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

Author Department

Healthcare Quality; Medicine; Cardiology; Pulmonary/Critical Care Medicine

Document Type

Article, Peer-reviewed

Publication Date



Rationale: Pulmonary rehabilitation (PR) after a hospitalization for COPD is recommended by guidelines, however few patients participate and rates vary between hospitals.

Objective: To identify contextual factors and strategies that may promote participation in PR following 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, ≥ 6.58%. To learn from hospitals that demonstrated a commitment to improving rates of PR, regardless of post-discharge PR rates, we identified innovative hospitals based on 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 9 hospitals (7 high-performers and 2 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 an admission for COPD in response to CMS/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 overcoming barriers.

Conclusions: Our findings suggest that successful efforts to increase participation in PR may be most effective when part of larger strategy to improve outcomes for patients with COPD. Further research is necessary to test the generalizability of our findings.