Strategies to Improve Enrollment and Participation in Pulmonary Rehabilitation Following a Hospitalization for COPD: RESULTS OF A NATIONAL SURVEY : Journal of Cardiopulmonary Rehabilitation and Prevention

Secondary Logo

Journal Logo

Pulmonary Rehabilitation

Strategies to Improve Enrollment and Participation in Pulmonary Rehabilitation Following a Hospitalization for COPD


Kotejoshyer, Rajashree ScD; Eve, Julianna PhD; Priya, Aruna MA, MSc; Mazor, Kathleen EdD; Spitzer, Kerry A. PhD, MPA; Pekow, Penelope S. PhD; Pack, Quinn R. MD, MSc; Lindenauer, Peter K. MD, MSc

Author Information
Journal of Cardiopulmonary Rehabilitation and Prevention 43(3):p 192-197, May 2023. | DOI: 10.1097/HCR.0000000000000735


  • This is the first study at the national level to describe strategies used to promote participation in pulmonary rehabilitation after a hospitalization for chronic obstructive pulmonary disease.
  • Opportunities to implement strategies to promote greater participation exist at the organization, provider, and patient level.
  • Future research is needed to rigorously test these strategies, individually and in combination.

Chronic obstructive pulmonary disease (COPD) affects more than 16 million individuals in the United States, and exacerbations result in approximately 1.5 million emergency department visits and >700 000 hospitalizations annually.1–3 Recovery from a COPD exacerbation is gradual and characterized by reduced functional status and quality of life, and elevated risk of rehospitalization and death.4–8 Among Medicare beneficiaries, the risk of readmission at 1 yr is >60%, and mortality approaches 26%.9

Pulmonary rehabilitation (PR) is a comprehensive program of exercise training and self-management support, typically offered over 8-12 wk. Pulmonary rehabilitation has been shown to improve exercise capacity, reduce dyspnea, and improve quality of life in both stable COPD and after an exacerbation.10–13 Rehabilitation is particularly beneficial when initiated following a hospitalization, an event that is associated with acute reduction in skeletal muscle function and a self-reinforcing cycle of dyspnea-related deconditioning—clinical features that are key targets of PR. Meta-analyses of randomized trials suggest that, when initiated after an exacerbation, PR lowers patient risk of readmission and may improve survival.14–16 On the basis of this evidence, the guidelines of the American Thoracic Society/European Respiratory Society, the American College of Chest Physicians, and the Global Initiative for Obstructive Lung Disease recommend that all patients begin PR after a COPD exacerbation.17–19

Although recommended by clinical guidelines, <2% of patients begin PR within 6 mo of hospitalization for COPD.20,21 Among the subset of patients who attend ≥1 session, less than half complete a full course of treatment. Barriers to higher rates of participation in PR have been reported at all levels of the health care system including the payor, program, provider, and patient.22–26 Common barriers to patients include lack of knowledge of PR, transportation and financial burden, and low levels of patient motivation.23,24,26 Given the poor uptake of PR in the United States, we sought to describe current practices related to promoting participation after a hospitalization for COPD. The goal was to identify practices at the organization, provider, and patient level that may offer the greatest opportunities to improve care.


The study was approved by the Institutional Review Board at Baystate Medical Center.

A 39-item survey was developed based on findings from interviews conducted using a positive deviance framework between July 2019 and June 2020 intended to generate hypotheses regarding the contextual factors and strategies that might help PR programs achieve high rates of participation after a COPD hospitalization.27 Seventeen high-performing hospitals were invited for qualitative key informant interviews of which nine participated, five declined, and three did not respond. Of the nine respondents, seven were “high-performing” PR programs, which were programs ranked in the top 5% of United States hospitals for PR enrollment after a hospitalization for COPD among Medicare beneficiaries in 2017. The two other respondents were “innovator” programs, which were selected by the authors based on review of their presentations at the American Association of Cardiovascular and Pulmonary Rehabilitation/American Thoracic Society in 2017-2019. Interviewees included medical directors of PR programs, pulmonologists, hospitalists, respiratory therapists, physical therapists, nurses, social workers, and navigators and represented programs, which varied in location (urban/rural), teaching status, and whether they were associated with a lung transplant program. Survey items (see Supplemental Digital Content 1, available at: focused on organization, provider, and patient-level strategies used to enroll patients in PR prior to the pandemic, and potentially relevant contextual factors. Response options included nominal (yes/no), multiple-choice, and short answer.

Using Medicare claims data, 1647 hospitals were identified that delivered PR services in 2018 and that had >10 annual COPD admissions. From these 1647, we utilized “PROC SURVEYSELECT” in SAS (SAS Institute, Inc) with the option of SRS (simple random sampling without replacement) to select 350 PR programs to invite to take part in our survey. Hospitals were contacted by phone in 2021 to verify that the PR program was active and to obtain the name and contact information of program leadership. A total of 27 programs reported closing since 2018, leaving a sample of 323 active programs (see Supplemental Digital Content 2, available at: Intended respondents included PR directors, managers, or other key PR staff. A pre-notification letter was mailed to each program contact announcing the study followed 10 d later by a paper copy of the survey, which was accompanied by a $25 gift card. Ten days after the initially mailing, a reminder postcard was sent containing a QR access code, which facilitated completion of the survey online. A second paper survey was sent to nonrespondents 14 d later, and then made up to four attempts to contact the remaining nonrespondents by telephone.


A descriptive analysis was performed to delineate hospital and PR program characteristics. Responses with text for “other” categories were coded and added to the main category when relevant. Free-text responses were coded qualitatively by two research staff, and consensus reached by the research team. Survey responses are reported with n (%) for the categorical variables, mean ± SD for continuous variables. Missing data were infrequent with ≤2% of certain responses being missing in the survey. Missing responses were included as their own category while computing the proportion of responses throughout the survey. All data were analyzed using SAS, version 9.4 (SAS Institute, Inc) and STATA 17 (StataCorp).


Of 323 programs surveyed, 209 (65%) responded. Approximately half (53%, n = 111) of the respondents described their current role as a manager/director of PR. With regard to professional background, approximately 43% (n = 90) of respondents were trained as respiratory therapists, 22% (n = 45) as nurses, and 19% (n = 40) as exercise physiologists. The median practice time was 8 yr (4, 20 yr). The median of observed PR rates among Medicare beneficiaries at the 209 programs was very low at 2.9% (1.5, 5.0%).


Characteristics of PR programs that responded to the survey are presented in Table 1. All programs served patients in the outpatient setting; 88% (n = 184) were located in the hospital or on the hospital campus, while the remaining 12% (n = 25) were located off-site. Approximately half (48%, n = 101) of all programs were affiliated with hospitals operating 100-399 beds, 39% (n = 81) were at teaching hospitals, and 39% (n = 82) were located in the Midwest. The survey respondents spanned 43 states across the United States with ≥10 programs each from Florida, Iowa, Michigan, Minnesota, and Pennsylvania. Most programs reported sharing space with cardiac rehabilitation (CR; 13%, n = 27) or another hospital service (83%, n = 173). Approximately 7% (n = 15) reported having fully dedicated staff, while the majority reported sharing their administrative and clinical staff with CR (25%, n = 53) and other hospital programs (69%, n = 144). Approximately 10% (n = 20) of programs were affiliated with hospitals performing lung transplantation.

Table 1 - Characteristics of the Hospitals/Outpatient Pulmonary Rehabilitation Programs (n = 209)
Pulmonary Rehabilitation Program Characteristics n %
Hospital size, beds
Small (1-99) 59 28.2
Medium (100-399) 101 48.3
Large (≥400) 49 23.4
PR program location
Urban 142 67.9
Rural 67 32.1
Hospital region
Northeast 41 19.6
South 65 31.1
Midwest 82 39.2
West 21 10.1
PR program affiliated with a teaching hospital 81 38.8
AACVPR-certified PR program 69 33.8
Patient enrollment into PR
Enrolled as a group (cohort) 19 9.1
Individual enrollment on a rolling basis 192 91.9
PR wait times from referral to first PR visit, wk
<2 73 35.1
2-4 94 45.2
5-8 24 11.5
>8 7 3.4
Unsure 10 4.8
PR program allowed active smokers
Yes, without conditions 16 7.7
Yes, with conditions (eg, committed to quitting, if allowed by insurance) 116 56.0
No, all PR participants must have quit smoking 72 34.8
Unsure 3 1.5
PR program had a champion 135 64.9
PR program affiliated with a specialized hospital for lung transplants 20 9.6
Abbreviations: AACVPR, American Association of Cardiovascular and Pulmonary Rehabilitation; PR, pulmonary rehabilitation.

The vast majority (92%, n = 192) of PR programs enrolled individual patients on a rolling basis as space became available. A majority (80%, n = 167) of programs reported a typical wait time of up to 4 wk between referral and the first PR visit. Approximately 65% (n = 135) of programs had a “PR champion,” which was defined as someone who actively supports PR, promotes the program to hospital physicians, administrators, and hospital staff, and helps overcome barriers to program improvement. These PR champions commonly included medical directors (50%, n = 68), respiratory therapists (46%, n = 62), pulmonologists (21%, n = 28), and nurses (14%, n = 19). Others serving as a PR champion included exercise physiologists, physical therapists, and PR coordinators. Approximately 56% (n = 116) of PR programs reported enrolling current smokers provided that certain conditions were met (eg, committed to quitting, or dependent on health insurance), 8% (n = 16) programs allowed entry of smokers without preconditions, and 35% (n = 72) of PR programs excluded current smokers from PR.


Strategies to increase patient referral at the organization level included active surveillance to identify patients with COPD, as well as direct outreach to patients at the bedside. In many instances increasing participation in PR was tied to broader quality improvement and readmission reduction strategies (Table 2).

Table 2 - Organization-Level Strategies
Reported Use of Strategies at Organization Level n %
Engagement in quality improvement projects to improve outcomes for COPD patients 117 56.0
Quality improvement focused on increasing PR enrollment after discharge 77 66.0
Presence of systematic processes to identify COPD patients for quality improvement or readmission reduction efforts 100 47.8
COPD patients admitted to specialized units such as respiratory units 41 19.6
Type of reminders used to promote evidence-based therapies to treat COPD
Computerized pop-ups/decision support/best practice alerts 35 16.8
Order sets/care sets 113 54.1
Chart review by quality assurance specialists during inpatient stay 63 30.1
Pharmacist reminders 12 5.7
Physician emails 6 2.9
Othera 16 7.7
Unsure 68 32.5
Presence of strategies aimed at reducing COPD readmissions 131 62.7
Abbreviations: COPD, chronic obstructive pulmonary disease; PR, pulmonary rehabilitation.
aOther strategies reported as reminders to evidence-based therapies for COPD in the hospitals were respiratory therapy consult, staff education on PR, and having navigators.

Nearly half (48%, n = 100) of programs reported having a systematic process to identify patients with COPD who might be eligible for PR, and 20% (n = 41) reported cohorting patients with COPD on a specialized respiratory unit. Approximately half (49%, n = 102) of programs had COPD-focused staff (eg, navigators, pulmonary nurses, or other nonphysician providers) meet with patients face-to-face while hospitalized to discuss PR, disease self-management, or transitional care planning.

More than half of programs (56%, n = 117) reported ongoing quality improvement projects to improve the outcomes for COPD patients, and of these 66% (n = 77) incorporated PR as a component of the overall strategy. Open-ended responses commonly reported on quality improvement strategies (n = 75) included use of order sets/automated referral, patient education, inpatient consultation, physician education, navigators, and screening for COPD.

Nearly two-thirds of programs (63%, n = 131) reported working with hospital staff to reduce COPD readmissions. Among these 131 responses, strategies included post-discharge phone calls/text messages (66%, n = 87); referral to PR (65%, n = 85); transitional care support from a case manager/navigator (57%, n = 75); post-discharge clinic (26%, n = 34); and support from a community health worker (11%, n = 14).

Of the PR programs surveyed, 85% (n = 177) reported use of ≥1 of these organizational level strategies, and 50% (n = 104) reported ≥3. About 15% (n = 32) had none of these strategies in place.


Strategies to promote referral at the provider level focused on increasing provider awareness and knowledge, decision support, and automation (Figure 1).

Figure 1.:
Percentage of respondents reporting use of provider-level strategies. (a) Includes responses such as staff “too busy” and sent therapy reports to primary care physician. (b) Includes responses such as autoreferral not supported; PR referral placed in work queue by a physician; and working on adding “opt out” for PR in electronic medical record. Abbreviation: PR, pulmonary rehabilitation.

Specific approaches included development and distribution of educational materials (45%, n = 94); conducting outreach visits to referring providers (43%, n = 89); recruiting PR champions (25%, n = 53); and audit/feedback of referral rates (14%, n = 30).

Strategies in this domain included the development of order sets for patients with COPD that included a referral to PR (45%, n = 93), electronic reminders (eg, best practice alerts) (18%, n = 38), and automated referrals (23%, n = 48).

Of the PR programs, 80% (n = 167) reported ≥1 provider-level strategy, and 37% (n = 77) reported ≥3. Approximately 20% (n = 42) of programs had not implemented any of these provider-level strategies.


Strategies to improve enrollment at the patient level fell into the following categories: increasing patient knowledge, increasing motivation, and overcoming transportation and financial barriers (Figure 2).

Figure 2.:
Percentage of respondents reporting use of patient-level strategies. (a) Includes responses such as lack of adequate staffing; PR ads on hospital Facebook page; radio spots; and navigator position removed prior to COVID. (b) Includes responses such as progressive incentives and staff encouragement, goal setting, follow-up calls, and T-shirts upon completion of program. (c) Includes responses such as gave patients numbers for transportation and patients use transportation companies services set up by their insurance. (d) Foundation funds available if the patient was willing for us to ask on their behalf; Catholic Health Charities; scholarship fund for a visit or two. Abbreviations: PR, pulmonary rehabilitation; SWAG, stuff we all get.

Specific strategies to improve patient knowledge included bedside education about PR (53%, n = 111); distribution of educational flyers (49%, n = 103); the use of other promotional media, such as mailings to patients or videos in hospital rooms (23%, n = 48); community outreach efforts, such as PR staff visits to senior centers (18%, n = 38); and tours of the PR facility to hospitalized COPD patients (8%, n = 17).

Strategies used to increase patient motivation included motivational interviewing by a health coach or a provider (33%, n = 69); promotional gifts such as travel mugs and t-shirts (18%, n = 37); and peer support or navigator programs (12%, n = 26).

Strategies to mitigate transportation barriers included providing free parking or parking vouchers (90%, n = 187); facilitated rides with nonprofits (35%, n = 73); vouchers for ride-sharing programs (13%, n = 28); direct transportation assistance (7%, n = 15); and offering telerehabilitation programs (4%, n = 8).

Strategies to address financial barriers included offering payment plans (67%, n = 139); financial counseling (64%, n = 134); and financial incentives tied to participation or completion (6%, n = 13).

Roughly three-quarters (78%, n = 163) of programs had ≥1 patient-level strategy in place, and 39% (n = 82) reported ≥3. Approximately one in five programs (22%, n = 46) had not implemented any of these patient-level strategies.

Based on the effectiveness of automatic referral and bedside recruitment (liaisons) in the setting of CR,28,29 we report on the combination of these strategies in PR. Thirty-eight (18%) of programs reported both automatic referral and bedside recruitment, while 42% (n = 88) had neither of these evidence-based strategies in place.


Despite strong evidence demonstrating the benefits of PR and guidelines recommending initiation of PR following a COPD exacerbation, few patients ever complete a single PR session.19–26 This survey of 209 PR programs from across the United States identified current strategies used to promote participation following a hospitalization for COPD. Although most programs have implemented some of the approaches that we hypothesized to be effective, our findings highlight ongoing opportunities to address barriers to referral and enrollment at the organizational, provider, and patient level.

The process of ensuring that a patient begins PR after a hospitalization for COPD is complex. A referral to PR is a prerequisite, yet many hospital-based physicians remain unfamiliar with the evidence regarding the benefits of PR, are uncertain about eligibility requirements, do not see referral to PR as their responsibility, or are preoccupied by other concerns encountered in the acute care setting.30 To overcome these barriers programs often distribute educational and promotional materials, conduct outreach to referring providers, and create order sets that include a referral to PR. Many programs also had a PR champion. To keep potentially eligible patients from slipping through the cracks, some programs reported conducting routine surveillance to identify COPD admissions, while others have developed automated systems for ensuring referral to PR. Use of order sets and automated referrals as a strategy to improve PR has been previously described by Milner et al,31 who recommended that these strategies be combined with provider education and training.

Even when a patient has been identified as potentially eligible for PR and a provider has placed an order for referral, there are numerous other barriers to enrollment and attendance.30 These include lack of knowledge of the benefits of PR, low self-efficacy, fear, and low levels of motivation. The most common approaches for addressing these barriers included educational flyers, bedside education, and motivational interviewing by navigators, and trained staff/health coaches. These methods are supported by Guo and Bruce,32 who found that adherence can be improved by strategies that increase confidence, promote tangible benefits of participation, and by recognizing and addressing issues such as readiness and fear. Studies in CR have shown that an automatic referral process combined with bedside recruitment can achieve enrollment rates of up to 70%.27,28,33 Given the high levels of participation achieved when those strategies have been combined in the CR context, it is especially notable that only 18% of PR programs reported having both of these strategies in place, and that 42% had neither. Rates of PR participation from our previous analysis with Medicare beneficiaries were much lower than has been reported in CR.20,34 It is possible that limited use of bedside liaison and automatic referrals in PR may explain some of these differences. However, dyspnea and the chronic progressive nature of COPD represent barriers to PR that are not routinely present among patients referred to CR after a myocardial infarction or coronary bypass surgery.

Among patients who accept referral and are initially motivated to attend, additional barriers to participation include the time involved, transportation, cost, the possibility of intercurrent illness, and the challenges of sustained behavior change. Strategies reported by programs to address these barriers included free parking and parking vouchers, financial counseling, and even financial incentives. A recent systematic review of strategies to increase referral and patient enrollment in PR found that patient education and use of financial incentives were associated with significant improvement.35 An interesting finding of our study was that <10% of programs allow smokers to attend PR unconditionally, while one-third never allow active smokers into PR. This appears to be a missed opportunity, as prior research has shown that PR is similarly effective in smokers and nonsmokers.36,37 Although it remains a source of controversy, some advocates have argued that smoking cessation counseling and treatment should be fully integrated into PR.38,39

This study has several strengths. First, it is the first national survey that we are aware of describing strategies used by PR programs to foster enrollment after hospitalization for COPD. Second, the survey was developed after conducting site visits to a diverse group of hospitals that achieved high rates of PR participation, suggesting that the strategies asked about in our survey may indeed represent best practices. Despite these strengths our study has a few limitations. First, although a high (65%) response rate was achieved, it is possible that participating programs were not fully representative of all PR programs in the United States. Along these lines, lung transplant centers, which typically have robust PR programs, were overrepresented. Second, program characteristics and strategies were self-reported, as it was not practical to collect or verify this information independently. Third, we were unable to examine the association between specific strategies and hospital rates of participation because rates of participation in PR were extremely low across most hospitals, precluding the stability and/or reliability of any results that might come from this form of analysis. As a result, it is not possible to know with any confidence from our data alone what specific strategies were associated with higher or lower rates of PR participation.


This study describes current practices used to promote participation in PR after a hospitalization for COPD in the United States highlighting opportunities to implement strategies targeting organization, provider, and patient-level barriers to enrollment. To achieve the full public health benefit of PR, policy makers should consider developing and funding initiatives to promote greater levels of participation after discharge.


The research was supported by the National Heart, Lung, and Blood Institute of the National Institutes of Health under Award Number R01HL133046. Dr Pack was supported by a grant from the National Heart, Lung, and Blood Institute of the National Institutes of Health (1K23HL135440). We would like to thank Kolbi Bradley for assisting with data collection efforts, and Kyle McAnally for assisting with formatting and proof-reading the manuscript.


1. Croft JB, Wheaton AG, Liu Y, et al. Urban-rural county and state differences in chronic obstructive pulmonary disease—United States, 2015. MMWR Morb Mortal Wkly Rep. 2018;67(7):205–211.
2. Ford ES. Hospital discharges, readmissions, and ED visits for COPD or bronchiectasis among US adults. Chest. 2015;147(4):989–998.
3. Centers for Disease Control and Prevention. FASTSTATS—Chronic Lower Respiratory Disease. Published May 3, 2017. Accessed June 1, 2018.
4. Seemungal TA, Donaldson GC, Paul EA, Bestall JC, Jeffries DJ, Wedzicha JA. Effect of exacerbation on quality of life in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 1998;157(5, pt 1):1418–1422.
5. Seemungal TA, Donaldson GC, Bhowmik A, Jeffries DJ, Wedzicha JA. Time course and recovery of exacerbations in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2000;161(5):1608–1613.
6. Spencer S, Jones PW; GLOBE Study Group. Time course of recovery of health status following an infective exacerbation of chronic bronchitis. Thorax. 2003;58(7):589–593.
7. Doll H, Miravitlles M. Health-related QOL in acute exacerbations of chronic bronchitis and chronic obstructive pulmonary disease: a review of the literature. Pharmacoeconomics. 2005;23(4):345–363.
8. Esteban C, Quintana JM, Moraza J, et al. Impact of hospitalisations for exacerbations of COPD on health related quality of life. Respir Med. 2009;103(8):1201–1208.
9. Lindenauer PK, Dharmarajan K, Qin L, Lin Z, Gershon AS, Krumholz HM. Risk trajectories of readmission and death in the first year following hospitalization for COPD. Am J Respir Crit Care Med. 2018;197(8):1009–1017.
10. Spruit MA, Singh SJ, Garvey C, et al. An official American Thoracic Society/European Respiratory Society statement: key concepts and advances in pulmonary rehabilitation. Am J Respir Crit Care Med. 2013;188(8):e13–e64.
11. Nici L, Donner C, Wouters E, et al. American Thoracic Society/European Respiratory Society statement on pulmonary rehabilitation. Am J Respir Crit Care Med. 2006;173(12):1390–1413.
12. Ries AL, Bauldoff GS, Carlin BW, et al. Pulmonary rehabilitation: joint ACCP/AACVPR evidence-based clinical practice guidelines. Chest. 2007;131(5 suppl):4S–42S.
13. Griffiths TL, Burr ML, Campbell IA, et al. Results at 1 year of outpatient multidisciplinary pulmonary rehabilitation: a randomised controlled trial. Lancet. 2000;355(9201):362–368.
14. Puhan MA, Gimeno-Santos E, Cates CJ, Troosters T. Pulmonary rehabilitation following exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2016;12(12):CD005305.
15. Ryrsø CK, Godtfredsen NS, Kofod LM, et al. Lower mortality after early supervised pulmonary rehabilitation following COPD-exacerbations: a systematic review and meta-analysis. BMC Pulm Med. 2018;18(1):154.
16. Wageck B, Cox NS, Lee JY, Romero L, Holland AE. Characteristics of pulmonary rehabilitation programs following an exacerbation of chronic obstructive pulmonary disease: a systematic review. J Cardiopulm Rehab Prev. 2021;41(2):78–87.
17. Criner GJ, Bourbeau J, Diekemper RL, et al. Prevention of acute exacerbations of COPD: American College of Chest Physicians and Canadian Thoracic Society guideline. Chest. 2015;147(4):894–942.
18. Wedzicha JA, Miravitlles M, Hurst JR, et al. Management of COPD exacerbations: a European Respiratory Society/American Thoracic Society guideline. Eur Respir J. 2017;49(3):1600791.
19. Global Initiative for Chronic Obstructive Lung Disease (GOLD). NHLBI/WHI Global Strategy for the Diagnosis, Management and Prevention of COPD.
20. Spitzer KA, Stefan MS, Priya A, et al. Participation in pulmonary rehabilitation after hospitalization for chronic obstructive pulmonary disease among Medicare beneficiaries. Ann Am Thorac Soc. 2019;16(1):99–106.
21. Vercammen-Grandjean C, Schopfer DW, Zhang N, Whooley MA. Participation in pulmonary rehabilitation by Veterans Health Administration and Medicare beneficiaries after hospitalization for chronic obstructive pulmonary disease. J Cardiopulm Rehabil Prev. 2018;36(8):406–410.
22. Cox NS, Oliveira CC, Lahham A, Holland AE. Pulmonary rehabilitation referral and participation are commonly influenced by environment, knowledge, and beliefs about consequences: a systematic review using the Theoretical Domains Framework. J Physiother. 2017;63(2):84–93.
23. Sami R, Salehi K, Hashemi M, Atashi V. Exploring the barriers to pulmonary rehabilitation for patients with chronic obstructive pulmonary disease: a qualitative study. BMC Health Serv Res. 2021;21(1):828.
24. Oates GR, Niranjan SJ, Ott C, et al. Adherence to pulmonary rehabilitation in COPD: a qualitative exploration of patient perspectives on barriers and facilitators. J Cardiopulm Rehabil Prev. 2019;39(5):344–349.
25. Watson JS, Adab P, Jordan RE, Enocson A, Greenfield S. Referral of patients with chronic obstructive pulmonary disease to pulmonary rehabilitation: a qualitative study of barriers and enablers for primary healthcare practitioners. Br J Gen Pract. 2020;70(693):e274–e284.
26. Keating A, Lee A, Holland AE. What prevents people with chronic obstructive pulmonary disease from attending pulmonary rehabilitation? A systematic review. Chron Respir Dis. 2011;8(2):89–99.
27. Bradley EH, Curry LA, Ramanadhan S, Rowe L, Nembhard IM, Krumholz HM. Research in action: using positive deviance to improve quality of health care. Implement Sci. 2009;4:25.
28. Grace SL, Russell KL, Reid RD, et al. Effect of cardiac rehabilitation referral strategies on utilization rates: a prospective, controlled study. Arch Intern Med. 2011;171(3):235–241.
29. Grace SL, Angevaare KL, Reid RD, et al. Effectiveness of inpatient and outpatient strategies in increasing referral and utilization of cardiac rehabilitation: a prospective, multi-site study. Implement Sci. 2012;7:120.
30. Lahham A, Holland AE. The need for expanding pulmonary rehabilitation services. Life (Basel). 2021;11(11):1236.
31. Milner SC, Boruff JT, Beaurepaire C, Ahmed S, Janaudis-Ferreira T. Rate of, and barriers and enablers to, pulmonary rehabilitation referral in COPD: a systematic scoping review. Respir Med. 2018;137:103–114.
32. Guo SE, Bruce A. Improving understanding of and adherence to pulmonary rehabilitation in patients with COPD: a qualitative inquiry of patient and health professional perspectives. PLoS One. 2014;9(10):e110835.
33. Wall HK, Stolp H, Wright JS, et al. The Million Hearts Initiative. Catalyzing utilization of cardiac rehabilitation and accelerating implementation of new care models. J Cardiopulm Rehabil Prev. 2020;40(5):290–293.
34. Pack QR, Squires RW, Lopez-Jimenez F, et al. Participation rates, process monitoring, and quality improvement among United States cardiac rehabilitation programs: a national survey. J Cardiopulm Rehabil Prev. 2015;35(3):173–180.
35. Early F, Wellwood I, Kuhn I, Deaton C, Fuld J. Interventions to increase referral and uptake to pulmonary rehabilitation in people with COPD: a systematic review. Int J Chron Obstruct Pulmon Dis. 2018;13:3571–3586.
36. Sahin H, Naz I. The effect of pulmonary rehabilitation on smoking and health outcomes in COPD patients. Clin Respir J. 2021;15(8):855–862.
37. Singh SJ, Vora VA, Morgan MDL. Does pulmonary rehabilitation benefit current and nonsmokers? Am J Respir Crit Care Med. 1999;159:A764
38. Hayton C, Clark A, Olive S, et al. Barriers to pulmonary rehabilitation: characteristics that predict patient attendance and adherence. Respir Med. 2013;107(3):401–407.
39. Lacasse Y, Maltais F, Goldstein RS. Smoking cessation in pulmonary rehabilitation: goal or prerequisite? J Cardiopulm Rehabil. 2002;22(3):148–153.

COPD hospitalization; enrollment; implementation; pulmonary rehabilitation; referral; strategies

Supplemental Digital Content

© 2022 The Authors. Published by Wolters Kluwer Health, Inc.