Long-term effects of web-based pedometer-mediated intervention on COPD exacerbations

Causal relationships of physical activity and leisure sedentary behaviors with COPD: A Mendelian randomization study

BACKGROUND

Chronic diseases such as chronic obstructive pulmonary disease (COPD) have been linked to low levels of physical activity (PA) and higher frequency of leisure sedentary behavior (LSB). The main causes of COPD include respiratory and peripheral muscle dysfunction, low levels of PA, and LSB which are associated with a higher risk of developing COPD. The attribution relationship between PA or LSB and COPD risk or COPD respiratory insufficiency is unclear. To explore this further, we conducted a Mendelian randomization (MR) study using a genotype-simulated randomized trial group to systematically evaluate the causal relationships of PA/LSB on COPD risk and respiratory insufficiency.

METHODS

The exposure data were obtained from large-scale genome-wide association studies (GWAS), including the PA dataset (N = 729,373) and LSB dataset (N = 1,109,337). The outcome data were derived from the Finn-Gen COPD dataset (N = 381,392). The causal effects were estimated with IVW1, MR-Egger, and WM2. Sensitivity analysis was conducted using Cochran's Q test, MR-Egger intercept test, MR-PRESSO3, leave-one-out analysis, and funnel plot to estimate the robustness of our findings.

RESULTS

Genetically predicted leisure television (TV) watching significantly increased the risk of COPD (OR = 2.4895, 95 % CI: 1.85259 to 3.34536; P = 1.44 × 10-9) and COPD respiratory insufficiency (OR = 2.55, 95 % CI: 1.53 to 4.27; P = 3.54 × 10-4). No casual effect of other PA or LSB phenotypes on COPD risk or respiratory insufficiency was observed.

CONCLUSION

Our study provides evidence that TV watching may increase the risk of COPD and its related respiratory insufficiency. These findings emphasized the importance of promoting regular physical exercise and reducing leisure sedentary behavior to prevent COPD.

Maintenance Pulmonary Rehabilitation: An Update and Future Directions

The Global Initiative for Chronic Obstructive Lung Disease guidelines recommend pulmonary rehabilitation (PR) for individuals with COPD to improve exercise capacity and health-related quality of life (HRQOL) and reduce symptoms of dyspnea. For cost-effectiveness in COPD care, PR is second only to smoking cessation. However, PR programs typically last 9-12 weeks. The benefits of PR in terms of exercise capacity and HRQOL often decrease toward pre-PR levels as early as 3-6 months after completing PR if patients do not continue to engage in exercise. This review will (1) briefly summarize the efficacy data that informed the 2023 American Thoracic Society (ATS) clinical practice guidelines for maintenance PR, (2) discuss exercise components of maintenance PR studied since 2020 when the last papers were included in the ATS guidelines, (3) explore future directions for delivery of maintenance PR using technology-mediated models, and (4) examine the need for behavior change techniques informed by theoretical models that underpin long-term behavior change. This review will focus on persons with COPD who have completed an out-patient core initial PR program as most of the data on maintenance PR have been published in this patient population. Core PR typically implies a facility-based initial intensive structured program. All patients who complete a core initial PR program should be counseled by PR staff at the discharge visit to engage in ongoing exercise. This usual care is equally as important as referral to a formal PR maintenance program. It is critical to emphasize that usual care after core initial PR means all patients should be supported to participate in regular ongoing exercise, regardless of whether supervised maintenance PR is available. Currently, the optimal frequency, exercise and/or physical activity content, and delivery mode for maintenance PR in persons with COPD and other chronic respiratory diseases remain unknown. Patient safety and degree of in-person supervision required due to the severity of the underlying lung disease need to be considered. Future research of maintenance PR should be underpinned by behavior change techniques. Finally, in the setting of finite resources, balancing the competing priorities of core initial programs with those of maintenance PR programs needs to be achieved.

Value of Information Analysis of a Web-Based Self-Management Intervention for Chronic Obstructive Pulmonary Disease

Objective: Technology-based programs can be cost-effective in the management of chronic obstructive pulmonary disease (COPD). However, cost-effectiveness estimates always contain some uncertainty, and decisions based upon them carry some risk. We conducted a value of information (VOI) analysis to estimate the value of additional research of a web-based self-management intervention for COPD to reduce the costs associated with uncertainty. Methods: We used a 10,000-iteration cost-effectiveness model from the health care payer perspective to calculate the expected value of perfect information (EVPI) at the patient- and population-level. An opportunity loss was incurred when the web-based intervention did not produce a greater net monetary benefit than usual care in an iteration. We calculated the probability of opportunity loss and magnitude of opportunity costs as a function of baseline health utility. We aggregated opportunity costs over the projected incident population of inpatient COPD patients over 10 years and estimated it as a function of the willingness-to-pay (WTP) threshold. Costs are in 2022 U.S. Dollars. Results: Opportunity losses were found in 22.7% of the iterations. The EVPIpatient was $78 per patient (95% confidence interval: $75-$82). The probability that the intervention was the optimal strategy varied across baseline health utilities. The EVPIpopulation was $506,666,882 over 10 years for a WTP of $50,000. Conclusions: Research estimated to cost up to $500 million would be warranted to reduce uncertainty. Future research could focus on identifying the impact of baseline health utilities to maximize the cost savings of the intervention. Other considerations for future research priorities include implementation efforts for technology-based interventions.

Feedback Intervention for the Control of Glucocorticoid Prescription in Primary Care Institutions: A Cluster Randomized Cross-Over Controlled Trial in Southwest China

Purpose

The purpose of this study is to assess the effect of glucocorticoid prescription feedback intervention in complex primary care institutions for regulating its inappropriate use.

Design Setting and Interventions

A six-month cluster randomized cross-over controlled trial was conducted in primary care institutions. A total of 347 physicians from 69 participating institutions were randomly allocated to either group A or group B. Both groups were given feedback interventions or serve as control. The feedback intervention comprised two components: a real-time pop-up warning of inappropriate glucocorticoid prescriptions based on the Hospital Information System and a high-proportion prescription feedback intervention warning system.

Outcome Measures

The primary outcome measure was the 10-day inappropriate glucocorticoid prescription rate, while the 10-day glucocorticoid prescription rate served as secondary outcome measure.

Results

At baseline, the 10-day inappropriate glucocorticoid prescription rates were 66.63% and 66.57% in group A and group B, respectively, showing no significant difference (p = 0.140). Following the intervention, group A exhibited a significant reduction in 10-day inappropriate glucocorticoid prescription rate at the crossing point by 13.69% (p < 0.001). In contrast, group B, which served as the control group, experienced an increase of 5.93% (p = 0.037) at the same crossover point. After the crossover point, there was a decrease in 10-day inappropriate glucocorticoid prescription rate for both groups. Group B as the intervention group demonstrated a reduction of 28.22% compared to the crossing point (p < 0.001), whereas group A showed a decrease of 12.20% (p = 0.339). The characteristics of physicians did not significantly influence the inappropriate glucocorticoid prescription rate.

Conclusion

The real-time pop-up warning of inappropriate glucocorticoid prescriptions based on the Hospital Information System and high-proportion prescription feedback intervention warning system can effectively regulate the inappropriate glucocorticoid prescribing behavior of physicians.

Trial Registration

ISRCTN11747547.

Association Between Regular Moderate to Vigorous Physical Activity Initiation Following COPD Diagnosis and Mortality: An Emulated Target Trial Using Nationwide Cohort Data

BACKGROUND

Moderate to vigorous physical activity (MVPA) in patients with COPD affects their overall health outcomes, including symptom relief and improved quality of life. However, the magnitude of the effect of MVPA initiation on real-world clinical outcomes has not been well investigated.

RESEARCH QUESTION

How does MVPA initiation affect mortality and severe exacerbation in patients who have not engaged in MVPA prior to COPD diagnosis?

STUDY DESIGN AND METHODS

This study included patients with COPD aged ≥ 40 years who were not performing MVPA prior to COPD diagnosis and who had at least one health screening visit prior to and following their COPD diagnosis between January 1, 2010, and December 31, 2018. The main exposure was MVPA, defined as vigorous aerobic exercise > 20 min per day on ≥ 3 days per week or moderate aerobic exercise > 30 min per day on ≥ 5 days per week. The primary end point was all-cause mortality, and the secondary end point was initial severe exacerbation as the time to event following COPD diagnosis.

RESULTS

In total, 110,097 person-trials were included (27,564 MVPA increases and 82,533 control groups). No differences were observed between the covariates following matching. The adjusted hazards ratio of all-cause mortality for the MVPA group compared with the control group was 0.84 (95% CI, 0.79-0.89). In the subgroup analysis, patients aged > 65 years, female patients, those who had never smoked, and patients with a higher Charlson Comorbidity Index score displayed a stronger effect of MVPA on reducing mortality than younger male patients, those who had ever smoked, and patients with a lower Charlson Comorbidity Index score (Pinteraction < .05). The fully adjusted hazards ratio for the risk of severe exacerbation (MVPA group vs control) was 0.90 (95% CI, 0.87-0.94).

INTERPRETATION

Initiation of MVPA can potentially reduce mortality and severe exacerbations in patients with COPD, although personalized interventions and further clinical trials are necessary.

Rural disparities impact response to a web-based physical activity self-management intervention in COPD: A secondary analysis

PURPOSE

This secondary exploratory analysis examined rural-urban differences in response to a web-based physical activity self-management intervention for chronic obstructive pulmonary disease (COPD).

METHODS

Participants with COPD (N = 239 US Veterans) were randomized to either a multicomponent web-based intervention (goal setting, iterative feedback of daily step counts, motivational and educational information, and an online community forum) or waitlist-control for 4 months with a 12-month follow-up. General linear modeling estimated the impact of rural/urban status (using Rural-Urban Commuting Area [RUCA] codes) on (1) 4- and 12-month daily step-count change compared to waitlist-control, and (2) intervention engagement (weekly logons and participant feedback).

FINDINGS

Rural (n = 108) and urban (n = 131) participants' mean age was 66.7±8.8 years. Rural/urban status significantly moderated 4-month change in daily step counts between randomization groups (p = 0.041). Specifically, among urban participants, intervention participants improved by 1500 daily steps more than waitlist-control participants (p = 0.001). There was no difference among rural participants. In the intervention group, rural participants engaged less with the step-count graphs on the website than urban participants at 4 months (p = 0.019); this difference dissipated at 12 months. More frequent logons were associated with greater change in daily step counts (p = 0.004); this association was not moderated by rural/urban status.

CONCLUSIONS

The web-based intervention was effective for urban, but not rural, participants at 4 months. Rural participants were also less engaged at 4 months, which may explain differences in effectiveness. Technology-based interventions can help address urban-rural disparities in patients with COPD, but may also contribute to them unless resources are available to support engagement with the technology.

Wearable technology interventions in patients with chronic obstructive pulmonary disease: a systematic review and meta-analysis

Chronic obstructive pulmonary disease (COPD) is the third leading cause of death and is associated with multiple medical and psychological comorbidities. Therefore, future strategies to improve COPD management and outcomes are needed for the betterment of patient care. Wearable technology interventions offer considerable promise in improving outcomes, but prior reviews fall short of assessing their role in the COPD population. In this systematic review and meta-analysis we searched ovid-MEDLINE, ovid-EMBASE, CINAHL, CENTRAL, and IEEE databases from inception to April 2023 to identify studies investigating wearable technology interventions in an adult COPD population with prespecified outcomes of interest including physical activity promotion, increasing exercise capacity, exacerbation detection, and quality-of-life. We identified 7396 studies, of which 37 were included in our review. Meta-analysis showed wearable technology interventions significantly increased: the mean daily step count (mean difference (MD) 850 (494-1205) steps/day) and the six-minute walk distance (MD 5.81 m (1.02-10.61 m). However, the impact was short-lived. Furthermore, wearable technology coupled with another facet (such as health coaching or pulmonary rehabilitation) had a greater impact that wearable technology alone. Wearable technology had little impact on quality-of-life measures and had mixed results for exacerbation avoidance and prediction. It is clear that wearable technology interventions may have the potential to form a core part of future COPD management plans, but further work is required to translate this into meaningful clinical benefit.

Stakeholder Perceptions of a Web-Based Physical Activity Intervention for COPD: A Mixed-Methods Study

Technology-based physical activity interventions have been shown to be efficacious in chronic obstructive pulmonary disease (COPD), though their potential impact has not been fully realized due to ineffective implementation. We used a convergent, parallel mixed-methods design to identify patient- and provider-facing barriers and facilitators to implementing a rigorously studied web-based physical activity intervention for COPD. Quantitative surveys (based on the unified theory of acceptance and use of technology; range 1 (poor usability)-5 (high usability)) and semi-structured interviews (guided by the practical robust implementation and sustainability model) assessed the perspectives of 15 patients and 15 health care providers. The patients and providers rated the usability of the intervention as high (median = 5.0, IQR = 1.0). For both patients and providers, the main facilitators included: the potential high impact of the intervention on patient health, the usefulness of the intervention for unmet clinical needs, and the perceived ease of use of the intervention. The main barriers identified were digital literacy and its fit with current clinical workflows. Implementation efforts may benefit from supporting patients' use of the website and developing strategies to integrate referrals to the intervention and the monitoring of patients into current clinical infrastructures.

Depression Symptoms and Physical Activity in Veterans With COPD: Insights From a Web-Based, Pedometer-Mediated Physical Activity Intervention

BACKGROUND

Depression is known to limit physical activity (PA) among individuals with chronic obstructive pulmonary disease (COPD). However, whether and how depression influences the effectiveness of PA interventions is unknown.

PURPOSE

The study examined the association between baseline depression symptoms and change in daily step count and whether group assignment to a web-based, pedometer-mediated PA intervention moderated the association between baseline depression symptoms and change in daily step count.

METHODS

Secondary analysis included two cohorts of U.S. Veterans with COPD (n = 212; 97% male; mean age 69 ± 8 years) assessed at baseline and 3 months. Cohorts 1 and 2 were randomly assigned to the same PA intervention (n = 111) or a control group (n = 101). Multivariate regressions tested the main effects of baseline depression symptoms (BDI-II total and cognitive-affective and somatic subscales) on change in daily steps, as well as the interaction between baseline BDI-II and subscales and group assignment on change in daily steps.

RESULTS

Greater BDI-II total score (B = -31.8, SE = 14.48, p = .030) and somatic subscale scores (B = -99.82, SE = 35.76, p = .006) were associated with less improvement in daily step count. There was a significant interaction between baseline cognitive-affective subscale and the intervention predicting change in daily step count (B = -88.56, SE = 42.31, p = .038). When cognitive-affective subscale scores were ≥1 SD above the mean, the intervention was no longer associated with an increase in daily step count (p = .585).

CONCLUSIONS

Depression should be routinely assessed and targeted as part of PA promotion efforts.

Clinicians' Perspectives of Wearable Technology to Detect and Monitor Exacerbations of Chronic Obstructive Pulmonary Disease: Mixed-Method Survey

Objective

To investigate clinicians' perspectives on the current use of wearable technology for detecting COPD exacerbations, and to identify potential facilitators and barriers to its adoption in clinical settings.

Methods

A mixed-method survey was conducted through an online survey platform involving clinicians working with COPD patients. The questionnaires were developed by an expert panel specialising in respiratory medicine at UCL. The questionnaire evaluated clinicians' perspectives on several aspects: the current extent of wearable technology utilisation, the perceived feasibility, and utility of these devices, as well as the potential facilitators and barriers that hinder its wider implementation.

Results

Data from 118 clinicians were included in the analysis. Approximately 80% of clinicians did not currently use information from wearable devices in routine clinical care. A majority of clinicians did not have confidence in the effectiveness of wearables and their consequent impact on health outcomes. However, clinicians highlighted the potential value of wearables in helping deliver personalised care and more rapid assistance. Ease of use, technical support and accessibility of data were considered facilitating factors for wearable utilisation. Costs and lack of technical knowledge were the most frequently reported barriers to wearable utilisation.

Conclusion

Clinicians' perspectives of the use of wearable technology to detect and monitor COPD exacerbations are variable. While accessibility and technical support facilitate wearable implementation, cost, technical issues, and knowledge act as barriers. Our findings highlight the facilitators and barriers to using wearables in patients with COPD and emphasise the need to assess patients' perspectives on wearable acceptability.

Benefits and Harms of Digital Health Interventions Promoting Physical Activity in People With Chronic Conditions: Systematic Review and Meta-Analysis

BACKGROUND

Digital health interventions for managing chronic conditions have great potential. However, the benefits and harms are still unclear.

OBJECTIVE

This systematic review and meta-analysis aimed to investigate the benefits and harms of digital health interventions in promoting physical activity in people with chronic conditions.

METHODS

We searched the MEDLINE, Embase, CINAHL, and Cochrane Central Register of Controlled Trials databases from inception to October 2022. Eligible randomized controlled trials were included if they used a digital component in physical activity promotion in adults with ≥1 of the following conditions: depression or anxiety, ischemic heart disease or heart failure, chronic obstructive pulmonary disease, knee or hip osteoarthritis, hypertension, or type 2 diabetes. The primary outcomes were objectively measured physical activity and physical function (eg, walk or step tests). We used a random effects model (restricted maximum likelihood) for meta-analyses and meta-regression analyses to assess the impact of study-level covariates. The risk of bias was assessed using the Cochrane Risk of Bias 2 tool, and the certainty of the evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation.

RESULTS

Of 14,078 hits, 130 randomized controlled trials were included. Compared with usual care or minimal intervention, digital health interventions increased objectively measured physical activity (end of intervention: standardized mean difference [SMD] 0.29, 95% CI 0.21-0.37; follow-up: SMD 0.17, 95% CI 0.04-0.31) and physical function (end of intervention: SMD 0.36, 95% CI 0.12-0.59; follow-up: SMD 0.29, 95% CI 0.01-0.57). The secondary outcomes also favored the digital health interventions for subjectively measured physical activity and physical function, depression, anxiety, and health-related quality of life at the end of the intervention but only subjectively measured physical activity at follow-up. The risk of nonserious adverse events, but not serious adverse events, was higher in the digital health interventions at the end of the intervention, but no difference was seen at follow-up.

CONCLUSIONS

Digital health interventions improved physical activity and physical function across various chronic conditions. Effects on depression, anxiety, and health-related quality of life were only observed at the end of the intervention. The risk of nonserious adverse events is present during the intervention, which should be addressed. Future studies should focus on better reporting, comparing the effects of different digital health solutions, and investigating how intervention effects are sustained beyond the end of the intervention.

TRIAL REGISTRATION

PROSPERO CRD42020189028; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=189028.

A Web-Based Mind-Body Intervention (Mindful Steps) for Promoting Walking in Chronic Cardiopulmonary Disease: Insights From a Qualitative Study

Background

Given the deleterious effects of physical inactivity in persons with chronic obstructive pulmonary disease (COPD) and/or heart failure (HF), interventions that promote long-term daily physical activity are needed. Mindful Steps, designed to promote walking behaviors in COPD and HF, is a multicomponent intervention that integrates mind-body content with other self-regulatory components. The aim of the current qualitative study was to characterize participants' experiences with Mindful Steps and understand the perceived influence of the intervention on walking and health.

Method

In the context of a pilot randomized controlled feasibility trial comparing the year-long Mindful Steps program to usual care among individuals with COPD and HF, semi-structured qualitative interviews were administered at 6- and 12-months. Interviews were audio recorded and transcribed. The constant comparative method was used to code transcripts, identify categories, and develop interrelated themes.

Results

Nineteen participants (63% female; Mage = 70.2 years, SD = 6.95) who were randomized to the intervention group completed the 6-month interview and 17 completed the 12-month interview. The pedometer with feedback, live group classes, and mind-body videos were described as the most helpful intervention components. Participants learned several strategies that helped their walking (e.g., breathing regulation and awareness, body awareness, mind-body techniques, pacing), described walking as enjoyable, and identified internal reasons for walking (e.g., to feel good). They also reported several physical and mental health benefits of the intervention. Some participants reported limited influence of the intervention on walking or health. Many participants continued to use the strategies they learned in the first half of the intervention at 12-months.

Conclusions

The mind-body content of Mindful Steps appeared to positively influence walking behaviors. Participants' experiences with the intervention helped to identify areas for future intervention refinement. Future quantitative work is needed to corroborate these qualitative findings and assess the efficacy of the intervention on long-term physical activity engagement.

Trial Registration

This trial is registered in Clinical Trials.gov, ID number NCT01551953.

Cost savings associated with a web-based physical activity intervention for COPD

OBJECTIVE

To estimate the cost savings associated with a pedometer-based, web-mediated physical activity intervention in a cohort of US veterans with chronic obstructive pulmonary disease (COPD).

STUDY DESIGN

Economic analysis.

METHODS

We constructed a decision tree from the health care system perspective incorporating adjusted relative risk of a pedometer-based, web-mediated intervention for COPD-related acute exacerbations, acute exacerbation-related costs (ie, emergency department visits and hospitalizations), and intervention-related costs. Total COPD-related costs were estimated per patient across 12 months. Probabilistic sensitivity analysis with Monte Carlo simulation was used to estimate uncertainty in the model findings.

RESULTS

In the deterministic (base case) model, the model estimated costs to be $4236 per participant who used the pedometer-based, web-mediated intervention compared with $7913 per participant in the control group (estimated $3677 saved in 1 year compared with the control group). The model findings were robust to probabilistic sensitivity analysis, with a difference in mean costs of $4582 (95% probability interval, $4084-$5080; P < .001). Cost savings in the model were driven by the adjusted relative risk of the web-based intervention, probability of a COPD-related acute exacerbation, rate of hospitalization, probability of hospitalization, and cost of hospitalization.

CONCLUSIONS

A pedometer-based, web-mediated physical activity intervention yielded substantial cost savings. Increased implementation of the intervention could markedly reduce the economic burden of COPD for payers and patients.

Improving Physiological, Physical, and Psychological Health Outcomes: A Narrative Review in US Veterans with COPD

The Veterans Health Administration (VHA) is the largest integrated healthcare system in the United States (US) providing healthcare to an increasing number of middle-aged and older adults who remain at greater risk for chronic obstructive pulmonary disease (COPD) compared to their civilian counterparts. The VHA has obligated research funds, drafted clinical guidelines, and built programmatic infrastructure to support the diagnosis, treatment, and care management of Veterans with COPD. Despite these efforts, COPD remains a leading cause of morbidity and mortality in Veterans. This paper provides a narrative review of research conducted with US Veteran samples targeting improvement in COPD outcomes. We review key physiological, physical, and psychological health outcomes and intervention research that included US Veteran samples. We conclude with a discussion of directions for future research to continue advancing the treatment of COPD in Veterans and inform advancements in COPD research within and outside the VHA.

Screening for Chronic Obstructive Pulmonary Disease: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force

IMPORTANCE

Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality in the US.

OBJECTIVE

To conduct a targeted systematic review to update the evidence on the effectiveness of screening for COPD and the treatment of COPD to inform the US Preventive Services Task Force (USPSTF) update of the 2016 recommendation statement on COPD screening.

DATA SOURCES

MEDLINE, the Cochrane Central Register of Controlled Trials, and CINAHL for relevant studies published between January 1, 2015, to January 22, 2021; surveillance through March 25, 2022.

STUDY SELECTION

English-language studies of screening in individuals who do not recognize or report respiratory symptoms; studies of treatment in persons with mild or moderate, or minimally symptomatic, COPD.

DATA EXTRACTION AND SYNTHESIS

Two reviewers independently appraised the articles and extracted relevant data from fair- or good-quality studies; no quantitative synthesis was conducted.

MAIN OUTCOMES AND MEASURES

COPD-related morbidity or mortality, measures of health-related quality of life, and adverse events.

RESULTS

The review included no trials on the effectiveness of screening, 3 trials or analyses (n = 20 058) of pharmacologic treatment published since 2015, 13 trials (n = 3657) on nonpharmacologic interventions, and 2 large observational studies (n = 243 517) addressing the harms of pharmacologic treatment published since 2015. The results from the clinical trials of pharmacologic therapy are consistent with the previous review supporting the USPSTF that bronchodilators with or without inhaled corticosteroids can reduce COPD exacerbations and tiotropium can improve health-related quality of life in adults with moderate COPD. Overall, there was no consistent benefit observed for any type of nonpharmacologic intervention across a range of patient outcomes. None of the included treatment trials that reported adverse effects found significant harms. Two large observational studies in a screen-relevant population demonstrated an association of the initiation of a long-acting muscarinic antagonist or long-acting beta agonist with the risk of a serious cardiovascular event in treatment-naïve patients and an association of inhaled corticosteroids use with the risk of developing diabetes.

CONCLUSIONS AND RELEVANCE

The findings of this targeted evidence update are generally consistent with the findings of the previous systematic review supporting the 2016 USPSTF recommendation. Evidence of pharmacologic treatment was still largely limited to persons with moderate airflow obstruction, and there was no consistent benefit observed for a range of nonpharmacologic interventions in mild to moderate COPD or in minimally symptomatic persons with COPD.

The Long-Term Maintenance Effect of Remote Pulmonary Rehabilitation via Social Media in COPD: A Randomized Controlled Trial

Background

Although the benefits of conventional pulmonary rehabilitation (PR) maintenance are well documented, it is challenged by many difficulties. We investigated whether remote home-based PR maintenance strategy via social media (WeChat) is effective on clinical improvements and reducing the risk for acute exacerbation of chronic obstructive pulmonary disease (COPD).

Methods

The eligible stable COPD patients completing an initial 8-week PR were allocated into three groups randomly. Group A: PR maintenance via social media supervision at home. Group B: PR maintenance at hospital. Group C: Usual care. During a 12-month follow-up, the frequency of acute exacerbation of COPD (AECOPD), 6 minutes walking test (6MWT), COPD assessment test (CAT), and modified Medical Research Council scale (mMRC) were evaluated every 3 months.

Results

At the end of the follow-up, compared to the decline in the usual care group (n = 49), the clinical improvements of 6MWD, CAT, and mMRC were sustained in both the home-based group (n = 47) and the hospital-based maintenance group (n = 44) (p < 0.001), no difference was observed between these two groups (p > 0.05). In multivariate analysis, the home-based PR maintenance and hospital-based PR maintenance were independent predictors of lower risk for AECOPD (incidence rate ratio (IRR) 0.712, 95% CI 0.595–0.841, p < 0.001 and IRR 0.799, 95% CI 0.683–0.927, p = 0.002), respectively.

Conclusion

Remote PR maintenance via social media is effective in reducing the risk for AECOPD and keeping the clinical improvement from decline. Remote PR maintenance via social media might be used to deliver alternatives to conventional PR.

Efficacy of Web-Based Supportive Interventions in Quality of Life in COPD Patients, a Systematic Review and Meta-Analysis

Background: Adults living with Chronic Obstructive Pulmonary Disease (COPD) often have difficulties when trying to access health care services. Interactive communication technologies are a valuable tool to enable patients to access supportive interventions to cope with their disease. The aim of this revision and meta-analysis is to analyze the content and efficacy of web-based supportive interventions in quality of life in COPD. Methods: Medline (via PubMed), Web of Science, and Scopus were the databases used to select the studies for this systematic review. A screening, analysis, and assessment of the methodological quality was carried out by two independent researchers. A meta-analysis of the extracted data was performed. Results: A total of 9 of the 3089 studies reviewed met the inclusion criteria. Most repeated web content elements were educational and involved communication with healthcare professional content. Finally, seven of the nine studies were included in a quantitative analysis. Web-based supportive interventions significantly improved quality of life when added to usual care (SMD = −1.26, 95% CI = −1.65, −0.86; p < 0.001) but no significant differences were found when compared with an autonomous pedometer walking intervention (p = 0.64) or a face-to-face treatment (p = 0.82). Conclusion: This systematic review and meta-analysis suggests that web-based supportive interventions may complement or accompany treatments in COPD patients due to the advantages of online interventions. The results obtained should be treated with caution due to the limited number of studies in this area and methodological weaknesses.

A randomised trial of a web-based physical activity self-management intervention in COPD

Improving exercise capacity is a primary objective in COPD. Declines in exercise capacity result in reduced physical activity and health-related quality of life (HRQoL). Self-management interventions can teach patients skills and behaviours to manage their disease. Technology-mediated interventions have the potential to provide easily accessible support for disease self-management. We evaluated the effectiveness of a web-based self-management intervention, focused on physical activity promotion, on exercise capacity in COPD. This 6-month randomised controlled trial (NCT02099799) enrolled 153 persons with COPD at two US sites (VABoston, n=108; VABirmingham, n=45). Participants were allocated (1:1) to the web-based self-management intervention (physical activity promotion through personalised, progressive step-count goals, feedback, online COPD-related education and social support via an online community) or usual care. The primary outcome was exercise capacity (6-min walk distance (6 MWD)). Secondary outcomes included physical activity (daily steps per day), HRQoL (St. George's Respiratory Questionnaire Total Score), dyspnoea, COPD-related knowledge and social support. Change in step-count goals reflected intervention engagement. Participants' mean age was 69 (sd=7), and mean forced expiratory volume in 1 s % predicted was 61% (sd=21%). Change in 6MWD did not differ between groups. Intervention participants improved their mean daily step counts by 1312 more than those in the usual care group (p<0.001). Groups did not differ on other secondary outcomes. VABirmingham participants were significantly more engaged with the intervention, although site did not modify the effect of the intervention on 6MWD or secondary outcomes. The intervention did not improve exercise capacity but improved physical activity at 6 months. Additional intervention modifications are needed to optimise its COPD self-management capabilities.

A web-based self-management intervention improved physical activity but not exercise capacity. There is a need to develop and study accessible self-management interventions for COPD.https://bit.ly/3iT1yvU

Molecular markers of aging, exercise capacity, & physical activity in COPD

BACKGROUND

Exercise capacity (EC) and physical activity (PA) are independent, potentially modifiable predictors of clinical outcomes in COPD. Molecular measures of biological age may help characterize variability in EC and PA observed among COPD patients.

METHODS

Veterans with COPD (FEV₁/FVC<0.7 or emphysema on chest computed tomography) enrolled in 2 cohorts at VA Boston completed questionnaires, a 6-min walk distance (6MWD) for EC, and blood collection at enrollment. PA data (average daily step count) was collected using an HJ-720 ITC pedometer over ≥5 days. A subset of subjects returned for repeat assessment after 12 weeks. DNA methylation data was generated using the HumanMethylationEPIC platform; epigenetic estimates of biological age and age acceleration were generated using established algorithms. Multivariable models examined the associations between biological age, 6MWD, PA and future acute exacerbations (AEs), adjusting for chronological age, sex, race, smoking status, pack-years, body mass index, cohort, and estimated cell counts.

RESULTS

Subjects (n = 269) were predominantly male (98.5%), white (92.9%), and elderly (70.6 ± 8.5 years) with average FEV₁% of 57.7 ± 21.1, 6MWD of 374.3 ± 93.5 m, and daily steps of 3043.4 ± 2374 at baseline. In adjusted models, multiple measures of baseline epigenetic age and age acceleration were inversely associated with 6MWD; only GrimAge was inversely associated with PA. Longitudinal change in Hannum-Age was inversely associated with change in EC at 12 weeks (n = 94). No measures of biological age were significantly associated with prospective AEs over 1.3 ± 0.3 years.

CONCLUSIONS

Epigenetic measures of biological age are independent predictors of EC and PA, but not AEs, among individuals with COPD.

Pain in Veterans with COPD: relationship with physical activity and exercise capacity

BACKGROUND

Pain is a common but underappreciated symptom experienced by people with Chronic Obstructive Pulmonary Disease (COPD). The relationships between pain and physical activity (PA) and exercise capacity are poorly understood.

METHODS

This retrospective secondary analysis includes three cohorts of Veterans with COPD who participated in longitudinal studies evaluating PA and exercise capacity with objective measures of daily step counts and 6-min walk test (6MWT) distance, respectively. Pain was assessed using the bodily pain domain of the Veterans RAND-36. In two cohorts, participants were randomly assigned to a web-based, pedometer-mediated PA intervention which has previously been demonstrated to improve PA.

RESULTS

Three-hundred and seventy-three (373) unique study participants were included in this analysis. Eighty-three percent (n = 311) of the population reported at least mild pain and/or at least a little bit of interference due to pain at baseline. Cross-sectionally, greater bodily pain was associated with lower 6MWT distance (β = 0.51; 95% CI 0.20, 0.82; p = 0.0013). Longitudinally, worsening bodily pain was associated with a decline in 6MWT distance (β = 0.30; 95% CI 0.03, 0.58; p = 0.0312). There was no association between baseline bodily pain and baseline daily step counts, baseline bodily pain and change in PA, or change in bodily pain and change in PA. Compared to usual care, our PA intervention improved bodily pain scores (β = 6.17; 95% CI 1.84, 10.45; p = 0.0054). Bodily pain scores did not affect the impact of the intervention on daily step counts.

CONCLUSION

Pain is highly prevalent and significantly associated with lower exercise capacity among Veterans with COPD. Worsening pain co-occurred with decline in exercise capacity but not PA. Our intervention reduced pain, although pain did not affect the impact of the intervention on PA.

Co-occurrence of pain and dyspnea in Veterans with COPD: Relationship to functional status and a pilot study of neural correlates using structural and functional magnetic resonance imaging

Persons with COPD experience co-occurring dyspnea and pain. Little is known about the relationship between symptom co-occurrence with physical activity (PA) and exercise. Novel diagnostic tools are needed for accurate symptom discrimination. In this secondary analysis, we examined relationships between baseline assessments of pain, dyspnea, objectively measured PA, and exercise capacity in persons with COPD who previously enrolled in three PA studies. Pain was assessed with the bodily pain domain of the Veterans RAND-36 (VR-36), and dyspnea with the modified Medical Research Council (mMRC) scale. Average daily step count was assessed with the Omron HJ-720ITC or FitBit Zip pedometer, and exercise capacity with 6-minute walk test (6MWT). We also conducted a pilot neuroimaging study. Neuroimaging data were acquired on a Siemens 3-Tesla Magnetom Prismafit whole-body scanner. Analysis of variance assessed trends in daily step count and 6MWT distance across categories of co-occurring pain and dyspnea. General linear models examined relationships between cortical thickness and resting state functional connectivity (fc) with symptoms and functional status. In 373 Veterans, 98% were male with mean age 70.5± 8.3 years and FEV1% predicted 59 ± 21%. Compared to those with no co-occurrence of pain and dyspnea, those with co-occurrence walked 1,291-1,444 fewer steps per day and had an 80-85 m lower 6MWT distance. Ten males participated in the pilot neuroimaging study. Predominant findings were that lower cortical thickness and greater fc were associated with higher pain and dyspnea, p<0.05. Greater cortical thickness and lower fc were associated with higher daily step count and 6MWT distance, p<0.05. Regional patterns of associations differed for pain and dyspnea, suggesting that cortical thickness and fc may discriminate symptoms. Co-occurring dyspnea and pain in COPD are associated with significant reductions in PA and exercise capacity. It may be feasible for neuroimaging markers to discriminate between pain and dyspnea.

Objectively measured physical activity as a COPD clinical trial outcome

BACKGROUND

Reduced physical activity is common in COPD and is associated with poor outcomes. Physical activity is therefore a worthy target for intervention in clinical trials, however, trials evaluating physical activity have used heterogeneous methodologies.

RESEARCH QUESTION

What is the available evidence on the efficacy and/or effectiveness of various interventions to enhance objectively measured physical activity in patients with COPD, taking into account minimal preferred methodological quality of physical activity assessment?

STUDY DESIGN AND METHODS

In this narrative review, the COPD Biomarker Qualification Consortium (CBQC) task force searched three scientific databases for articles that reported the effect of an intervention on objectively-measured physical activity in COPD. Based on scientific literature and expert consensus, only studies with ≥7 measurement days and ≥4 valid days of ≥8 hours of monitoring were included in the primary analysis.

RESULTS

37 of 110 (34%) identified studies fulfilled the criteria, investigating the efficacy and/or effectiveness of physical activity behavior change programs (n=7), mobile health or eHealth interventions (n=9), rehabilitative exercise (n=9), bronchodilation (n=6), lung volume reduction procedures (n=3) and other interventions (n=3). Results are generally variable, reflecting the large variation in study characteristics and outcomes. Few studies show an increase beyond the proposed minimal important change of 600-1100 daily steps, indicating that enhancing physical activity levels is a challenge.

INTERPRETATION

Only a third of clinical trials measuring objective physical activity in people with COPD fulfilled the pre-set criteria regarding physical activity assessment. Studies showed variable effects on physical activity even when investigating similar interventions.

Exploring Tai Chi Exercise and Mind-Body Breathing in Patients with COPD in a Randomized Controlled Feasibility Trial

In this pilot feasibility randomized controlled trial, participants with moderate to severe COPD were randomized to a 12-week tai chi or MBB intervention. Participants were assessed at baseline, 12 weeks, and 24 weeks. Feasibility, as assessed by intervention adherence, was the primary outcome. We also estimated preliminary between-group differences in COPD symptoms and health-related quality of life, cognitive-emotional function, and functional status across three timepoints: baseline, 12, and 24 weeks. A total of 92 participants were randomized 2:1 to tai chi (n = 61) or MBB (n = 31). The overall group adherence in the first 12 weeks was 62% in tai chi and 75% in MBB. From baseline to 12 weeks, tai chi demonstrated greater improvements in depressive symptoms (Cohen's d effect size (ES) = -.53; adj mean diff = -2.31 [-5.7, 1.07]), 6-minute walk test distance (ES = .47; adj mean diff = 62.04 [2.85, 121.22]), social support (ES = .36; adj mean diff = .19 [-0.11, 0.49]) and chair stand (ES = .44; adj mean diff = .91 [-0.05, 1.86]). Only improvements in social support were maintained at 24-week follow-up. Tai chi and MBB are feasible for individuals with COPD. Preliminary effects suggest that while our mindful breathing intervention may not be sufficient to impact outcomes, tai chi may result in short-term benefits in mood, social support and functional capacity. More work is needed to better understand mindful breathing for COPD and to examine methods for maintaining improvements from tai chi over time.Supplemental data for this article is available online at https://doi.org/10.1080/15412555.2021.1928037 .

Development of a Novel Intervention (Mindful Steps) to Promote Long-Term Walking Behavior in Chronic Cardiopulmonary Disease: Protocol for a Randomized Controlled Trial

BACKGROUND

Despite current rehabilitation programs, long-term engagement in physical activity remains a significant challenge for patients with chronic obstructive pulmonary disease (COPD) and heart failure (HF). Novel strategies to promote physical activity in these populations are greatly needed. Emerging literature on the benefits of both mind-body interventions and web-based interventions provide the rationale for the development of the Mindful Steps intervention for increasing walking behavior.

OBJECTIVE

This study aims to develop a novel multimodal mind-body exercise intervention through adaptation of an existing web-based physical activity intervention and incorporation of mind-body exercise, and to pilot test the delivery of the new intervention, Mindful Steps, in a randomized controlled feasibility trial in older adults with COPD and/or HF.

METHODS

In phase 1, guided by a theoretical conceptual model and review of the literature on facilitators and barriers of physical activity in COPD and HF, we convened an expert panel of researchers, mind-body practitioners, and clinicians to inform development of the novel, multimodal intervention. In phase 2, we are conducting a pilot randomized controlled feasibility trial of the Mindful Steps intervention that includes in-person mind-body exercise classes, an educational website, online mind-body videos, and a pedometer with step-count feedback and goals to increase walking behavior in patients with COPD and/or HF. Outcomes include feasibility measures as well as patient-centered measures.

RESULTS

The study is currently ongoing. Phase 1 intervention development was completed in March 2019, and phase 2 data collection began in April 2019.

CONCLUSIONS

Through the integration of components from a web-based physical activity intervention and mind-body exercise, we created a novel, multimodal program to impact long-term physical activity engagement for individuals with COPD and HF. This developmental work and pilot study will provide valuable information needed to design a future clinical trial assessing efficacy of this multimodal approach.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03003780; https://clinicaltrials.gov/ct2/show/NCT03003780.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/27826.

Can Technology-Based Physical Activity Programs for Chronic Obstructive Pulmonary Disease Be Cost-Effective?

Objective: To evaluate the cost-effectiveness of a technology-based physical activity (PA) intervention for chronic obstructive pulmonary disease (COPD). Design: A secondary data analysis was performed from a randomized controlled trial in COPD of an activity monitor alone or an activity monitor plus a web-based PA intervention. Models estimated cost per quality-adjusted life year (QALY) and incremental cost-effectiveness ratios (ICERs) compared with usual care. Results: The estimated ICER for both groups was below the willingness-to-pay threshold of $50,000/QALY (activity monitor alone = $10,437/QALY; website plus activity monitor intervention = $13,065/QALY). A probabilistic simulation estimated 76% of the activity monitor-alone group and 78% of the intervention group simulations to be cost-effective. Conclusion(s): Both the activity monitor-alone group and the activity monitor plus website group were cost-effective at the base case by using conventional willingness-to-pay thresholds. Further research would benefit from a more direct estimate of health utilities and downstream health care costs. Clinical Trials.gov NCT01102777.

BEAM study (Breathing, Education, Awareness, Movement): a randomised controlled feasibility trial of tai chi exercise in patients with COPD

BACKGROUND

Despite therapeutic advances, the management of chronic obstructive pulmonary disease (COPD) remains complex. There is growing interest in multidimensional, mind-body exercises to improve both physical and psychosocial aspects of COPD burden. Few US data are available in this population on tai chi (TC) a mind-body exercise incorporating physical activity, breathing and mindful awareness. We explored feasibility and preliminary efficacy of TC in COPD in an US academic medical setting.

METHODS

Patients with COPD Global Obstructive Lung Disease (GOLD) stages 2-4 were randomised to a 12-week TC programme or education control. At 12 weeks, those in TC were randomised again to continue in maintenance classes or not to further explore optimal duration. All groups were followed to 24 weeks. Feasibility/safety parameters were analysed descriptively. Preliminary between-group differences were estimated in symptoms (dyspnoea, fatigue), health-related quality-of-life (Chronic Respiratory Questionnaire CRQ), cognitive-emotional measures (mood, COPD self-efficacy) and functional status (6 min walk test, lower body strength, flexibility, physical activity).

RESULTS

Ninety-two subjects were randomised (N=61 TC, N=31 education). Mean age was 68±8 years, 66% male, mean forced expiratory volume in 1 s % predicted 57±13, 28% were GOLD stage 3-4. Overall retention was 85%. Nineteen adverse events occurred, most being study-unrelated COPD exacerbations. From baseline to 12 weeks, there were between-group improvements favouring TC, in CRQ-total (Cohen's d effect size (ES)=0.46; adj mean diff (AMD)=0.31), CRQ-emotion (ES=0.54; AMD=0.49), Centre for Epidemiologic Studies Depression (ES=-0.37; AMD=2.39) and Patient-Reported Outcome Measurement Information System (PROMIS)-fatigue (ES=-0.34; AMD=-0.17). From baseline to 24 weeks, there was an improvement favouring TC in CRQ-dyspnoea (ES=0.41; AMD=0.46). Among TC participants, there was a positive effect of maintenance classes on self-efficacy (ES=-0.69; AMD=-0.40), 6 min walk (ES=0.56; AMD=49.26 feet), PROMIS-fatigue (ES=-0.41; AMD=-0.28) and chair stand (0.43; AMD=0.56).

CONCLUSION

TC in patients with COPD is feasible and safe. Preliminary analyses support a potential modest role in improving quality-of-life, cognitive-emotional health and function that should be further studied.

TRIAL REGISTRATION NUMBER

NCT01551953.

IRB REFERENCE

BIDMC 2010P-000412; VA 2540.

Long-Term Effects of Pedometer-Based Physical Activity Coaching in Severe COPD: A Randomized Controlled Trial

Background and Objective

Limited evidence on long-term effects of physical activity programs in COPD is available. The aim of the study was to investigate the effects of a three-month program combining physical activity counselling and pedometer-based feedback in addition to usual care, followed by a nine-month unsupervised observation period as compared to usual care in participants with severe to very severe COPD.

Methods

Participants were randomized to either a control group receiving usual care or an intervention group receiving motivational support, an activity diary with an individual step count goal (ie, an increase of ≥15% from baseline) and a pedometer in addition to usual care. The intervention ended after three months and an unsupervised observational period followed until twelve months. Primary outcome was daily step count after one year.

Results

Seventy-four participants were included, 61 (82%) completed the study. Linear regression modelling, adjusted for baseline step count, showed no significant difference in change in step count after 12 months between the groups (Β = 547.33, 95% CI = -243.55/1338.20).

Conclusion

A three-month program combining physical activity counselling and pedometer-based feedback in addition to usual care does not attenuate the declining course of physical activity in participants with severe and very severe COPD during a long term follow-up of one year as compared to usual care. This result was primarily determined by the low intervention response rates to the combined program.

Clinical Trial Registration

www.ClinicalTrials.gov, NCT03114241.

Recognition of Common Non-Normal Walking Actions Based on Relief-F Feature Selection and Relief-Bagging-SVM

Action recognition algorithms are widely used in the fields of medical health and pedestrian dead reckoning (PDR). The classification and recognition of non-normal walking actions and normal walking actions are very important for improving the accuracy of medical health indicators and PDR steps. Existing motion recognition algorithms focus on the recognition of normal walking actions, and the recognition of non-normal walking actions common to daily life is incomplete or inaccurate, resulting in a low overall recognition accuracy. This paper proposes a microelectromechanical system (MEMS) action recognition method based on Relief-F feature selection and relief-bagging-support vector machine (SVM). Feature selection using the Relief-F algorithm reduces the dimensions by 16 and reduces the optimization time by an average of 9.55 s. Experiments show that the improved algorithm for identifying non-normal walking actions has an accuracy of 96.63%; compared with Decision Tree (DT), it increased by 11.63%; compared with k-nearest neighbor (KNN), it increased by 26.62%; and compared with random forest (RF), it increased by 11.63%. The average Area Under Curve (AUC) of the improved algorithm improved by 0.1143 compared to KNN, by 0.0235 compared to DT, and by 0.04 compared to RF.