Respiratory rehabilitation is currently defined by the American Thoracic Society/European Respiratory Society (ATS/ERS) as “a comprehensive intervention based on a thorough patient assessment followed by patient-tailored therapies that include, but are not limited to, exercise training, education, and behavior change, designed to improve the physical and psychological condition of people with chronic respiratory disease and to promote the long-term adherence to health-enhancing behaviors”.1 Although the benefits of respiratory rehabilitation programs in patients with chronic obstructive pulmonary disease (COPD) on dyspnea, health-related quality of life and exercise capacity have been widely established,2 patients must be carefully selected if the best results are to be obtained.3 However, despite appropriate patient selection and a multidisciplinary approach to treatment, adherence to rehabilitation programs varies widely, with reports in the literature of substantial drop-out rates and poor attendance (between 10% and 32%)4; these circumstances have been linked with poor clinical outcomes. Several reasons for dropping out of rehabilitation programs have been identified, some of the most important being ongoing comorbidities, transport problems, no perception of improvement, lack of family support, depression, smoking, etc.4–8 Evidence suggests that even the attitude of the doctor when explaining the need to join programs could improve adherence.9 However, the variables that might predict poorer compliance with respiratory rehabilitation programs have not been fully defined, and even the definition of adherence differs between studies, with some authors including patients who refuse to participate after being offered a program among non-adherents.8 In the papers cited, less information is provided on functional characteristics, including maximal and submaximal exercise tests, and certain clinical features, such as use of concomitant medication or specific respiratory therapies. The objectives of our study were to identify the main causes of drop-out from a specific COPD respiratory rehabilitation program, along with the characteristics of patients with poor adherence, focusing particularly on specific clinical and functional aspects.

A total of 83 patients were evaluated, of which 26 were excluded: 13 (15.7%) refused to participate in the program, and the other 13 failed to meet inclusion criteria. Of those who did not meet the inclusion criteria, the causes recorded were: unstable angina (1 patient), mental disease (2 patients), severe musculoskeletal disease (2 patients), few symptoms (3 patient), did not attend evaluations (5 patients). Finally, 57 patients were included, of whom 35 completed the program and 22 dropped out (Fig. 1).

Fig. 1.

STROBE flow chart of study participants.

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Reasons for Drop-Out

The drop-out rate from our program was 38.5%. The main causes recorded were lack of motivation (8 patients), transport problems due to distance from the hospital/travel time (4 patients), severe concomitant disease (3 patients), death (3 patients), severe orthopedic disease preventing continuation (2 patients), and frequent exacerbations (2 patients) (Fig. 2).

Fig. 2.

Reasons for drop-out from the respiratory rehabilitation program.

Values expressed as percentage of a total of 22 patients.

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Our study, aimed at characterizing non-adherent patients in a respiratory rehabilitation program, found that drop-outs presented more exacerbations, greater forced vital capacity (probably indicating increased air trapping), and worse results on exercise tests; generally, then, patients with a more severe profile.

Respiratory rehabilitation is an evidence-based treatment with clear benefits that should be offered to all COPD patients, irrespective of their severity grade. However, we are aware that the success of rehabilitation programs is largely dependent on the correct selection of patients, but the patients evaluated often do not meet the eligibility criteria or refuse to participate. In our study, almost 16% of patients refused to participate in the program, and the drop-out rate was high (38.5%), but close to that described in the literature.5,8 In a similar study to ours,8 around 40% of patients did not complete the program, although the definition of non-adherence included patients who refused to participate (the majority), as well as those who dropped out after starting. Although this latter group was much smaller than ours (6 patients), the short program duration (4 weeks) may have had an impact, particularly if we take into account that in our study, attendance for at least 8 weeks was required.

The reasons for dropping out of the program varied, although lack of motivation and transport problems or distance from the site were the most common,4,8,18 even though an ambulance service was provided to facilitate transport to the hospital.

With respect to the demographic and clinical characteristics, most studies4,7,8,19,20 have reported active smoking as a determinant factor for poor adherence. In our case, although non-adherents smoked more, the difference was not significant, and was probably associated with the sample size. Another consideration, also described in the literature, is that attending a rehabilitation program may indicate a greater inclination to stop smoking.20

A trend toward a higher dyspnea grade among non-adherents was also observed, which might explain the loss of motivation if the patient feels more poorly or more limited in their exercise capacity. Hogg et al.6 reported similar findings in a study in which patients with higher MRC dyspnea grade had significantly poorer adherence. Moreover, FVC, which might cause greater air trapping resulting in dynamic hyperinflation and limited exercise capacity, was significantly worse in patients who dropped out of the program. This may also be associated with the presence of a larger proportion of patients on NIMV in the adherent group, since some evidence suggests that NIMV in stable COPD patients improves pulmonary hyperinflation and may allow the patient to achieve more intense exercise levels, suggesting that this intervention is beneficial not only during sleep, but also as an aid to rehabilitation.1,21 It should be pointed out that the criterion for indicating NIMV was the same in all cases (according to the consensus recommendations), and that it was indicated after hospital admission for hypercapnic encephalopathy. Moreover, none of the patients had concomitant neuromuscular disease or rib cage abnormalities.

In general, patients who drop out of the program appear to be those with greater functional decline (worse results on exercise tests) and use of oral corticosteroids. Few studies have evaluated so many functional parameters, particularly cardiopulmonary exercise tests, so closely. Fisher et al.,22 in a 12-weeek study evaluating cardiopulmonary exercise tests, failed to identify any demographic, clinical or psychological factors that could predict drop-out. Similar results were reported by other groups.4,8,23 Hayton et al.,24 however, support our results; these authors suggested, on the basis of a shuttle walking test, that patients who drop out of rehabilitation programs may have poorer exercise tolerance.

With regard to medication, one study8 did not find any association with the occasional use of cycles of oral corticosteroids. In our experience, the use of oral corticosteroids might reflect the fact that non-adherents were patients with more severe and advanced disease, and with higher exacerbation rates (more than double that of the other group), with the subsequent negative effect on program adherence. The side effects of steroids, such as osteoporosis and myopathies, would also have a negative impact on the physical activity of these patients.

Like other authors, such as Young et al.8 or Fan et al.,25 we found no relationship between quality of life, anxiety and depression, and lack of adherence. However, our results conflict with those of other studies which reported that lack of adherence was associated with depression,4,5 psychological profile,26 or worse scores on the St. George's questionnaire.5 In this respect, it should be pointed out that one of the benefits of rehabilitation is improved levels of anxiety and depression, common comorbidities among COPD patients.27

One of the limitations of our study is the sample size, which may have prevented factors with a trend toward significance from becoming statistically significant or unsuspected differences from emerging. The mean age of the patients is rather high, and most have severe or very severe COPD, so this population could be more inflexible in terms of behavior and beliefs, and find it more difficult to adopt lifestyle changes and modification of habits. Additionally, the fact that most patients are men may limit the generalization of results, but while the latest studies in COPD are already showing increased proportions of women, perhaps these changes are not yet so obvious in populations of older patients seen in our clinics. However, this is a study performed under standard clinical practice conditions (elderly patients with advanced disease), and clearly reflects the population that might be encountered in a respiratory rehabilitation clinic. It may be of great importance to remind all healthcare professionals that respiratory rehabilitation has proven benefits, and that it should be implemented when the disease is in its early stages, particularly if we understand that a poorer functional status may be associated with poorer adherence rates.

In conclusion, low adherence to rehabilitation programs appears to be associated not only with motivation or distance from the hospital, but also with a specific patient profile. This group, who we found to present the most severe disease (worse functional tests, chronic users of oral corticosteroids, higher rates of exacerbations and smoking), needs special attention and a more individualized approach. It would also be of interest to implement strategies to help motivate not only patients who join the program but also those who are unwilling to even start. Larger studies are needed to identify predictive factors for low adherence and to introduce effective strategies to promote compliance.

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  Planning and preparation of the research project: Teodoro Montemayor Rubio.

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  Design and data collection: Virginia Almadana Pacheco, Ana Gómez-Bastero Fernández, Ana Mirian Muñiz Rodríguez, Rodrigo Tallón Moreno.

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  Analysis and presentation of results: Virginia Almadana Pacheco, María Pavón Masa.

The authors state that they have no conflict of interest.