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In general, the referred patients reported a worse HRQoL according to 15D than what is shown in a recent Finnish study of COPD patients also using 15D (14). Of course, [http://www.selleckchem.com/products/Vandetanib.html Vandetanib chemical structure] we can only make inferences from the participating patients/centres, and a possible bias occurs if the demography of patients in the non-participating centres varies substantially. Unfortunately, we have no data on patients from the non-responding sites. However, this is not a randomised study; hence selection bias is not a major issue, and we believe the internal validity is preserved despite a considerable proportion of non-participation. To our surprise, we found that even patients with severe (26%) to very severe (8%) COPD were referred to rehabilitation at the participating centres even though the general perception [http://www.selleckchem.com/products/Verteporfin(Visudyne).html click here] is that municipalities should only perform rehabilitation in patients with moderate COPD or patients with severe COPD but without any co-morbidity. This probably reflects that not all hospitals are having a formalised setting for COPD rehabilitation or maybe that the spirometry was carried out in the health-care centre and not upon referral. It is also noteworthy that staging of COPD was missing in 18% of the patients, i.e. the general practitioner/hospital did not provide any information on spirometry results, indicating room for improvement in diagnosis and referral of patients for rehabilitation. Furthermore, of 1552 patients with information on MRC level, 557 (36%) had MRC level 1 or 2 at baseline, indicating that they should not have been offered this type of specialised COPD rehabilitation at all. Since stratifying level of dyspnoea using the MRC scale is only recently implemented in general practitioners' guidelines [https://en.wikipedia.org/wiki/Itraconazole Itraconazole] for managing COPD, it is likely that MRC was not assessed when patients were referred.Once referred, the newly established health-care centres have probably not refused participation of patients with MRC?