Table 1.

Study characteristics

Study and setting	Sample size	Demographicsa	Source of participants	Study design	Intervention	Comparator group	Outcome measures	Findings relevant to this review
<a>Studies measuring referral
Angus et al;24 primary care, urban, semirural, and rural, UK	16 General practices; 18 practice nurses; 293 patients	Age: mean 69.7 (SD 10.1) Male: 55.6%	COPD registers	Descriptive observational study	Computer-guided review, based on NICE guidance, by practice nurses during routine COPD review	None	Change to primary diagnosis. Percentage of patients recommended for inhaler prescription, smoking cessation support, oxygen assessment, PR referral	24% (47/191) of patients with confirmed COPD diagnosis were referred to PR
Deprez et al;36 primary care, rural, USA	18 General practices (>25 primary care physicians and mid-level providers); 1,210 patient records	Not reported	Samples of records from each participating practice	Before and after audit of patient charts	1) Team-based model. Three collaborative learning sessions to educate and empower clinical staff with ideas to implement and sustain practice changes 2) On-site visits, email, and telephone support from faculty 3) Change tools: COPD flow sheet, COPD registry, patient self-management worksheet 4) Feedback from patient focus groups	None	Percentage of patients with documented spirometry results, COPD stage, annual influenza vaccine, pneumonia vaccine, diet, exercise counseling, PR referral. Percentage of visits with documented smoking status, self-management goals, respirator education, smoking cessation counseling (smokers only)	5% Increase in PR referral (7%–12%, 16 practices) (P=0.048)*
Hopkinson et al;27 respiratory ward, acute hospital, London, UK	1 Respiratory ward; 94 patients	Age: mean 74.6 (11.2) Male: 64%	Patients on ward from October 2009 to September 2010	Before and after study of process indicators	1) Ward-based staff education 2) Discharge care bundle with referral for PR assessment 3) Patient offered phone call 48–72 hours postdischarge to check if they were improving, if not then community input expedited 4) PDSA cycles to refine the process 5) Prize draw for staff completing checklist 6) Ward staff attended hospital PR sessions 7) PR patient information leaflet	Usual care (historical)	Compliance with smoking cessation advice. PR referral. Self-management plan administered. Inhaler technique reviewed. Follow-up arrangements documented	54.4% Increase in PR referral (13.6%–68%)
Hull et al;28 primary care trust, inner London, UK	36 General practices	Not reported	COPD management data routinely collected from participant practices	Longitudinal audit, borough- wide quality improvement project	1) Eight networks of 4–5 general practices 2) Financially incentivized KPIs 3) Care package based on NICE guidance 4) IT infrastructure to monitor networks and KPIs 5) Support from community respiratory team 6) Network boards to review practice performance against targets, supported by clinical leads 7) Quarterly community COPD multidisciplinary team meeting 8) Rapid email/phone advice from respiratory consultant	COPD management data from two neighboring PCTs. UK-wide QOF for national performance comparison	Number of COPD cases on network registers. Completed care plans. Referral to community-based PR. Flu immunization. Smoking prevalence. Stop smoking attempts. Rates of emergency hospital admission for COPD	25% Increase in PR referral (45%–70%, between 2010 and 2013). No comparative data reported
Lange et al;30 primary care, Denmark	186 GPs; 4,943 patients	1st audit: Age: mean 70.7 (8.7) Male: 44.2% Current smoker: 42.3% FEV1 %: 56.4 (23.3)	20 Consecutive patients visiting each GP over two 4-month periods 1 year apart	Before and after audit of GP patient notes	Educational program: individual meeting with consultant from sponsoring company focused on GOLD guidelines; regional meetings with 30 GPs and staff, pulmonary specialist, and GP from steering committee to discuss the guidelines; symposium for all GPs and staff, plenary sessions, workshops, practical issues	None	Proportion of patients having spirometry testing (primary parameter). Secondary parameters: compliance with inhaler technique, smoking cessation advice (current smokers), referral to COPD rehabilitation, physical exercise advice, dietary instruction, influenza vaccination, inhaled corticosteroids in mild and severe COPD	3.5% Increase in referral for COPD rehabilitation (16.7%–20.2%) (P<0.01)*
Lange et al;31 outpatient clinics, Denmark	1,868 Patients; 22 hospitals with outpatient departments	1st audit: Age: mean 69.2 (10.7) Male: 45% Current smoker: 29.2% FEV1 %: 43.6 (17.7)	30–50 Consecutive patients from each department over two 3-month periods 1 year apart	Before and after audit of hospital records	1) Educational program: regional meeting; local meeting at department level with workshops on evidence-based diagnosis and treatment of COPD, rationale for COPD assessment, documentation tools 2) A nurse from each department completed an advanced diploma course on COPD	None	Care quality indicators recorded: height, weight, BMI, smoking status, pack-years, FEV1 % predicted, FVC % predicted, pulse oximetry, smoking cessation advice (current smokers), PR referral, nutritional advice if relevant, inhaler technique checked	6.4% Increase in PR referral (56.3%–62.7%) (P=0.006). Not significant in weighted analysis due to considerable variation between hospitals, 95% CI (-2%; 22%)
Roberts et al;29 primary care, North East London, UK	20 General practices (10 intervention, 10 control); 1,235 patients (640 intervention, 595 control)	Not reported	Patients on practice lists with COPD diagnosis	Quasi- experimental, pragmatic nonrandomized controlled study	1) Patient-held scorecard containing six care quality indicators comparing patient’s care to the standard. Sent to patient with letter advising patient to discuss scorecard at the next COPD review 2) Telephone helpline for patients	Usual care	Compliance with care quality indicators: diagnosis confirmed by postbronchodilator spirometry, annual review performed, self-management plan received, PR referral for patients with MRC score ≥3, patients quit smoking	7.4% Increase in PR referral for intervention group (1.2%–8.6%) compared to 1.3% increase for control group (0.9%–2.2%). Difference between groups of 6.1% (P=0.03)*
Tøttenborg et al;32 hospital outpatients, Denmark	56 Hospitals; 32,018 patients	Reported by year (2008–2011); 2008 outpatients: Age: median 70.1 Male: 45% Current smoker: 32.6% FEV1%: median 41	All patients aged ≥30 seen at hospital outpatient clinic from January 2008 to December 2011	Before and after audit. Nationwide, population- based quality improvement initiative	Continuous mandatory monitoring of quality of hospital-based COPD care via Danish Clinical Register of COPD. Focus on six care quality indicators. Patient data prospectively registered as part of clinical routine	None	Fulfillment of care quality indicators for each year: lung function (FEV1 % predicted), BMI, MRC dyspnea score, smoking status, smoking cessation (current smokers), PR offer where MRC score ≥3	36% Increase in PR referral (55%–91%) (RR 2.78, 95% CI, 2.65; 2.90)*
Ulrik et al;33 primary care, Denmark	124 GPs; 3,058 patients	1st audit: Age: mean 68 (range 35–95) Male: 44%	20 Consecutive patients visiting each GP during two 4-month periods 1 year apart	Before and after audit surveys	Educational program for GPs and staff: individual meeting with consultant from sponsoring company focused on GOLD guidelines; meetings with GPs and staff with steering committee, pulmonologist, and a GP to discuss GOLD guidelines; regional symposiums for GPs and staff; individual meeting with consultant from a sponsoring company focusing on GP’s data	None	Proportion of patients with spirometric data (primary parameter). Secondary parameters: BMI, dietary instruction given, instruction for inhaler technique, smoking cessation advice, monitoring of MRC dyspnea score, referral to COPD rehabilitation	4% Increase in referral to COPD rehabilitation (12% vs 16%) (NS)
<a>Studies measuring referral and uptake
Foster et al;25 primary care, Stoke on Trent, UK	8 Primary care practices; 126 patients	Current smoker: 34.9%	Patients on COPD registers eligible for PR	Before and after audit of practice data. Survey of practitioners and patients	Participatory action research: clinician questionnaire to assess knowledge and attitudes about PR and ideas for increasing referrals; briefing note based on questionnaire feedback and literature review with suggestions for standardizing PR knowledge and increasing referral (in- house education, practice protocols, “pop-ups,” and memory aids to prompt discussion about PR)	None	Audit data: COPD register size, number of patients eligible for PR, number of eligible patients coded for conversation about PR, outcome of conversation about PR (referred, referral declined, completed, not completed). Cross-sectional survey of patients eligible for PR: PR referral accepted, reasons for declining referral, whether a conversation about PR had taken place	Patients with PR code and PR referral ranged from 27% to 100% across 6/8 practices; proportion coded as attending PR ranged from 0% to 25% (data collected at one time point only). 25.7% (126/490) of patients returned the survey: 66% (84/126) had discussed PR with a clinician, of which 70.2% (59/84) had accepted PR referral
<a>Studies measuring uptake
Graves et al;26 setting unclear, North Bristol, UK	600 Patients (400 inter- vention, 200 noninter- vention)	Intervention group who opted in (n=235):	Patients invited to PR program	Observational study	GOIS (1.5 hours) prior to assessment for PR; run by physiotherapist and clinical psychologist; discussion of patient case study, self- management, PR information, alternatives to PR		Rates of attendance at GOIS. Attendance at PR assessment. Starting PR. PR drop out. PR graduation	16.3% Fewer patients in the intervention group attended pre-course assessment compared to usual care (58.7% vs 75%) (P<0.001)*
Harris et al;34 secondary and outpatient, Adelaide, Australia	3 Respiratory outpatient clinics; 249 patients (125 intervention, 124 control)	Intervention group: Age: mean 73.6 Male: 55% Current smoker: 18%	Patients with moderate to severe COPD identified through inpatient admission for COPD and at respiratory outpatient clinics	Controlled before and after	Patient manual summarizing Cochrane evidence on COPD treatments, related topics, and suggested questions to ask the doctor	Usual care including single sheet information pamphlet about COPD	Main outcomes: PR enrollment, rates of influenza vaccination, bone density testing. Secondary outcomes: COPD mastery, COPD knowledge, communication with usual doctor, satisfaction with disease-related information, anxiety	18% Increase in PR enrollment for the most socioeconomically disadvantaged patients in the intervention group compared to 0% in the control group (P=0.05)*. 12% Increase for the least socioeconomically disadvantaged patients in the intervention group compared to 7% in the control group (NS)
Jones et al;37 no restriction on setting	0	N/a	N/a	Systematic review	Review of RCTs of interventions to improve patient uptake and/or completion of PR in COPD	Any concurrent control group referred to and/or enrolled on to PR but not receiving an intervention aimed to improve uptake and/or completion	Uptake of PR: received baseline assessment and/or enrolled on to PR. Completion of PR: received discharge assessment; total number of sessions attended	No studies of uptake identified
Zwar et al;35 community, Sydney, Australia	44 General practices; 56 GPs; 451 patients (234 intervention, 217 control)	Intervention group: Age: mean 65.8 (10.3) Male: 47% Current smoker: 31.6%	Patients in participant practices with COPD diagnosis	Cluster RCT	Individualized care plan based on clinical practice guidelines delivered by nurses in patient’s home over 6 months. Partnership model of working between nurses and GPs	GPs provided with a copy of COPD guidelines. Patients received usual care	Primary outcome: health- related quality of life. Secondary outcomes: overall quality of life, lung function, smoking status, immunization status, attendance at PR, patient knowledge of COPD	21.5% Difference in the number attending PR in the intervention group compared to the control group (31.1% vs 9.6%) (OR 5.16 (2.40–11.10)) (P=0.002)*

Notes:

^aStudies varied in their reporting of patient characteristics. Here, we present age, sex, smoking status, and lung function where reported. Some studies also reported other patient characteristics.

^*Statistically significant at P<0.05.

Abbreviations: BMI, body mass index; FEV, forced expiratory volume; GOIS, group opt-in session; GP, general practitioner; IT, information technology; KPI, key performance indicator; MRC score, score on Medical Research Council Dyspnea Scale; NICE, National Institute for Clinical Excellence (UK); NS, not significant; PCT, primary care trust; PDSA, plan, do study, act; PR, pulmonary rehabilitation; QOF, Quality and Outcomes Framework; RCT, randomized controlled trial.