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Effects of community-based pulmonary rehabilitation in 33 municipalities in Denmark – results from the KOALA project

Nina Godtfredsen, Tina Brandt Sørensen, Marie Lavesen, et al.

Intl J Chron Obstruct Pulmon Dis 2019;14:93–100.


In patients with moderate-to-very severe COPD, the beneficial effects of hospital-based PR on exercise capacity, perception of dyspnoea and quality of life is well documented. However, the evidence is limited for patients with less advanced disease, even more so when the effects of intervention are in a home-based or community-based setting.

Since 2006, it has been recommended in Denmark that all COPD patients with a dyspnoea grade of 3 or above (according to the MRC scale) be offered PR: mild-to-moderate in a primary care setting and severe-to-very severe in hospital-based outpatient clinics. These rehabilitation programmes have been in place in all 98 municipalities in Denmark since 2007. The KOALA database (Boehringer Ingelheim Denmark A/S) was developed and offered to all municipalities to enter data and clinical parameters.

The aim of the non-randomised, real-world study reported here was to analyse the efficacy of community-based rehabilitation in a large COPD patient population on exercise capacity (measured using the 6-minute walking distance test) and health-related quality of life (measured using the 15D questionnaire) as primary endpoints.

Data from 33 participating centres were reported, and included 803 COPD patients who were referred to and participated in PR between October 2011 and August 2012. Of these, 581 completed the full rehabilitation programme of 64 days.

Community-based PR showed statistically significant and clinically meaningful effects of the outcomes (above). These results were almost identical to other recently published studies of community-based multicentre PR from Australia and the UK.

Strengths of the study included: (1) a reflection of current clinical practice, and therefore greater relevance than the selected populations normally recruited to clinical trials, and (2) a large number of participants from many centres. Among the study’s limitations were: (1) absence of follow-up visits after completion of the rehabilitation programme; (2) no registration of healthcare utilisation; (3) some missing data on lung function measurements, and (4) no recording of reasons for drop-out during the PR.

The authors concluded that PR is effective when conducted in community-based facilities and that a significant improvement in walking distance of 45 metres is similar to current knowledge regarding PR in a less intensive setting. There is also a positive effect on quality of life, most notably in patients with the largest symptom burden.

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