines on

the management of AECOPD repeatedly recommend participation in PR within 3-4 weeks9-11 of

hospital discharge, individual studies show that a large proportion of approached patients decline

participation in PR post-AECOPD. For example, in the studies by Eaton et al.20 and Greening et

al.,21 57% and 27% of the eligible patients respectively declined participation in PR post-

AECOPD. The authors of a recent randomized controlled trial (RCT),22 where patients completed

early PR either at the hospital or at their home after hospitalization due to an AECOPD,

concluded that recruitment and delivery of the intervention at the hospital was difficult. In this

study, the home program was more acceptable. This is in line with our findings that some HCPs

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recommended home-based programs to promote participation. Home-based PR programs have

been shown to produce clinical effects that are equivalent to hospital-based PR program in

patients with stable COPD;23,24 however, even when interventions are delivered at home with

simple exercises or no exercise at all post-AECOPD, a large proportion of patients still decline

participation. Orme et al.25 offered a home-based intervention focused on sedentary time rather

than structured exercise where patients post-AECOPD received education and a feedback device

to remind them to reduce sitting time, get up and walk around the house. Although the authors of

this study concluded that the intervention was feasible, only 30% of the approached patients

accepted participation and retention at 2 weeks was only 52%. In a recent pilot RCT26 where a

brief education program (with no exercise involved) was delivered at the hospital or home to

patients who had been hospitalized with AECOPD, only 50% of the approached patients accepted

to take part in the study.

It is clear that the interventions delivered to patients post-AECOPD are palatable to only a

subset of patients. The question is what can be done to make PR post-AECOPD acceptable to the

majority of patients post-AECOPD. Our study provides some insights on potential strategies that

could be used to motivate patients to participate in these interventions. First, researchers and

HCPs should consider patients’ opinions when offering PR post-AECOPD and individualize the

program according to patients’ barriers and preferences. A tailored intervention will respect

patients’ preferences while maintaining the core components of a PR program to ensure its

effectiveness. For example, options may be offered in terms of setting (e.g. home vs. hospital),

type of exercise and timing to commence exercise. Second, both patients and HCPs discussed

that some patients may prefer to start their rehabilitation journey with an education program or

psychological and social support and thereafter gradually transition to a comprehensive PR

program with structured and intense exercise. Stepped care approaches with focus on

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psychological support have been used within cardiac and stroke rehabilitation settings and have

been shown to be effective in reducing levels of anxiety and depression in these populations.27,28

This approach could also reduce negative emotions in patients post-AECOPD and potentially

improve participation in PR programs.29 The advantage of a stepped care approach is that it

would respect the different stages of behaviour change a patient may be at after an AECOPD

(e.g. pre-contemplation, contemplation, preparation and action stages).30 For most people, a

change in behaviour occurs gradually so for patients who are still pre-contemplative or

contemplative about participating in PR, different services (e.g. education and psychological

support) could be offered to help them transition from pre-contemplation or contemplation phases

to preparation or action phases and engage in a formal PR program at a later phase. Third, referral

at multiple time points (in the trajectory of their disease) and different settings (primary,

secondary, tertiary care) may be another strategy that could ultimately enhance participation in

PR. It may be that we need to offer entry to PR at the hospital as well as at the time of follow up

when patients may be feeling better and have had the chance to go home and reflect on what they

can do to better manage their disease (contemplation phase). Moreover, as suggested by one

patient, perhaps HCPs may also focus their efforts on offering PR when patients are stable and/or

at the time of diagnosis where education and exercise may serve as preventative measures for

future AECOPD requiring hospitalization. A summary of the strategies that could be used to

enhance participation in PR programs post-AECOPD is outlined in Figure 1. Although these

strategies have the potential to increase acceptability of PR programs post-AECOPD, they will

require rigorous evaluation in subsequent clinical trials before we can be confident of their

effectiveness in improving referral and uptake of PR post-AECOPD as well as their cost-

effectiveness.

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Although education was considered by both patients and HCPs as an important factor that

can promote participation in PR post-AECOPD, their concept of “education” differed. HCPs

focused on how they could educate patients about their disease and how better to manage it while

patients would like to receive more information on what PR is and programs available in their

neighbourhoods. These findings suggest that HCPs should also focus their efforts on raising

awareness of the importance of PR among patients, as well as increasing their own knowledge

about what programs are available in their communities. Perhaps healthcare societies in each

country (e.g. American, Canadian and British Thoracic Societies, etc) could sponsor an up-to-

date repository of local PR programs.

This study included patients and HCPs from two centres in Montreal and therefore the

findings may not be generalizable to other centres. However, qualitative research studies “are

meant to study a specific issue or phenomenon in a certain population of a focused locality in a

particular context, hence generalizability of qualitative research findings is usually not an

expected attribute”.31

Conclusions

Although one specific formula for how to make PR post-AECOPD more acceptable to

patients may not exist, our findings lay the foundation for the development of a more diverse and

flexible stepped-care approach to delivering such an intervention which is tailored according to

the needs and preferences of the individual. It is important to raise the awareness of PR, delivered

in hospital, home or community settings prior to an AECOPD, whilst patients are at an early

disease stage or in a stable state.

Acknowledgements

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The authors would like to thank Dr. Nathalie Saad for facilitating the recruitment of some

patients at Mt Sinai Hospital as well as Ms. Kim van der Braak and Dr. Sébastien Gagnon for

providing meaningful feedback on the revised version of this manuscript. The authors also would

like to thank the patients and HCPs from the Mt Sinai Hospital and Montreal Chest Institute who

participated in the study. The study was funded by a grant from the Canadian Respiratory Health

Professionals (Canadian Lung Association). Dr. Tania Janaudis-Ferreira holds the Junior 1

Research Scholar Career Award from the Fonds de Recherche du Québec – Santé (FRQS).

376

377

378

379

380

381

382

383

Table 1. Patient characteristics (n=13)

CharacteristicsAge (mean ± SD) 70.9 ± 9.9 years

Sex (n) 10 males; 3 females

FEV1 (L) (mean ± SD) 1.10 ± 0.78

FEV1 (% predicted) (mean ± SD) 29.30 ± 14.72

MMRC scale grade (0-4) (mean ± SD) 2.77 ± 0.93

Current smokers (n) 0

Number of years smoking (mean ± SD) 42.4 ±11.3

Number of packs/day (mean ± SD) 1.5 ± 0.6

Duration (in years) of COPD diagnosis (mean ± SD)

10.7 ± 7.4

Previous number of exacerbations (mean ± SD)

5.8 ± 4.7

Number of hospitalizations as a result of an exacerbation (mean ± SD)

3.8 ± 4.8

Previous referral to PR (n) Yes: 6No: 7

Previous participation in PR (n) Yes: 5No: 8

Enrolment in PR at time of interview (n) Yes: 5No: 8

SD: standard deviation; MMRC: Modified Medical Research Council; FEV1: forced expiratory volume in one second.

384385

386387388389

Table 2. Characteristics of HCPs (n=11)

CharacteristicsMean age (mean ± SD) 44.2 ± 9.7 years

Sex 7 females; 4 males

Profession Physiotherapist (n=3)Physician (n=3)Registered Nurse (n=2)Dietician (n=1)Occupational Therapist (n=1)Psychologist (n=1)

Location of employment Rehabilitation hospital: 6Acute care hospital: 5

Years of experience working with COPD population (mean ± SD)

17.4 ± 10.5 years

SD: standard deviation

Legend

Figure 1. Potential strategies to enhance participation in PR post-AECOPD.

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