A Qualitative Study to Inform a More Acceptable Pulmonary Rehabilitation Program after Acute Exacerbation of Chronic Obstructive Pulmonary Disease

Implementation of virtual pulmonary rehabilitation during the COVID-19 pandemic: Experiences and perceptions of patients and healthcare providers

BACKGROUND

Pulmonary rehabilitation (PR) plays an important role in the management of symptomatic patients with chronic respiratory diseases (CRD). While studies have investigated the feasibility and efficacy of virtual PR (VPR), it is important to understand the experiences of patients and healthcare providers (HCPs) during the rapid digital health transformation that occurred in the COVID-19 pandemic.

OBJECTIVES

To explore the experiences and perspectives of patients and HCPs who participated in VPR during the pandemic.

METHODS

Semi-structured interviews were conducted with CRD patients and HCPs. This study used a qualitative descriptive approach and a team-based inductive thematic analysis.

RESULTS

Participants included 11 HCPs (7 female; 29-55 years) and 19 CRD patients (11 male; 62-83 years; 15 COPD, 4 COPD/ILD). Three major themes and 10 subthemes were identified: i) the pandemic response: a 'trial by fire' (navigating uncertainty, emotional impact of change, shifting practice amid complexity); ii) beyond the emergency: navigating a 'new normal' (eligibility and assessment for VPR, virtual exercise, virtual education and resources, clinical supervision and patient safety); and iii) care beyond boundaries: the implications of using technology for PR (benefits and limitations of technology, psychosocial implications, VPR in the future).

CONCLUSION

The pivot to VPR was acknowledged as positive by both patients and HCPs although both groups were mindful of the implementation challenges. These findings provide insight into the experience of HCPs and patients in introducing VPR in response to the pandemic and will inform future implementation of VPR for individuals with CRD.

Pulmonary Rehabilitation for Adults with Chronic Respiratory Disease: An Official American Thoracic Society Clinical Practice Guideline

Background: Despite the known benefits of pulmonary rehabilitation (PR) for patients with chronic respiratory disease, this treatment is underused. Evidence-based guidelines should lead to greater knowledge of the proven benefits of PR, highlight the role of PR in evidence-based health care, and in turn foster referrals to and more effective delivery of PR for people with chronic respiratory disease. Methods: The multidisciplinary panel formulated six research questions addressing PR for specific patient groups (chronic obstructive pulmonary disease [COPD], interstitial lung disease, and pulmonary hypertension) and models for PR delivery (telerehabilitation, maintenance PR). Treatment effects were quantified using systematic reviews. The Grading of Recommendations, Assessment, Development and Evaluation approach was used to formulate clinical recommendations. Recommendations: The panel made the following judgments: strong recommendations for PR for adults with stable COPD (moderate-quality evidence) and after hospitalization for COPD exacerbation (moderate-quality evidence), strong recommendation for PR for adults with interstitial lung disease (moderate-quality evidence), conditional recommendation for PR for adults with pulmonary hypertension (low-quality evidence), strong recommendation for offering the choice of center-based PR or telerehabilitation for patients with chronic respiratory disease (moderate-quality evidence), and conditional recommendation for offering either supervised maintenance PR or usual care after initial PR for adults with COPD (low-quality evidence). Conclusions: These guidelines provide the basis for evidence-based delivery of PR for people with chronic respiratory disease.

Telerehabilitation in pulmonary diseases

PURPOSE OF REVIEW

Telerehabilitation is an alternative delivery model for pulmonary rehabilitation, an evidence-based nonpharmacological intervention, in people with chronic pulmonary disease. This review synthesizes current evidence regarding the telerehabilitation model for pulmonary rehabilitation with an emphasis on its potential and implementation challenges, as well as the clinical experiences from the COVID-19 pandemic.

RECENT FINDINGS

Different models of telerehabilitation for delivering pulmonary rehabilitation exist. Current studies comparing telerehabilitation to centre-based pulmonary rehabilitation primarily focus on the evaluation in people with stable chronic obstructive pulmonary disease, which demonstrated equivalent improvements in exercise capacity, health-related quality of life and symptoms with improved programme completion rates. Although telerehabilitation may improve access to pulmonary rehabilitation by addressing travel burden, improving schedule flexibility and geographic disparity, there are challenges of ensuring satisfaction of healthcare interactions and delivering core components of initial patient assessment and exercise prescription remotely.

SUMMARY

Further evidence is needed on the role of telerehabilitation in various chronic pulmonary diseases, as well as the effectiveness of different modalities in delivering telerehabilitation programmes. Economic and implementation evaluation of currently available and emerging models of telerehabilitation in delivering pulmonary rehabilitation are needed to ensure sustainable adoption into clinical management for people with chronic pulmonary disease.

Promoting Participation in Pulmonary Rehabilitation after Hospitalization for Chronic Obstructive Pulmonary Disease, Strategies of Top-performing Systems: A Qualitative Study

Rationale: Pulmonary rehabilitation (PR) after hospitalization for chronic obstructive pulmonary disease (COPD) is recommended by guidelines; however, few patients participate, and rates vary between hospitals. Objectives: To identify contextual factors and strategies that may promote participation in PR after hospitalization for COPD. Methods: Using a positive-deviance approach, we calculated hospital-specific rates of PR after hospitalization for COPD among a cohort of Medicare beneficiaries. At a purposive sample of high-performing and innovative hospitals in the United States, we conducted in-depth interviews with key stakeholders. We defined high-performing hospitals as having a PR rate above the 95th percentile, at least 6.58%. To learn from hospitals that demonstrated a commitment to improving rates of PR, regardless of PR rates after discharge, we identified innovative hospitals on the basis of a review of American Thoracic Society conference research presentations from prior years. Interviews were audio-recorded and transcribed verbatim. Using a directed content analysis approach, transcripts were coded iteratively to identify themes. Results: Interviews were conducted with 38 stakeholders at nine hospitals (seven high-performers and two innovators). Hospitals were diverse regarding size, teaching status, PR program characteristics, and geographic location. Participants included PR medical directors, PR managers, respiratory therapists, inpatient and outpatient providers, and others. We found that high-performing hospitals were broadly focused on improving care for patients with COPD, and several had recently implemented new initiatives to reduce rehospitalizations after admission for COPD in response to the Centers for Medicare and Medicaid Services/Medicare's Hospital Readmission Reduction Program. Innovative and high-performing hospitals had systems in place to identify patients with COPD that enabled them to provide patient education and targeted discharge planning. Strategies took several forms, including the use of a COPD navigator or educator. In addition, we found that high-performing hospitals reported effective interprofessional and patient communication, had clinical champions or external change agents, and received support from hospital leadership. Specific strategies to promote PR included education of referring providers, education of patients to increase awareness of PR and its benefits, and direct assistance in overcoming barriers. Conclusions: Our findings suggest that successful efforts to increase participation in PR may be most effective when part of a larger strategy to improve outcomes for patients with COPD. Further research is necessary to test the generalizability of our findings.

Listen to Me! - A Mixed-Methods Study of Thoughts and Attitudes Towards Participation in Pulmonary Telerehabilitation Among People with Severe and Very Severe COPD Who Declined Participation in Pulmonary Rehabilitation

INTRODUCTION

Pulmonary rehabilitation (PR) is a key standard treatment for people with chronic obstructive pulmonary disease (COPD) with documented effect on symptom relief, improved physical function, and quality of life. However, referral, uptake and adherence rates remain low. Pulmonary telerehabilitation (PTR) is a safe and effective alternative to conventional PR. This study explores associations, thoughts and attitudes towards PTR in patients with COPD who decline referral to outpatient hospital-based routine PR.

METHODS

A mixed-methods study with integration of survey data (n=84) and semi-structured interviews (n=9).

RESULTS

We found a significant association between belief of effect of PTR and willingness to participate. Increasing age was significantly associated with reduced odds of daily use of central processing unit (CPU) or tablet. One-third of the participants were undecided about potential participation in PTR. Qualitative findings highlight that participants perceived participating in PTR as more convenient and had preferences for individualized, supervised, and monitored rehabilitation.

CONCLUSION

Those willing to participate in a PTR program believed in the benefits, were comfortable with technological devices, had preferences for exercising at home, and saw opportunities in the social setting. Future PTR programs should include monitoring, preferably managed by a familiar health care professional (HCP).

Expert opinion and patients' in-depth interviews on the impact of pulmonary complications in systemic sclerosis

OBJECTIVE

To qualitatively explore the perceptions and opinions of experts dealing with systemic sclerosis (SSc) and patients with SSc on the impact of the disease and pulmonary complications on economic status, psycho-social wellbeing and the diagnostic and therapeutic journey, and to identify which strategies/interventions may be useful to address patients' and their family's needs.

METHODS

An expert meeting was conducted using the NGT to discuss the consequences of pulmonary complications on the Italian SSc community. The direct experience of five patients with SSc and pulmonary complications was described through in-depth interviews conducted by psychologists.

RESULTS

The experts' meeting and patients' in-depth interviews underline the complexity of SSc and the consequences of pulmonary involvement on patients' and caregivers' health-related quality of life, working ability, psychological wellbeing and social interactions. Panellists suggest that improved communication between physicians, associations and institutions could help protect the working status of patients with SSc. Granting patients disability benefits, providing access to part-time jobs and productivity-focused training could also help decrease the economic burden of the disease. A multidisciplinary approach is recommended to reduce treatment burden, together with the implementation of standard diagnostic and therapeutic paths and increased use of telemedicine via platforms that ensure secure health data sharing. Both patients and caregivers may benefit from psychological support.

CONCLUSION

SSc and pulmonary fibrosis have profound consequences on patients' and caregivers' health-related quality of life, working ability, psychological wellbeing and social interactions. Some activities may help patients and families deal with these aspects of the disease.

Experiences of Pulmonary Rehabilitation in People Living with Chronic Obstructive Pulmonary Disease and Frailty. A Qualitative Interview Study

Rationale: People living with both chronic obstructive pulmonary disease (COPD) and frailty have high potential to benefit from pulmonary rehabilitation but face challenges completing programs. However, research to understand ways to optimize participation in this group is lacking.

Objectives: To explore the experiences, needs, and preferences of people with COPD and frailty referred for outpatient pulmonary rehabilitation.

Methods: Semistructured interviews with people with COPD and physical frailty, purposively sampled by age, living status, level of frailty, and completion of pulmonary rehabilitation. Thematic analysis with a critical realist perspective was used, involving relevant stakeholders with clinical, academic, and lived experience for interpretive rigor.

Results: Nineteen people with COPD and frailty were interviewed, with a median age of 78 years (range, 58–88). Nine did not complete their pulmonary rehabilitation program. Four themes were identified: striving to adapt to multidimensional loss, tensions of balancing support with independence, pulmonary rehabilitation as a challenge worth facing, and overcoming unpredictable disruptions to participation. Participants described constantly adapting to their changing health and resulting multidimensional losses (e.g., functional abilities, relationships, confidence). This involved traversing between independence and seeking support, set against a mismatch between their needs and what support is available. People with COPD and frailty can be highly motivated to participate in pulmonary rehabilitation, despite the physical and mental demands it entails, and report a range of benefits. Yet in the context of changeable health, they must often overcome multiple unpredictable disruptions to completing rehabilitation programs. Participant determination and flexibility of services can facilitate ongoing attendance, but for some, these unpredictable disruptions erode their motivation to attend.

Conclusions: People with COPD and frailty experience accumulating, multidimensional loss. This group are motivated to complete pulmonary rehabilitation but often require additional support and flexibility owing to fluctuating and unpredictable health. Person-centered approaches should be considered to minimize disruptive health events and support pulmonary rehabilitation participation and completion. Service adaptations could allow more flexibility to meet the changing needs of this group and enable communication around how pulmonary rehabilitation might align with their priorities.

Rapid access rehabilitation after exacerbations of COPD - A qualitative study

PURPOSE

Rehabilitation after acute exacerbations of chronic obstructive pulmonary disease (AECOPD) is beneficial, but its feasibility is questionable. Feasibility is potentiated by stakeholder involvement during program development. We aimed to explore the perspectives of various stakeholders towards an innovative rapid access rehabilitation (RAR) program for patients immediately following hospitalization for an AECOPD.

METHOD

Semi-structured interviews were conducted with patients recently hospitalized for AECOPD, healthcare professionals (HCP) and policymakers providing care for such patients. Thematic analysis was performed.

RESULTS

Three patients (1 female; 62-89 years; GOLD D), ten HCP (3 females, 31-71 years) and three policymakers (3 females, 38-55 years) participated. Patients, HCP and policymakers shared similar visions for the development of a RAR program. Five main themes and ten subthemes were identified. They comprised: Pre-RAR aspects (Management properties, Eligibility), RAR program (Outcomes, Structure, Components), RAR optimization (Referral, Uptake), Partnership (Collaboration, Dedicated Coordinator) and COVID-19 (Adaptations). Essential elements included: identifying clear eligibility criteria, addressing patients' needs at the time of hospital discharge, having a structured education and self-management program and modifying to respond to unexpected events (e.g., COVID). Suggestions to optimize referrals included a clear referral pathway, improving program awareness, assigning dedicated care coordinators to provide patient support throughout the program and establishing strong partnerships among different care settings and providers.

CONCLUSIONS

Identifying the essential program elements and approaches to optimize referrals, were considered to be key design approaches for success in establishing RAR.

Experiences of a home-based fall prevention exercise program among older adults with chronic lung disease

BACKGROUND

Individuals with chronic obstructive pulmonary disease (COPD) often have mobility limitations; these may include challenges with balance and being at high risk of falling. Risk of falling can be reduced through exercise programs targeting balance; however, older adults with COPD may experience many barriers to exercise adherence. In this paper we present qualitative findings about the feasibility of a six-month home-based fall-prevention exercise program for older adults with COPD. The aim of the study is to describe the experiences of older adults with COPD who participated in a home-based fall prevention exercise program in order to determine their perceived facilitators and barriers to participation.

METHODS

15 participants with COPD who had completed the six-month home-based program participated in one-on-one semi-structured interviews over the phone. Interpretive description methodology and thematic analysis were used.

RESULTS

Two major themes emerged with respect to participants' perspectives of the intervention and facilitators and barriers to participation: program personalization based on each individual's characteristics, lifestyles, and preferences; and self-motivation and support from family, friends, and healthcare providers.

CONCLUSIONS

Fall prevention exercise programs that are personalized and focus on providing support for older adults with COPD may help to improve adherence and reduce participants' risk of falling.Implications for rehabilitationIndividuals with COPD often have balance problems and a high risk of falling.Fall prevention programs can improve balance, but adherence is a commonly cited challenge.Patient experiences suggest that fall prevention programs should be personalized and incorporate social support to improve adherence to fall prevention exercises.

Web-Based Self-management Program (SPACE for COPD) for Individuals Hospitalized With an Acute Exacerbation of Chronic Obstructive Pulmonary Disease: Nonrandomized Feasibility Trial of Acceptability

BACKGROUND

Hospital admissions due to the acute exacerbation of chronic obstructive pulmonary disease (AECOPD) are costly for individuals and health services. Pulmonary rehabilitation (PR) is known to reduce hospital readmissions when delivered after hospitalization, but the uptake and completion of PR following hospitalization remains poor (<10% of those eligible in the UK audit data). A web-based platform of the SPACE (Self-management Program of Activity Coping and Education) for COPD (chronic obstructive pulmonary disease) has previously shown promising results in patients with stable COPD but has not been tested following an AECOPD.

OBJECTIVE

This study aims to assess the feasibility and acceptability of a web-based self-management program.

METHODS

A nonrandomized feasibility study for patients with confirmed AECOPD who were deemed web literate was conducted. All patients consented during their hospitalization and received access to the website following discharge in addition to usual care. The program aims to facilitate patients to better understand and manage their condition through education and home-based exercises. Participants were asked to complete the Bristol COPD Knowledge Questionnaire at baseline and after 6 months. A total of 14 participants were also interviewed (n=8 completers; n=6 noncompleters) regarding their experiences with the web-based program and trial. The interviews were analyzed using thematic analysis.

RESULTS

In total, 2080 patients were screened for eligibility, of which 100 patients (age: mean 71.2 years, SD 9.3 years; male: 55/100, 55%; forced expiratory volume in 1 second/forced vital capacity ratio: mean 0.46, SD 0.14; pack-years: mean 50.2, SD 31.0; current smokers: 35/100, 35%) were recruited (4.8% of those screened). The main reason for ineligibility was a lack of web literacy (1366/1980, 68.98%). In total, 18% (18/100) of patients had completed the web program by 6 months, with others still registered in the program (27/100, 27%), and more than half did not register (55/100, 55%). There was a mean change in Bristol COPD Knowledge Questionnaire scores at 6 months of 7.8 (SD 10.2) points. Qualitative interviews identified three main themes: preparing for, engagement with, and benefits of the study and program. A total of 57% (57/100) accepted a referral to PR on discharge and 19% (19/100) had completed the program after 6 months.

CONCLUSIONS

On the basis of the challenges of recruiting, retaining, and engaging participants in a web-based self-management program, it is not a feasible approach to roll out widely. This study acknowledges that this is a challenging time for patients with an AECOPD to engage in exercise and self-management education. However, for patients who were able to engage in such an intervention, the completion rate of PR was double the previous audit estimates from the United Kingdom, disease knowledge improved, and the intervention was of value to patients.

TRIAL REGISTRATION

ISRCTN Registry 13081008; https://www.isrctn.com/ISRCTN13081008.

Perceptions and experiences of older patients and healthcare professionals regarding shared decision-making in pulmonary rehabilitation: A qualitative study

OBJECTIVE

To understand the perceptions and experiences of older patients with chronic obstructive pulmonary disease (COPD) and healthcare professionals (HCPs) regarding shared decision-making in pulmonary rehabilitation (PR).

DESIGN

A qualitative study using single, semi-structured interviews, and thematic analysis.

SETTING

Face-to-face interviews were conducted in the Jiangnan University, in hospital and in patients' homes.

PARTICIPANTS

Twenty-two older patients with COPD and 29 HCPs.

METHODS

An initial codebook and semi-structured interview guide were developed based on the shared decision-making 3-circle conceptual model. Thematic analysis was used to analyze data.

RESULTS

The study identified 10 themes that describe the perceptions and experiences of patients and HCPs involved in PR decision-making: (1) patients' confidence, (2) patients' perceptions of the cost-benefit of decisions, (3) patients' perceived stress about the consequences of decision-making, (4) HCPs' perceived stress on shared decision-making, (5) cognitive biases of patients toward illness and rehabilitation, (6) shared decision-making as a knowledge gap, (7) the knowledge gap between patients and HCPs, (8) authority effect, (9) family support, (10) human resources. These themes were then divided into three groups according to their characteristics: (1) the feelings of the participants, (2) knowledge barriers, and (3) support from the social system.

CONCLUSION

Patients and HCPs described their negative perceptions and experiences of participating in decision-making in PR. The implementation of shared decision-making in PR is currently limited; therefore, health education for patients and families should be strengthened and a training system for HCPs in shared decision-making should be established.

Integrating Home-Based Exercise Training with a Hospital at Home Service for Patients Hospitalised with Acute Exacerbations of COPD: Developing the Model Using Accelerated Experience-Based Co-Design

BACKGROUND

Hospital at home (HaH) schemes allow early discharge of patients hospitalised with an acute exacerbation of chronic obstructive pulmonary disease (AECOPD). Traditional outpatient pulmonary rehabilitation (PR) following an AECOPD has an established evidence-base, but there are issues with low referral, uptake and completion. One commonly cited barrier to PR post-hospitalisation relates to poor accessibility. To address this, the aim of this project was to enrol service users (patients with COPD and informal carers) and healthcare professionals to co-design a model of care that integrates home-based exercise training within a HaH scheme for patients discharged from hospital following AECOPD.

METHODS

This accelerated experience-based co-design project included three audio-recorded stakeholder feedback events, using key "touchpoints" from previous qualitative interviews and a recent systematic review. Audio-recordings were inductively analysed using directed content analysis. An integrated model of care was then developed and finalised through two co-design groups, with the decision-making process facilitated by the tables of changes approach.

RESULTS

Seven patients with COPD, two informal carers and nine healthcare professionals (from an existing outpatient PR service and HaH scheme) participated in the stakeholder feedback events. Four key themes were identified: 1) individualisation, 2) progression and transition, 3) continuity between services, and 4) communication between stakeholders. Two patients with COPD, one informal carer and three healthcare professionals participated in the first joint co-design group, with five healthcare professionals attending a second co-design group. These achieved a consensus on the integrated model of care. The agreed model comprised face-to-face supervised, individually tailored home-based exercise training one to three times a week, delivered during HaH scheme visits where possible by a healthcare professional competent to provide both home-based exercise training and usual HaH care.

CONCLUSION

An integrated model of care has been co-designed by patients with COPD, informal carers and healthcare professionals to address low uptake and completion of PR following AECOPD. The co-designed model of care has now been integrated within a well-established HaH scheme.

The Effects of a Video Intervention on Posthospitalization Pulmonary Rehabilitation Uptake. A Randomized Controlled Trial

Rationale: Pulmonary rehabilitation (PR) after hospitalizations for exacerbations of chronic obstructive pulmonary disease (COPD) improves exercise capacity and health-related quality of life and reduces readmissions. However, posthospitalization PR uptake is low. To date, no trials of interventions to increase uptake have been conducted.Objectives: To study the effect of a codesigned education video as an adjunct to usual care on posthospitalization PR uptake.Methods: The present study was an assessor- and statistician-blinded randomized controlled trial with nested, qualitative interviews of participants in the intervention group. Participants hospitalized with COPD exacerbations were assigned 1:1 to receive either usual care (COPD discharge bundle including PR information leaflet) or usual care plus the codesigned education video delivered via a handheld tablet device at discharge. Randomization used minimization to balance age, sex, FEV₁ % predicted, frailty, transport availability, and previous PR experience.Measurements and Main Results: The primary outcome was PR uptake within 28 days of hospital discharge. A total of 200 patients were recruited, and 196 were randomized (51% female, median FEV_1% predicted, 36 [interquartile range, 27-48]). PR uptake was 41% and 34% in the usual care and intervention groups, respectively (P = 0.37), with no differences in secondary (PR referral and completion) or safety (readmissions and death) endpoints. A total of 6 of the 15 participants interviewed could not recall receiving the video.Conclusions: A codesigned education video delivered at hospital discharge did not improve posthospitalization PR uptake, referral, or completion.

"You Leave There Feeling Part of Something": A Qualitative Study of Hospitalized COPD Patients' Perceptions of Pulmonary Rehabilitation

Rationale

Current guidelines recommend that patients hospitalized for acute exacerbations of chronic obstructive pulmonary disease (COPD) initiate pulmonary rehabilitation (PR) shortly after discharge from the hospital. However, fewer than 2 percent of Medicare beneficiaries do so. Few studies have examined hospitalized patients’ perceptions of the barriers and facilitators to enroll in PR. The aim of this study was to develop an understanding of these factors by interviewing patients.

Methods

We conducted semi-structured interviews with patients during a hospitalization for COPD exacerbation in a large teaching hospital. Directed content analysis was used to code and analyze interview transcripts.

Results

Of the 15 patients we interviewed, 9 had participated in PR prior to their hospitalization, 10 were women; 4 were black, and 1 was Hispanic. Facilitators of enrollment included a desire to learn more about the disease, social support, and trust in the health-care provider recommending PR. Barriers to enrollment included lack of awareness, family obligations, lack of motivation, and transportation. For those who had previous experience with PR, but who did not complete the program, another barrier was not feeling well enough. Facilitators to adherence included the educational component of the program; feeling better through exercise; and a social connection with both participants and staff. For some patients. PR contributed to a renewed sense of hope or meaning. Most interviewees expressed interest in a peer coaching program.

Conclusion

Our results highlight the importance of increasing awareness of PR and building trust between the provider and patients to facilitate initial enrollment. Future interventions to improve enrollment and adherence should address the need for education about the benefits of PR and the value of social support.

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Improving acceptance and uptake of pulmonary rehabilitation after acute exacerbation of COPD: Acceptability, feasibility, and safety of a PR "taster" session delivered before hospital discharge

The objectives of this study were to (1) assess the acceptability, feasibility, and safety of delivering a pulmonary rehabilitation (PR) "taster" session to patients hospitalized with acute exacerbations of chronic obstructive pulmonary disease; (2) evaluate the changes in patient knowledge and readiness to commence PR; and (3) make recommendations for future intervention iterations. Acceptability was measured by the proportion of patients that accepted to participate. Feasibility was measured by the proportion of eligible participants. Knowledge was evaluated using the modified versions of the Understanding COPD (UCOPD) and Bristol COPD Knowledge (BCKQ) questionnaires. Readiness to commence PR was measured by a modified version of the Readiness to Change Exercise Questionnaire. All measures were delivered pre- and post-intervention. Thirty-one of 34 eligible individuals were able to be approached. Prospective acceptability was low, with 24 individuals declining the intervention, 1 being discharged without making a decision, and only 6 participating. Positive median change was recorded in the modified UCOPD questionnaire (+8), but not the BCKQ (0). Three of the patients were already in the action phase pre-intervention, with all but one in that phase post-intervention. The delivery of a PR "taster" session was not prospectively acceptable to a large portion of patients and only feasible with modifications to the original protocol.