***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: BACKGROUND Pulmonary rehabilitation programmes improve the health of patients disabled by lung disease but their cost effectiveness is unproved . We undertook a cost/utility analysis in conjunction with a r and omised controlled clinical trial of pulmonary rehabilitation versus st and ard care . METHODS Two hundred patients , mainly with chronic obstructive pulmonary disease , were r and omly assigned to either an 18 visit , 6 week rehabilitation programme or st and ard medical management . The difference between the mean cost of 12 months of care for patients in the rehabilitation and control groups ( incremental cost ) and the difference between the two groups in quality adjusted life years ( QALYs ) gained ( incremental utility ) were determined . The ratio between incremental cost and utility ( incremental cost/utility ratio ) was calculated . RESULTS Each rehabilitation programme for up to 20 patients cost £ 12 120 . The mean incremental cost of adding rehabilitation to st and ard care was £ –152 ( 95 % CI –881 to 577 ) per patient , p = NS . The incremental utility of adding rehabilitation was 0.030 ( 95 % CI 0.002 to 0.058 ) QALYs per patient , p=0.03 . The point estimate of the incremental cost/utility ratio was therefore negative . The bootstrapping technique was used to model the distribution of cost/utility estimates possible from the data . A high likelihood of generating QALYs at negative or relatively low cost was indicated . The probability of the cost per QALY generated being below £ 0 was 0.64 . CONCLUSIONS This outpatient pulmonary rehabilitation programme produces cost per QALY ratios within bounds considered to be cost effective and is likely to result in financial benefits to the health service Background : Although it has been repeatedly suggested that chronic obstructive pulmonary disease ( COPD ) is associated with depression , no conclusion has so far been reached . A study was undertaken to investigate whether depression occurs more often in patients with COPD than in controls . The demographic and clinical variables associated with depression were also determined . Methods : Patients with a registered diagnosis of obstructive airway disease in general practice , aged ≥40 years , forced expiratory volume in 1 second ( FEV1 ) < 80 % predicted , FEV1 reversibility ≤12 % , FEV1/VC ≤ predicted – 1.64 × SD , and a history of smoking were selected . A r and om sample of subjects without a registered diagnosis of asthma or COPD aged 40 years or older acted as controls . Depression was assessed using the Centers for Epidemiologic Studies Depression ( CES-D ) scale . Results : In patients with severe COPD ( FEV1 < 50 % predicted ) , the prevalence of depression was 25.0 % compared with 17.5 % in controls and 19.6 % in patients with mild to moderate COPD . When the results were adjusted for demographic variables and comorbidity , the risk for depression was 2.5 times greater for patients with severe COPD than for controls ( OR 2.5 , 95 % CI 1.2 to 5.4 ) . In patients with mild to moderate COPD this increased risk of depression was not seen . Living alone , reversibility of FEV1 % predicted , respiratory symptoms and physical impairment were significantly associated with the scores on the CES-D scale . Conclusion : Patients with severe COPD are at increased risk of developing depression . The results of this study underscore the importance of reducing symptoms and improving physical functioning in patients with COPD Background : Chronic obstructive pulmonary disease ( COPD ) is characterised by both an accelerated decline in lung function and periods of acute deterioration in symptoms termed exacerbations . The aim of this study was to investigate whether these are related . Methods : Over 4 years ,  peak expiratory flow ( PEF ) and symptoms were measured at home daily by 109 patients with COPD ( 81 men ; median ( IQR ) age 68.1 ( 63–74 ) years ; arterial oxygen tension ( Pao2 ) 9.00 ( 8.3–9.5 ) kPa , forced expiratory volume in 1 second ( FEV1 ) 1.00 ( 0.7–1.3 ) l , forced vital capacity ( FVC ) 2.51 ( 1.9–3.0 ) l ) ; of these , 32 ( 29 men ) recorded daily FEV1 . Exacerbations were identified from symptoms and the effect of frequent or infrequent exacerbations ( > or < 2.92 per year ) on lung function decline was examined using cross sectional , r and om effects models . Results : The 109 patients experienced 757 exacerbations . Patients with frequent exacerbations had a significantly faster decline in FEV1 and peak expiratory flow ( PEF ) of –40.1 ml/year ( n=16 ) and –2.9 l/min/year ( n=46 ) than infrequent exacerbators in whom FEV1 changed by –32.1 ml/year ( n=16 ) and PEF by –0.7 l/min/year ( n=63 ) . Frequent exacerbators also had a greater decline in FEV1 if allowance was made for smoking status . Patients with frequent exacerbations were more often admitted to hospital with longer length of stay . Frequent exacerbations were a consistent feature within a patient , with their number positively correlated ( between years 1 and 2 , 2 and 3 , 3 and 4 ) . Conclusions : These results suggest that the frequency of exacerbations contributes to long term decline in lung function of patients with moderate to severe COPD BACKGROUND In spite of the well-demonstrated benefits for patients with COPD , pulmonary rehabilitation programmes show considerable drop-out and suboptimal attendance rates . The purpose of this prospect i ve study is to examine causes for drop-out and non-attendance during a 12 week multidisciplinary pulmonary rehabilitation programme , and to investigate whether sociodemographic and medical factors as well as patients ' perception of their illness are related to drop-out and non-attendance . METHODS Two hundred and seventeen patients with COPD who were referred to a rehabilitation centre participated in this multicentre study . Prior to treatment , patients received a question naire , which included the Illness Perception Question naire-Revised . Clinical data were drawn from medical records . Drop-out and attendance were recorded during the programme . RESULTS Fifty patients ( 23 % ) did not complete the rehabilitation course , of which half was due to medical reasons ( e.g. exacerbations , hospitalisations ) . Non-completion could not be predicted by baseline sociodemographic , clinical or psychological variables . Patients who declined treatment did not differ from patients who dropped out due to medical reasons . On average , patients attended 92 % of all scheduled appointments . Of all missed appointments , approximately 20 % were accountable to factors beyond patients ' control ( e.g. absent therapists , hospitalisations ) . Smoking , living alone , a lower fat free mass and lower confidence in treatment increased the chance of patients not attending an appointment during rehabilitation . CONCLUSION In general , adherence in rehabilitation is high . However , paying attention to patients ' nutritional status and creating a positive expectation of treatment during referral and intake appear to be important if one aims to optimise patients ' attendance during rehabilitation The aim of this study was to evaluate a novel patient-held manual design ed to reduce the evidence – practice gap in chronic obstructive pulmonary disease ( COPD ) . The intervention manual contained summaries of research evidence . It was developed using current best practice for patient information material s and design ed to cause discussion of evidence between patient and doctor . A controlled before- and -after study was employed in two similar but geographically separate regions of metropolitan Adelaide , South Australia . Participants had moderate to severe COPD , with 249 included at baseline and 201 completing the study .  Evidence -based COPD management was measured using an indicator with three components : rates of influenza vaccination , bone density testing , and pulmonary rehabilitation . A survey of behavioral steps leading to practice change was conducted with the trial . Analysis , by median split of socioeconomic disadvantage , showed significant difference between study arms for only one component of the indicator of evidence -based practice , enrolment in pulmonary rehabilitation and only for the most socioeconomically disadvantaged stratum . For both socioeconomic strata , more intervention participants than control participants reported remembering being given the information material , reading part or all , and finding it very or quite helpful . Other significant differences were restricted to the stratum of greatest socioeconomic disadvantage : reading all of the material , learning from it , referring back , and talking to a doctor about a topic from the material . Above 90 % of all participants who received the manual reported reading from it , 42 % reported discussing topics with a doctor , but only 10 % reported treatment change attributable to the manual . We have found that people with COPD will read an evidence manual developed using current best practice . However , the study demonstrated improvement for only one of the three components of an indicator of evidence -based disease management for only the most socioeconomically disadvantaged stratum of participants . Future interventions should be design ed to better translate reading uptake into evidence -based disease management This study reports the costs associated with  rehabilitation  among participants in the National Emphysema Treatment Trial ( NETT ) , and evaluates factors associated with adherence to rehabilitation . Pulmonary rehabilitation is recommended for moderate-to-severe COPD and required by the Centers for Medicare and Medicaid Services ( CMS ) prior to lung volume reduction surgery ( LVRS ) . Between January 1998 and July 2002 , 1,218 subjects with emphysema and severe airflow limitation ( FEV1 ≤ 45 % predicted ) were r and omized . Primary outcome measures were design ated as mortality and maximal exercise capacity 2 years after r and omization . Pre-r and omization , estimated mean total cost per patient of rehabilitation was $ 2,218 ( SD $ 314 ; 2006 dollars ) for the medical group and $ 2,187 ( SD $ 304 ) for the surgical group . Post-r and omization , mean cost per patient in the medical and surgical groups was $ 766 and $ 962 respectively . Among patients who attended ≥ 1 post-r and omization rehabilitation session , LVRS patients , patients with an FEV1 ≥ 20 % predicted , and higher education were significantly more likely to complete rehabilitation . Patients with depressive and anxiety symptoms , and those who live > 36 miles compared to < 6 miles away were less likely to be adherent . Patients who underwent LVRS  completed more exercise sessions than those in the medical group and were more likely to be adherent with post-r and omization rehabilitation . A better underst and ing of patient factors such as socioeconomic status , depression , anxiety and transportation issues may improve adherence to pulmonary rehabilitation BACKGROUND The aim of this study was to determine whether cardiac patients ' perceptions of the barriers to and benefits of home exercise while in hospital and 6 weeks after discharge are predictive of nonadherence with regular home exercise 6 months after discharge from hospital . METHODS A prospect i ve longitudinal study of 459 patients age 75 years or less and discharged from any of six public hospitals in the Lower Hunter Region of New South Wales , Australia , with a diagnosis of acute myocardial infa rct ion or angina was conducted . RESULTS Multivariate logistic regression analysis , using data provided by 281 ( 61.2 % ) patients , showed that cardiac patients ' perceptions of the benefits of and the physical environment and time barriers to home exercise while in hospital were predictive of nonadherence with regular home exercise 6 months after discharge from hospital , after adjustment for potential confounders . Six weeks after discharge from hospital , patients ' perceptions of the enjoyment and time barriers to home exercise  were predictive of nonadherence at follow-up , after adjustment for potential confounders . CONCLUSIONS Cardiac patients ' perceptions of the barriers to and benefits of home exercise may be modifiable sources of nonadherence . A r and omized controlled trial is required to confirm and extend upon these findings OBJECTIVE : To test the feasibility of creating a valid and reliable checklist with the following features : appropriate for assessing both r and omised and non-r and omised studies ; provision of both an overall score for study quality and a profile of scores not only for the quality of reporting , internal validity ( bias and confounding ) and power , but also for external validity . DESIGN : A pilot version was first developed , based on epidemiological principles , review s , and existing checklists for r and omised studies . Face and content validity were assessed by three experienced review ers and reliability was determined using two raters assessing 10 r and omised and 10 non-r and omised studies . Using different raters , the checklist was revised and tested for internal consistency ( Kuder-Richardson 20 ) , test-retest and inter-rater reliability ( Spearman correlation coefficient and sign rank test ; kappa statistics ) , criterion validity , and respondent burden . MAIN RESULTS : The performance of the checklist improved considerably after revision of a pilot version . The Quality Index had high internal consistency ( KR-20 : 0.89 ) as did the subscales apart from external validity ( KR-20 : 0.54 ) . Test-retest ( r 0.88 ) and inter-rater ( r 0.75 ) reliability of the Quality Index were good . Reliability of the subscales varied from good ( bias ) to poor ( external validity ) . The Quality Index correlated highly with an existing , established instrument for assessing r and omised studies ( r 0.90 ) . There was little difference between its performance with non-r and omised and with r and omised studies . Raters took about 20 minutes to assess each paper ( range 10 to 45 
    Output:
    
Travel and transport were consistently identified as barriers to both uptake and completion .
A lack of perceived benefit of pulmonary rehabilitation also influenced both uptake and completion .
The limited data available regarding barriers to uptake indicated that disruption to usual routine , influence of the referring doctor and program timing were important .
In conclusion poor access to transport and lack of perceived benefit affect uptake of pulmonary rehabilitation .
Current smokers and patients who are depressed are at increased risk of non-completion .