Co-design and evaluation of an intervention to increase UPTake of pUlmonary RehabilitatioN for people living with chronic obstructive pulmonary disease: the UPTURN study.

Background Pulmonary rehabilitation (PR), a programme of exercise and education, is transformative for people with Chronic Obstructive Pulmonary Disease (COPD). PR reduces hospital admissions, improves breathlessness and quality of life. In England 31% of COPD patients referred do not attend the PR assessment particularly among deprived and ethnic minority communities. We conducted research to understand individual patient barriers to attendance at PR assessment and determined five patient requirements for an intervention. The NHS long term plan includes funding for transformative increases in PR referrals and capacity providing a receptive national context for such an intervention. Aims Develop and evaluate an intervention to overcome individual barriers in order to increase attendance at PR assessment. Implement a cross-cutting workstream to ensure meaningful involvement of deprived and ethnic minority communities so that the intervention works for all. Develop an implementation strategy for NHS adoption if proven appropriate for scaling. Objectives Co-design and feasibility test the intervention to provide personalised telephone support and printed information that can be culturally and locally tailored. It will identify and address patients particular barriers to attending PR assessment, for example informing them about the PR class, addressing uncertainty about the benefits or their capability to exercise. Determine through an individual randomised controlled trial (RCT) whether the intervention leads to increased attendance at PR assessment compared to usual care with a parallel process evaluation. Develop a sustainable delivery framework. Methods An Equality, Diversity and Inclusion plan will inform intervention development through engagement and sampling from communities of high deprivation and minority ethnicity. Work Package 1: Iterative co-design process to develop the intervention following the Engineering Better Care design framework. Use the Behaviour Change Wheel framework to identify modifiable influences that lead to attendance at PR assessment. Test feasibility of the intervention and trial delivery in three PR providers. Work Package 2: RCT recruiting 1,580 patients from 20 PR providers. Individually randomise patients to receive the intervention or usual care. Main outcome will be attendance at PR assessment. Secondary outcomes will be PR completion, health related quality of life and exercise capacity. Process evaluation to investigate implementation in each trial arm to explain trial findings and provide recommendations for wide-scale implementation. Evaluate intervention cost-effectiveness compared to usual care from NHS and personal social services perspectives. Work Package 3: Disseminate findings and develop a roll-out plan to include long term monitoring to assess whether study outcomes are replicated in practice. Timelines for delivery Outputs and deliverables will be rapidly deployable in the NHS with minimum training as the infrastructure for delivery will have been established. Anticipated Impact and Dissemination Our study aims for a target 8% increase in the number of patients attending PR assessment which is intended to yield a 5% improvement in PR completion. If translated to the 65,000 planned annual referrals within NHS England that would prevent 614 hospitalisations and save over £800,000 each year once intervention costs are accounted for.