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Zhang A, Wang L, Long L, Yan J, Liu C, Zhu S, Wang X. Effectiveness and Economic Evaluation of Hospital-Outreach Pulmonary Rehabilitation for Patients with Chronic Obstructive Pulmonary Disease. Int J Chron Obstruct Pulmon Dis 2020; 15:1071-1083. [PMID: 32523337 PMCID: PMC7237127 DOI: 10.2147/copd.s239841] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 03/27/2020] [Indexed: 01/05/2023] Open
Abstract
Objective Hospital-outreach pulmonary rehabilitation (PR) can improve health status and reduce health-care utilization by patients with chronic obstructive pulmonary disease (COPD). However, its long-term effects and costs versus benefits are still not clear. This study was conducted to develop, deliver, and evaluate the effects and monetary savings of a hospital-outreach PR program for patients with COPD. Methods A randomized controlled trial was conducted. Patients with COPD (n=208) were randomly assigned to the hospital-outreach PR program (treatment) or treatment as usual (control). The treatment group received a 3-month intensive intervention, including supervised physical exercise, smoking cessation, self-management education, and psychosocial support, followed by long-term access to a nurse through telephone follow-up and home visits up to 24 months. The control group received routine care, including discharge education and a self-management education brochure. Main outcomes were collected at 3, 6, 12, and 24 -months postrandomization. Primary outcomes included health-care utilization (ie, readmission rates, times, and days, and emergency department visits) and medical costs. Secondary outcomes included lung function (ie, FEV1, FEV1% predicted, FVC), dyspnea (mMCR), exercise capacity (6MWD), impact on quality of life (CAT), and self-management (CSMS). Results At the end of 24 months, 85 (81.7%) in the treatment group and 89 (85.6%) in the control group had completed the whole program. Compared with the control group, patients in the treatment group had lower readmission rates, times, and days at 6 and 12 months and during 12-24 months. Regarding costs during the 2 years, the program achieved CN¥3,655.94 medical savings per patient per year, and every ¥1 spent on the program led to ¥3.29 insavings. Patients in the treatment group achieved improvements in FEV1, FEV1% predicted, exercise capacity, and self-management. It also achieved relief of dyspnea symptoms and improvement in COPD's impact on quality of life. Conclusion The hospital-outreach PR program for patients with COPD achieved reductions in health-care utilization, monetary savings, and improvements in patient health outcomes. The effects of the program were sustained for at least 2 years. Trial Registration This trial was registered at the Chinese Clinical Trial Registry (ChiCTR-TRC-14005108).
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Affiliation(s)
- Aidi Zhang
- Nursing Department, Third Xiangya Hospital of Central South University, Changsha410013, People’s Republic of China
| | - Lianhong Wang
- The First Affiliated Hospital of Zunyi Medical University, Zunyi563003, People’s Republic of China
| | - Lu Long
- Nursing Department, Third Xiangya Hospital of Central South University, Changsha410013, People’s Republic of China
| | - Jin Yan
- Nursing Department, Third Xiangya Hospital of Central South University, Changsha410013, People’s Republic of China
- Xiang Ya Nursing School of Central South University,Changsha410013, People’s Republic of China
| | - Chun Liu
- Respiratory Department, Third Xiangya Hospital of Central South University, Changsha410013, People’s Republic of China
| | - Sucui Zhu
- Nursing Department, Third Xiangya Hospital of Central South University, Changsha410013, People’s Republic of China
| | - Xiaowan Wang
- Center for Health Policy and Management, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, People's Republic of China
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Stewart KFJ, Meis JJM, van de Bool C, Janssen DJA, Kremers SPJ, Schols AMWJ. Maintenance of a physically active lifestyle after pulmonary rehabilitation in patients with COPD: a qualitative study toward motivational factors. J Am Med Dir Assoc 2014; 15:655-64. [PMID: 24947760 DOI: 10.1016/j.jamda.2014.05.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Accepted: 05/08/2014] [Indexed: 10/25/2022]
Abstract
OBJECTIVES To explore determinants of behavior change maintenance of a physically active lifestyle in patients with chronic obstructive pulmonary disease (COPD) 8-11 months after completion of a 4-month outpatient pulmonary rehabilitation program. DESIGN A qualitative descriptive study of semistructured interviews. SETTING Pulmonary rehabilitation assessment center. PARTICIPANTS Patients with COPD. MEASUREMENTS Semistructured interviews until data saturation, coded by 2 independent researchers. Patients were classified as responder (maintenance or improvement) or nonresponder (relapse or decrease), based on 3 quantitative variables reflecting exercise capacity (Constant Work Rate Test), health-related quality of life (Short-Form health survey [SF-36]), and self-management abilities (Self-Management Ability Scale [SMAS-30/Version 2]). RESULTS Mean (SD) forced expiratory volume in the first second (FEV1) among interviewees was 52.5% (14.4%) predicted and the mean age was 63.5 years (range: 45-78). The group consisted of 15 responders and 7 nonresponders. Physical limitations reduced competence to engage in an active lifestyle and responders appeared to experience higher levels of perceived competence. Social support was found important and the experienced understanding from fellow patients made exercising together enjoyable. Particularly, responders expressed autonomous motivation and said they exercised because of the benefits they gain from it. Unexpectedly, only responders also experienced controlled motivation. CONCLUSION Perceived competence and autonomous motivation are important determinants for maintenance of an active lifestyle in patients with COPD. In contrast to common theoretical assumptions, a certain threshold level of controlled motivation may remain important in maintaining a physically active lifestyle after a pulmonary rehabilitation program.
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Affiliation(s)
- Kelly F J Stewart
- Department of Respiratory Medicine, NUTRIM School for Nutrition, Toxicology and Metabolism, Maastricht University Medical Center+, Maastricht, The Netherlands.
| | - Jessie J M Meis
- Department of Health Promotion, NUTRIM School for Nutrition, Toxicology and Metabolism, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Coby van de Bool
- Department of Respiratory Medicine, NUTRIM School for Nutrition, Toxicology and Metabolism, Maastricht University Medical Center+, Maastricht, The Netherlands; Department of Research and Education, CIRO+, Center of Expertise for Chronic Organ Failure, Horn, The Netherlands
| | - Daisy J A Janssen
- Department of Research and Education, CIRO+, Center of Expertise for Chronic Organ Failure, Horn, The Netherlands
| | - Stef P J Kremers
- Department of Health Promotion, NUTRIM School for Nutrition, Toxicology and Metabolism, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Annemie M W J Schols
- Department of Respiratory Medicine, NUTRIM School for Nutrition, Toxicology and Metabolism, Maastricht University Medical Center+, Maastricht, The Netherlands
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A qualitative assessment of COPD patients' experiences of pulmonary rehabilitation and guidance by healthcare professionals. Respir Med 2013; 108:500-10. [PMID: 24280544 DOI: 10.1016/j.rmed.2013.11.001] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2013] [Revised: 10/31/2013] [Accepted: 11/03/2013] [Indexed: 11/22/2022]
Abstract
BACKGROUND The present study aimed to assess COPD patients' experiences during an in-patient pulmonary rehabilitation program and the guidance provided by healthcare professionals. A third aim regarded examining ways to anticipate the transfer to the home environment after completion of the program. METHODS Focus groups and semi-structured interviews were used to collect data from seven COPD patients at the beginning and six other COPD patients at the end of an in-patient pulmonary rehabilitation program, supplemented by a focus group and semi-structured interviews with 14 healthcare professionals of the involved disciplines. Data were analyzed using a phenomenological approach. RESULTS Starting out, patients displayed trouble with acceptance of their disease, they had insufficient knowledge, and showed difficulties in setting specific realistic goals. Seeing fellow patients struggle with similar problems and tailored counseling by healthcare professionals helped them to overcome these barriers. During rehabilitation, patients became more confident in exercising and managing their daily life activities. Many patients evolved a desire to self-regulate their lives. Incorporating health-enhancing behaviors after returning home into their usual daily routines was anticipated to be tough. CONCLUSION Patients undergoing pulmonary rehabilitation experience a complex health behavior change process, in which healthcare professionals fulfill a major contributing role. Therefore, guiding patients through this health behavior change process is a vital component of healthcare professionals' work, regarding which the present study made practical implications such as applying a personalized approach by giving tailored advices, applying an autonomy-supportive counseling style, teaching self-management skills, and referring patients to local exercise facilities.
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Butts JF, Belfer MH, Gebke KB. Exercise for patients with COPD: an integral yet underutilized intervention. PHYSICIAN SPORTSMED 2013; 41:49-57. [PMID: 23445860 DOI: 10.3810/psm.2013.02.1999] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Chronic obstructive pulmonary disease (COPD) was the third leading cause of mortality in the United States in 2009 and accounts for millions of dollars in health care expenses annually. It is characterized by slow declines in functional ability and exercise tolerance, which are strongly predictive of poor health-related quality of life and survival. The cycle of physical, social, and psychosocial consequences of COPD is more easily prevented than remedied; therefore, maintaining baseline respiratory function is a key goal of early treatment. Although medical management of COPD is generally well understood and implemented by most primary care physicians, multidisciplinary approaches that include nonpharmacologic modalities (eg, exercise training) are not often used. Exercise training can alleviate dyspnea and improve exercise tolerance and health-related quality of life in patients with mild-to-severe COPD. Pulmonary rehabilitation, which includes exercise training, nutritional and psychological counseling, and patient education, is an important component of COPD treatment and management programs, and is currently underutilized in the United States. This article addresses the role of exercise as part of a multidisciplinary approach to the management of COPD, especially with regard to pulmonary rehabilitation.
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Affiliation(s)
- Jessica Favero Butts
- Department of Family Medicine and Sports Medicine, Indiana University, Indianapolis, IN, USA.
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Bentsen SB, Wentzel-Larsen T, Henriksen AH, Rokne B, Wahl AK. Anxiety and depression following pulmonary rehabilitation. Scand J Caring Sci 2012; 27:541-50. [PMID: 22924539 DOI: 10.1111/j.1471-6712.2012.01064.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
AIM The aim of this study was to evaluate changes and predictive factors of anxiety and depression in patients with chronic obstructive pulmonary disease (COPD) before and up to 3 months after pulmonary rehabilitation (PR). METHODS A single group longitudinal design of patients with COPD underwent a PR programme. The measurements took place at baseline (T1: N=100), immediately before (T2: N=66), immediately after (T3: N=54) and 3 months after (T4: N=43) the programme. The programme was a 6-week outpatient programme, including education, psychosocial support and training sessions. Anxiety and depression were measured by the Hospital Anxiety and Depression Scale, self-efficacy by the COPD self-efficacy scale, lung function by spirometry and exercise capacity by incremental shuttle walking test. Mixed effect model analyses were used. RESULTS Results showed a tendency of less anxiety and depression immediately after (T3) compared with immediately before (T2) the PR programme, but the changes were not significant. Results also showed that female reported significantly more anxiety than male (p=0.019), better exercise capacity predicted significantly less depression (p=0.049), and higher self-efficacy predicted both significantly less anxiety (p=0.001) and less depression (p=0.005). CONCLUSIONS A tendency of less anxiety and depression during the PR programme was found, but the changes were not significant. Higher level of self-efficacy and better exercise capacity are suggested to relieve anxiety and depression.
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Affiliation(s)
- Signe Berit Bentsen
- Department of Health Education, Stord/Haugesund University College, Haugesund, Norway.
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McFarland C, Willson D, Sloan J, Coultas D. A Randomized Trial Comparing 2 Types of In-Home Rehabilitation for Chronic Obstructive Pulmonary Disease. J Geriatr Phys Ther 2012; 35:132-9. [DOI: 10.1519/jpt.0b013e31824145f5] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Lin WC, Yuan SC, Chien JY, Weng SC, Chou MC, Kuo HW. The effects of respiratory training for chronic obstructive pulmonary disease patients: a randomised clinical trial. J Clin Nurs 2012; 21:2870-8. [PMID: 22672732 DOI: 10.1111/j.1365-2702.2012.04124.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
AIMS AND OBJECTIVES To assess the effects of respiratory training on lung function, activity tolerance and quality of life in patients with chronic obstructive pulmonary disease. BACKGROUND For patients with chronic obstructive pulmonary disease, pulmonary rehabilitation can increase activity tolerance and improve their psychological state by relieving dyspnoea and promoting their quality of life. DESIGN A randomised clinical trial was conducted in a local hospital. METHODS Patients with chronic obstructive pulmonary disease were randomly assigned to intervention (n=20) and control groups (n=20). Spirometry, six-minute walking distance and quality of life were used to assess the efficacy of respiratory training programme. RESULTS Significant improvement in lung function, including forced vital capacity (p=0.037), forced expiratory volume in one-second (p=0.006) and per cent predicted forced expiratory volume in one-second (p=0.008) in the intervention group. Regarding efficacy of the training programme for patients with chronic obstructive pulmonary disease, in forced expiratory volume in one-second (p=0.024) and per cent predicted forced expiratory volume in one-second (p=0.035), six-minute walking distance significantly increased. In addition, there were significant improvements for symptoms (p=0.018), impact (p<0.001) and total quality of life scores (p<0.001), as well as significantly decreased body mass, airflow obstruction, dyspnoea and exercise capacity index (p=0.004) in the intervention group. CONCLUSIONS A respiratory training programme for patients with chronic obstructive pulmonary disease was found to relieve dyspnoea, maintain lung function, increase activity tolerance and improve quality of life. RELEVANCE TO CLINICAL PRACTICE Respiratory training programme can be used as a routine rehabilitation protocol for patients with chronic obstructive pulmonary disease and can be used by nurses as a reference to monitor chronic obstructive pulmonary disease patients' health status.
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Affiliation(s)
- Wei-Chun Lin
- College of Nursing, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan
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Halding AG. Research. INTERNATIONAL JOURNAL OF THERAPY AND REHABILITATION 2011. [DOI: 10.12968/ijtr.2011.18.11.642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Abstract
People who live with chronic obstructive pulmonary disease (COPD) experience major changes in health. Coping with the illness and caring for themselves places extensive demands on them. Thus, pulmonary rehabilitation (PR) is recommended as a means to facilitate healthy transitions in everyday life with COPD. This study explores the experience of patients with COPD in terms of their transitions in health during and after PR. The research was inspired by interpretive phenomenology. Thirty-three individual qualitative interviews were conducted with eighteen patients recruited from Norwegian PR units. A thematic analysis of the interviews was performed. The interviewees described participation in PR as a time of increasing awareness of opportunities for health and well-being with strengthened hope. The year following PR was dominated by their ongoing challenge to acknowledge limitations and explore opportunities in everyday life. Continuation of healthy transitions was facilitated by peer and professional support. The study highlights the personal resources that patients with COPD have access to in order to promote their own health. The study also highlights their vulnerability during illness and rehabilitation. The findings critique time-limited PR and support the current trends towards patient-centred rehabilitation efforts that incorporate user involvement and self-management education.
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Affiliation(s)
- Anne-Grethe Halding
- Faculty of Health Studies, Sogn og Fjordane University College, Førde, Norway.
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Garvey C, Fromer L, Saver DF, Yawn BP. Pulmonary rehabilitation: an underutilized resource in primary COPD care. PHYSICIAN SPORTSMED 2010; 38:54-60. [PMID: 21150142 DOI: 10.3810/psm.2010.12.1825] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Pulmonary rehabilitation (PR) is an important component of chronic obstructive pulmonary disease (COPD) management. Physician use of PR for patients with COPD lags behind national and international guideline recommendations. In this article, we discuss the important components of PR, including exercise training, self-management education, and psychosocial and nutritional interventions, as based on the American Thoracic Society/European Respiratory Society and Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines. We also discuss the potential benefits of PR, including reduction of respiratory symptoms, decreased disability, and increased participation in physical and social activities. Increased activity promotes independence, improves quality of life, and reduces the number of COPD exacerbations and hospitalizations. In all stages of COPD, PR has been shown to result in improved exercise tolerance, with reduced dyspnea and fatigue, although the greatest improvement has been seen in patients with GOLD stages II to IV. Pulmonary rehabilitation is now a well-recognized therapy that should be available to all patients with symptomatic COPD. To facilitate inclusion of PR in COPD management, primary care physicians need to recognize and diagnose COPD, and regularly decide when PR best fits in an individual's COPD treatment program.
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Fromer L, Barnes T, Garvey C, Ortiz G, Saver DF, Yawn B. Innovations to achieve excellence in COPD diagnosis and treatment in primary care. Postgrad Med 2010; 122:150-64. [PMID: 20861599 DOI: 10.3810/pgm.2010.09.2212] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Recognition of chronic obstructive pulmonary disease (COPD) is often missed or delayed in primary care. Once recognized, COPD is often undertreated or episodically treated, focusing on acute exacerbations without establishing maintenance treatment to control ongoing disease. Diagnostic and therapeutic pessimism result in missed opportunities to reduce exacerbations, maintain physical functioning, and reduce emergent health care requirements. Proactive diagnosis and evidence-based management can alleviate the impact of COPD on patients' lives. Smoking cessation has been proven to slow the rate of lung function decline. Maintenance pharmacotherapy and immunizations reduce exacerbations. Pulmonary rehabilitation improves respiratory symptoms and physical functioning and reduces rehospitalizations after exacerbations. Self-management education improves health-related quality of life and reduces inpatient and emergency care usage. Maintenance treatment with long-acting inhaled bronchodilators is appropriate beginning in moderate COPD to maintain airway patency and reduce exacerbations. Tiotropium is US Food and Drug Administration (FDA) approved to treat bronchospasm and reduce exacerbations in patients with COPD; salmeterol/fluticasone is FDA approved to treat airflow obstruction in COPD and reduce exacerbations in patients with a history of exacerbations. Other maintenance long-acting bronchodilators-salmeterol, formoterol, and budesonide/formoterol-are FDA approved to treat airway obstruction in COPD but lack an approved indication against exacerbations. FDA warnings on the use of long-acting beta-adrenergic agents (LABAs) in asthma specifically exempt COPD and do not apply to LABA/inhaled corticosteroid combinations used in COPD. The actual effectiveness achieved in practice with any COPD therapies depends on patients' inhaler technique, adherence, and persistence. Medication usage rates and inhaler proficiency may be improved by concordance, in which the health care provider and patient collaborate to make treatment plans sustainable in the patient's daily life. Practice redesign for whole-patient primary care provides additional tools for comprehensive COPD management. Innovations such as group visits and the patient-centered medical home provide newer ways to interact with COPD patients and their families. Patient-focused and evidence-based options enable primary care practices to manage COPD longitudinally and improve patient outcomes through the course of the disease.
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Affiliation(s)
- Len Fromer
- Department of Family Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA, USA.
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Bentsen SB, Wentzel-Larsen T, Henriksen AH, Rokne B, Wahl AK. Self-efficacy as a predictor of improvement in health status and overall quality of life in pulmonary rehabilitation--an exploratory study. PATIENT EDUCATION AND COUNSELING 2010; 81:5-13. [PMID: 20356700 DOI: 10.1016/j.pec.2009.11.019] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/23/2009] [Revised: 11/12/2009] [Accepted: 11/24/2009] [Indexed: 05/29/2023]
Abstract
OBJECTIVE To evaluate developments in health status (HS) and overall quality of life (QOL), and the impact of self-efficacy on HS and QOL in relation to COPD pulmonary rehabilitation (PR). METHODS A longitudinal study of 100 COPD patients before and up to 3 months after COPD PR. Self-efficacy was measured by the COPD self-efficacy scale, HS by the St. George Respiratory Questionnaire and QOL by the Quality of Life Scale. Mixed effect models were used. RESULTS Patients reported significantly reduced psychosocial impact of disease (estimate=-4.05, p=0.019) immediately after the PR programme. Higher levels of self-efficacy at baseline predicted significantly reduced psychosocial impact of disease and improved physical activity, total HS and QOL (p<0.05). Better exercise capacity at baseline predicted significantly reduced psychosocial impact of disease, improved physical activity and QOL (p<0.05). Older age at baseline predicted significantly fewer respiratory symptoms and improved total HS (p<0.05). CONCLUSIONS Patients reported significantly reduced psychosocial impact of disease immediately after a COPD PR, and better exercise capacity and higher self-efficacy at baseline predicted significantly improved HS and QOL. PRACTICE IMPLICATIONS Increasing self-efficacy is suggested to be an important aim in relation to COPD PR.
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Affiliation(s)
- Signe Berit Bentsen
- Stord/Haugesund University College, Department of Nursing Education, Haugesund, Norway.
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