Dear Sirs,

We read with great interest the paper by Zakrisson et al1 in the December 2011 issue of the PCRJ. We thank and congratulate the authors for their interesting work.

Of particular interest to us is the issue of patients not attending a pulmonary rehabilitation (PR) programme and the reasons behind this. NICE guidelines for COPD2 recommend pulmonary rehabilitation for all patients who are functionally disabled due to their disease. In Zackrisson's study, out of 83 patients allocated to the PR intervention group, 56.6% completed the full programme, 2.4% dropped out before the end, and 41% declined to participate altogether.1 The reasons for not attending at all or leaving the programme before its completion were; patients leaving town (5.6%); their condition being bad (2.2%); they would not participate in groups (8.3%); and the time of the sessions being unsuitable (2.8%). The biggest group was where the reason was described as “other”. Full details of the reasons in this group were not specified.

In the semirural county of Somerset, UK, PR is provided in community-based centres. Patients are referred from primary as well as secondary care, and the PR programme runs for a period of six weeks. Attendance in this programme was poor, but the reasons for this had not previously been investigated. We therefore carried out a retrospective postal survey to investigate the extent of, and the reasons for, non-attendance at the PR programme, with the aim of making recommendations to improve future attendance. Our results are notably different to those obtained by Zakrisson et al.

We sent out questionnaires to 88 patients who had previously been invited to the PR programme. Out of the 48 responded, the response rate was 54.5%. Only 13% had completed the full PR programme, 34% dropped out before the end, and 53% did not participate at all.

21% of responders indicated that they had not received notification of the appointment. Amongst those who did receive the appointment, the top three reasons for not attending either in part or altogether were health-related reasons (37.5%), personal and social reasons (34.3%), and because patients did not think that PR would help them (31.2%). Other reasons were: inconvenient location (15.6%); lack of transport (9.3%); lack of enough information (3.1%); and not enough notice (3.1%). Only a minority of patients (21.8%) who failed to attend either part or the whole of the programme were sent a second appointment. The rest (88%) of this group indicated that they would not have attended even if they had been sent another appointment. Of those who indicated that they did not attend because the venue was inconvenient, 63.3% said they would not have attended even if they were offered a venue nearer to their home.

Although it might be difficult to influence patients' personal, health-and social-related issues in this context, telephone confirmation of the appointment beforehand, with explanation of the benefits of PR, the offer of transport, sufficient advance notice and a convenient venue, may help to improve attendance at the PR programme. Although these results were obtained from a specific geographical area, these general reasons for non-attendance at a PR programme are likely to be similar elsewhere. Not attending a PR programme deprives patients of the benefits of this extremely effective modality in the management of their COPD.