Participation in Pulmonary Rehabilitation by Veterans Health Administration and Medicare Beneficiaries After Hospitalization for Chronic Obstructive Pulmonary Disease

Use of implementation science to qualitatively identify implementation determinants of COPD practice guidelines in primary care

Objectives: Chronic Obstructive Pulmonary Disease (COPD) is a progressive respiratory disease with high morbidity and mortality. COPD guidelines (CPG) are greatly underutilized and studies attempting to improve this practice gap have yielded inconsistent results. We hypothesize that using implementation science can provide a detailed understanding of these practice gaps and the reasons behind them. Methods: Since primary care (PC) manages the bulk of COPD patients, in this pilot study, we use principles of implementation science to systematically explore the reasons for this implementation gap in a PC setting. We used the Consolidated Framework of Implementation Science (CFIR), a determinant framework to design semi-structured interview guides to conduct multistakeholder interviews to explore the barriers and facilitators to four key COPD-CPG with known poor uptake: inhaler education, spirometry, pulmonary rehabilitation and COPD-specific patient education from patient and provider perspectives. Qualitative analysis was performed using rapid analysis. Results: Seventeen respondents including both, patients and providers were interviewed. All these COPD-CPG were rated as 'highly important' suggesting that perceived importance alone is insufficient to bridge gaps in uptake. Respondents were least familiar with pulmonary rehabilitation. Physician time constraint was a significant reported barrier. There exist multilevel contextual barriers to each of these COPD-CPG. Discussion: To increase uptake of COPD guidelines, implementation efforts that address multilevel barriers and promote collaborative care by use of non-physician resources are likely to have higher buy-in and greater chances for success.

Effectiveness of a Home-Based Pulmonary Rehabilitation Program in Veterans

Purpose: This study examined the effectiveness and safety of a home-based pulmonary rehabilitation (HBPR) program in Veterans. Methods: Patients were evaluated from five Veteran Affairs facilities that enrolled in the 12-week program. Pre- to postchanges were completed on clinical outcomes using paired t-tests and the Wilcoxon signed rank sum test. Descriptive statistics were used for patient demographics, emergency room visits, and hospitalizations. Results: Two hundred eighty-five patients with a mean age of 69.6 ± 8.3 years enrolled in the HBPR program from October 2018 to March 2020. There was a 62% (n = 176) completion rate of both pre- and post assessments. Significant improvements were detected after completion of the HBPR program in dyspnea (modified Medical Research Council: 3.1 ± 1.1 vs. 1.9 ± 1.1; p < 0.0001); exercise capacity (six-minute walk distance: 263.1 m ± 96.6 m vs. 311.0 m ± 103.6 m; p < 0.0001; Duke Activity Status Index: 13.8 ± 9.6 vs. 20.0 ± 12.7; p < 0.0001; self-reported steps per day: 1514.5 ± 1360.4 vs. 3033.8 ± 2716.2; p < 0.0001); depression (patient health questionnaire-9: 8.3 ± 5.7 vs. 6.4 ± 5.1); nutrition habits (rate your plate, heart: 45.3 ± 9.0 vs. 48.9 ± 9.2; p < 0.0001); multicomponent assessment tools (BODE Index: 5.1 ± 2.5 vs. 3.4 ± 2.4; p < 0.0001), GOLD ABCD Assessment: p < 0.0009); and quality of life (chronic obstructive pulmonary disease assessment test: 25.4 ± 7.7 vs. 18.7 ± 8.5; p < 0.0001). No adverse events were reported due to participation in HBPR. Conclusions: The HBPR program is a safe and effective model and provides an additional option to address the gap in pulmonary rehabilitation access and utilization in the Veterans Affairs.

Insufficient Pulmonary Rehabilitation Uptake After Severe Exacerbation of COPD: A Multicentre Study in the South West Region of France

Purpose

Pulmonary rehabilitation (PR) is a type of multidisciplinary care strongly recommended after severe exacerbation of chronic obstructive pulmonary disease (COPD). Recently, a national French study reported a very low rate of PR uptake (8.6%); however, important clinical data were missing. Here, we aimed to identify the main factors associated with insufficient PR uptake after hospitalisation for COPD exacerbation.

Patients and Methods

This multicentre retrospective study included patients hospitalised with COPD exacerbation between 1 January 2017 and 31 December 2018, as identified by both coding and a detailed review of medical records. PR was defined as inpatient care in a specialised centre or unit within 90 days of discharge. Multivariate logistic regression was used to identify associations between PR uptake and patient characteristics, such as comorbidities, non-invasive ventilation (NIV), inhaled treatment, and forced expiratory volume in 1 second (FEV1).

Results

Among the 325 patients admitted for severe COPD exacerbation, 92 (28.3%) underwent PR within 90 days of discharge. In univariate analysis, relative to those who underwent PR, patients without PR had significantly more comorbidities, were less often treated with triple bronchodilator therapy or NIV, and had a higher FEV1. In multivariate analysis, variables independently associated with the lack of PR uptake were the presence of comorbidities (adjusted odds ratio (aOR) = 1.28 [1.10-1.53], p = 0.003) and a higher FEV1 (aOR = 1.04 [1.02-1.06], p < 0.001). There was no significant correlation between PR uptake and departmental PR centre capacity (notably, some departments had no PR facilities).

Conclusion

These data highlight the lack of PR in the early stages of COPD. Collaboration among all healthcare providers involved in patient management is crucial for improved PR uptake.

Pulmonary Rehabilitation Utilization in Older Adults with Chronic Obstructive Pulmonary Disease, 2013-2019

Rationale: Pulmonary rehabilitation (PR) is very effective in patients with chronic obstructive pulmonary disease (COPD) for improving exercise tolerance and functional capacity, alleviating dyspnea, and improving respiratory quality of life. Access to and use of PR remain poor. Objectives: To assess the trends in PR use and factors associated with PR use in adults with COPD. Methods: We retrospectively analyzed the use of PR in adults with COPD using a 20% Medicare beneficiary population from January 1, 2013, to December 31, 2019. Adults with COPD were identified by 1) two or more outpatient visits >30 days apart within 1 year with an encounter diagnosis of COPD or 2) hospitalization with COPD as the primary diagnosis or a primary diagnosis of acute respiratory failure with a secondary discharge diagnosis of COPD. PR use in each calendar year was identified using Current Procedural Terminology and Healthcare Common Procedure Coding System codes. Factors associated with PR use were tested in bivariate and multivariable logistic regression models. Results: There was a gradual but modest increase in the percentage of patients with COPD using PR; the proportion increased from 2.5% in 2013 to 4.0% in 2019. Overall, the percentage of patients using PR remained low. Factors associated with higher odds of using PR included younger age (66-74 yr), White race, higher socioeconomic status, lower comorbidity score, residence in a metropolitan urban area, and sole or comanagement by a pulmonologist. Conclusions: The use of PR by Medicare beneficiaries with COPD has not changed meaningfully in the past decade and remains low.

Pulmonary Rehabilitation for Adults with Chronic Respiratory Disease: An Official American Thoracic Society Clinical Practice Guideline

Background: Despite the known benefits of pulmonary rehabilitation (PR) for patients with chronic respiratory disease, this treatment is underused. Evidence-based guidelines should lead to greater knowledge of the proven benefits of PR, highlight the role of PR in evidence-based health care, and in turn foster referrals to and more effective delivery of PR for people with chronic respiratory disease. Methods: The multidisciplinary panel formulated six research questions addressing PR for specific patient groups (chronic obstructive pulmonary disease [COPD], interstitial lung disease, and pulmonary hypertension) and models for PR delivery (telerehabilitation, maintenance PR). Treatment effects were quantified using systematic reviews. The Grading of Recommendations, Assessment, Development and Evaluation approach was used to formulate clinical recommendations. Recommendations: The panel made the following judgments: strong recommendations for PR for adults with stable COPD (moderate-quality evidence) and after hospitalization for COPD exacerbation (moderate-quality evidence), strong recommendation for PR for adults with interstitial lung disease (moderate-quality evidence), conditional recommendation for PR for adults with pulmonary hypertension (low-quality evidence), strong recommendation for offering the choice of center-based PR or telerehabilitation for patients with chronic respiratory disease (moderate-quality evidence), and conditional recommendation for offering either supervised maintenance PR or usual care after initial PR for adults with COPD (low-quality evidence). Conclusions: These guidelines provide the basis for evidence-based delivery of PR for people with chronic respiratory disease.

Stepped care versus center-based cardiopulmonary rehabilitation for older frail adults living in rural MA: Design of a feasibility randomized controlled trial

Background

Cardiac and pulmonary rehabilitation programs are grossly underutilized, and participation is particularly low in rural regions.

Methods

We are conducting a 2-arm, randomized controlled feasibility trial. Eligible participants include older frail adults with cardiac or pulmonary disease living in a predominantly rural county in western Massachusetts. Participants are randomized 1:1 to treatment as usual or stepped care. Patients randomized to treatment as usual participate in twice weekly center-based rehabilitation sessions over eight weeks and are encouraged to exercise at home in between sessions. Patients randomized to the stepped-care arm are offered/enrolled in the center-based rehabilitation program followed by possible step up to three interventions based on prespecified non-response criteria: 1) Transportation-assisted center-based rehabilitation, 2) Home-based telerehabilitation, and 3) Community health worker-supported home-based telerehabilitation. The primary feasibility outcomes are average number of eligible patients randomized per month, baseline measure completion, proportion attending at least 70% of the prescribed sessions, average number of sessions attended in the stepped-care arm, and proportion in the stepped-care arm completing patient reported outcome measures. Each of these process indicators is evaluated by preset "Stop" and "Go" thresholds.

Conclusion

The proposed stepped-care model is an efficient, patient-centered, approach to expanding access to cardiac and pulmonary rehabilitation. Meeting the "Go" thresholds for the prespecified process indicators will justify conducting a definitive full-scale randomized controlled trial to compare the effectiveness and value (cost-effectiveness) of stepped-care versus center-based rehabilitation in older frail adults living rural counties.

Association of rural living with COPD-related hospitalizations and deaths in US veterans

It is unclear whether the high burden of COPD in rural areas is related to worse outcomes in patients with COPD or is because the prevalence of COPD is higher in rural areas. We assessed the association of rural living with acute exacerbations of COPD (AECOPDs)-related hospitalization and mortality. We retrospectively analyzed Veterans Affairs (VA) and Medicare data of a nationwide cohort of veterans with COPD aged ≥ 65 years with COPD diagnosis between 2011 and 2014 that had follow-up data until 2017. Patients were categorized based on residential location into urban, rural, and isolated rural. We used generalized linear and Cox proportional hazards models to assess the association of residential location with AECOPD-related hospitalizations and long-term mortality. Of 152,065 patients, 80,162 (52.7%) experienced at least one AECOPD-related hospitalization. After adjusting for demographics and comorbidities, rural living was associated with fewer hospitalizations (relative risk-RR = 0.90; 95% CI: 0.89-0.91; P < 0.001) but isolated rural living was not associated with hospitalizations. Only after accounting for travel time to the closest VA medical center, neighborhood disadvantage, and air quality, isolated rural living was associated with more AECOPD-related hospitalizations (RR = 1.07; 95% CI: 1.05-1.09; P < 0.001). Mortality did not vary between rural and urban living patients. Our findings suggest that other aspects than hospital care may be responsible for the excess of hospitalizations in isolated rural patients like poor access to appropriate outpatient care.

Strategies to Improve Enrollment and Participation in Pulmonary Rehabilitation Following a Hospitalization for COPD: RESULTS OF A NATIONAL SURVEY

PURPOSE

Pulmonary rehabilitation (PR) improves outcomes for patients with chronic obstructive pulmonary disease (COPD); however, very few patients attend. We sought to describe strategies used to promote participation in PR after a hospitalization for COPD.

METHODS

A random sample of 323 United States based PR programs was surveyed. Using a positive deviance approach, a 39-item survey was developed based on interviews with clinicians at hospitals demonstrating high rates of participation in PR. Items focused on strategies used to promote participation as well as relevant contextual factors.

RESULTS

Responses were received from 209 programs (65%), of which 88% (n = 184) were hospital-based outpatient facilities. Most (91%, n = 190) programs described enrolling patients continuously, and 80% (n = 167) reported a wait time from referral to the initial PR visit of <4 wk. Organization-level strategies to increase referral to PR included active surveillance (48%, n = 100) and COPD-focused staff (49%, n = 102). Provider-level strategies included clinician education (45%, n = 94), provider outreach (43%, n = 89), order sets (45%, n = 93), and automated referrals (23%, n = 48). Patient-level strategies included bedside education (53%, n = 111), flyers (49%, n = 103), motivational interviewing (33%, n = 69), financial counseling (64%, n = 134), and transportation assistance (35%, n = 73). Fewer than one-quarter (18%, n = 38) of PR programs reported using both bedside education and automatic referral, and 42% (n = 88) programs did not use either strategy.

CONCLUSIONS

This study describes current practices in the United States, and highlights opportunities for improvement at the organization, provider, and patient level. Future research needs to demonstrate the effectiveness of these strategies, alone or in combination.

Veterans Health Administration (VA) vs. Non-VA Healthcare Quality: A Systematic Review

BACKGROUND

The Veterans Health Administration (VA) serves Veterans in the nation's largest integrated healthcare system. VA seeks to provide high quality of healthcare to Veterans, but due to the VA Choice and MISSION Acts, VA increasingly pays for care outside of its system in the community. This systematic review compares care provided in VA and non-VA settings, and includes published studies from 2015 to 2023, updating 2 prior systematic reviews on this topic.

METHODS

We searched PubMed, Web of Science, and PsychINFO from 2015 to 2023 for published literature comparing VA and non-VA care, including VA-paid community care. Records were included at the abstract or full-text level if they compared VA medical care with care provided in other healthcare systems, and included clinical quality, safety, access, patient experience, efficiency (cost), or equity outcomes. Data from included studies was abstracted by two independent reviewers, with disagreements resolved by consensus. Results were synthesized narratively and via graphical evidence maps.

RESULTS

Thirty-seven studies were included after screening 2415 titles. Twelve studies compared VA and VA-paid community care. Most studies assessed clinical quality and safety, and studies of access were second most common. Only six studies assessed patient experience and six assessed cost or efficiency. Clinical quality and safety of VA care was better than or equal to non-VA care in most studies. Patient experience in VA care was better than or equal to experience in non-VA care in all studies, but access and cost/efficiency outcomes were mixed.

DISCUSSION

VA care is consistently as good as or better than non-VA care in terms of clinical quality and safety. Access, cost/efficiency, and patient experience between the two systems are not well studied. Further research is needed on these outcomes and on services widely used by Veterans in VA-paid community care, like physical medicine and rehabilitation.

Pulmonary rehabilitation after severe exacerbation of COPD: a nationwide population study

BACKGROUND

Acute exacerbations of chronic obstructive pulmonary disease (COPD) lead to a significant reduction in quality of life and an increased mortality risk. Current guidelines strongly recommend pulmonary rehabilitation (PR) after a severe exacerbation. Studies reporting referral for PR are scarce, with no report to date in Europe. Therefore, we assessed the proportion of French patients receiving PR after hospitalization for COPD exacerbation and factors associated with referral.

METHODS

This was a national retrospective study based on the French health insurance database. Patients hospitalized in 2017 with COPD exacerbation were identified from the exhaustive French medico-administrative database of hospitalizations. In France, referral to PR has required as a stay in a specialized PR center or unit accredited to provide multidisciplinary care (exercise training, education, etc.) and admission within 90 days after discharge was assessed. Multivariate logistic regression was used to assess the association between patients' characteristics, comorbidities according to the Charlson index, treatment, and PR uptake.

RESULTS

Among 48,638 patients aged ≥ 40 years admitted for a COPD exacerbation, 4,182 (8.6%) received PR within 90 days after discharge. General practitioner's (GP) density (number of GPs for the population at regional level) and PR center facilities (number of beds for the population at regional level) were significantly correlated with PR uptake (respectively r = 0.64 and r = 0.71). In multivariate analysis, variables independently associated with PR uptake were female gender (aOR 1.36 [1.28-1.45], p < 0.0001), age (p < 0.0001), comorbidities (p = 0.0013), use of non-invasive ventilation and/or oxygen therapy (aOR 1.52 [1.41-1.64], p < 0.0001) and administration of long-acting bronchodilators (p = 0.0038).

CONCLUSION

This study using the French nationally exhaustive health insurance database shows that PR uptake after a severe COPD exacerbation is dramatically low and must become a high-priority management strategy.

Predictors of Outpatient Pulmonary Rehabilitation Uptake, Adherence, Completion, and Treatment Response Among Male U.S. Veterans With Chronic Obstructive Pulmonary Disease

OBJECTIVE

To examine predictors of uptake (never start), adherence (drop out), and completion of pulmonary rehabilitation (PR), as well as PR treatment response based on minimal clinically important difference (MCID) on the 6-minute walk test (6MWT) distance and Chronic Respiratory Questionnaire-Self-Report (CRQ-SR).

DESIGN

Retrospective, cohort study.

SETTING

Veterans Health Administration.

PARTICIPANTS

U.S. veterans with chronic obstructive pulmonary disease (COPD) (N=253) referred to PR between 2010 and 2018.

INTERVENTIONS

Outpatient PR program.

MAIN OUTCOME MEASURES

Participants completed baseline (time 1) measures of depression (Beck Depression Inventory-II), health-related quality of life (CRQ-SR), self-efficacy (Exercise Self-Regulatory Efficacy Scale [Ex-SRES]), and COPD knowledge. Exercise capacity was assessed with the 6MWT. Participants who completed all 18 sessions of PR repeated assessments (time 2). Logistic regression models examined predictors of uptake, adherence, and completion of PR as well as treatment response based on MCID.

RESULTS

Participants were referred to PR with 24.90% never starting, 28.90% dropping out, and 46.20% completing. No differences emerged between never starters and dropouts. Having a history of any cancer increased the likelihood of completing PR (vs never starting; odds ratio [OR], 3.18; P=.003). Greater CRQ-SR dyspnea score, indicating less dyspnea, was associated with increased likelihood of completing PR (OR, 1.12; P=.006). Past smoking compared with current smoking was associated with increased likelihood of completion (OR, 3.89; P≤.002). Those without a history of alcohol use disorder had increased likelihood of completing PR (OR, 2.23; P=.048). Greater baseline 6MWT distance was associated with lower likelihood of achieving MCID in 6MWT (OR, 0.99; P<.001). Greater Ex-SRES was associated with decreased likelihood of achieving 6MWT MCID (OR, 0.98; P=.023).

CONCLUSIONS

Findings suggest that early psychoeducation on dyspnea management and smoking and alcohol cessation may increase completion of PR.

Will Remotely Based Pulmonary Rehabilitation Water Down Its Effectiveness?

Despite numerous benefits, traditional Pulmonary Rehabilitation (PR) as a resource remains underutilized in chronic lung disease. Less than 3% of eligible candidates for PR attend one or more sessions after hospitalization due to many barriers, including the ongoing COVID-19 pandemic. Emerging alternative models of PR delivery such as home-based PR, tele-rehabilitation, web-based PR, or hybrid models could help address these barriers. Numerous studies have tested the feasibility, safety, and efficacy of these methods, but there is wide variability across studies and methods. We conducted a literature review to help determine if these alternative delivery methods watered down the effectiveness of PR. To evaluate the effectiveness of remotely based PR, the authors performed a literature search for randomized controlled trials (RCTs), cohort studies, and case series using PubMed, CINAHL, and Medline to identify relevant articles through 1 May 2021. Twenty-six applicable studies were found in which 11 compared tele-rehabilitation to conventional clinic-based PR; 11 evaluated tele-rehabilitation using the patient’s baseline status as control; and four compared tele-rehabilitation to no rehabilitation. Despite the different technologies used across studies, tele-rehabilitation was found to be both a feasible and an efficacious option for select patients with lung disease. Outcomes across these studies demonstrated similar benefits to traditional PR programs. Thus the existing data does not show that remotely based PR waters down the effectiveness of conventional PR. Use of remotely based PR is a feasible and effective option to deliver PR, especially for patients with significant barriers to conventional clinic-based PR. Additional, well-conducted RCTs are needed to answer the questions regarding its efficacy, safety, cost-effectiveness and who, among patients with COPD and other lung diseases, will derive the maximum benefit.

Indications for medical antibiotic prophylaxis and potential targets for antimicrobial stewardship intervention: a narrative review

BACKGROUND

Most of the antimicrobial stewardship (AMS) literature has focused on antimicrobial consumption for the treatment of infections, for the prophylaxis of surgical site infection and for the prevention of endocarditis. The role of AMS for medical antibiotic prophylaxis (AP) has not been adequately addressed.

AIMS

To identify targets for AMS interventions for medical AP in adult patients.

SOURCES

Targeted searches were conducted in PubMed.

CONTENT

The various indications for medical AP and relevant evidence from practice guidelines are outlined. The following were identified as potential targets for AMS interventions: (a) addressing under-utilization of antibiotic-sparing strategies (e.g. for recurrent urinary tract infections, recurrent soft-tissue infections, recurrent exacerbations associated with bronchiectasis or chronic obstructive pulmonary disease), (b) reducing unnecessary AP beyond recommended indications (e.g. for acute pancreatitis, bite wounds, or urinary catheter manipulations), (c) reducing the use of AP with a broader spectrum than necessary, (d) reducing the use of AP for longer than the recommended duration (e.g. AP for prevention of osteomyelitis in open fractures or AP in high-risk neutropenia), (e) evaluating the role of antibiotic cycling to prevent the emergence of resistance during prolonged AP (e.g. in recurrent urinary tract infections or prophylaxis for spontaneous bacterial peritonitis), and (f) addressing research gaps regarding appropriate indications or antibiotic regimens for medical prophylaxis.

IMPLICATIONS

This review summarizes current trends in AP and proposes targets for AMS interventions.

Integrating Home-Based Exercise Training with a Hospital at Home Service for Patients Hospitalised with Acute Exacerbations of COPD: Developing the Model Using Accelerated Experience-Based Co-Design

BACKGROUND

Hospital at home (HaH) schemes allow early discharge of patients hospitalised with an acute exacerbation of chronic obstructive pulmonary disease (AECOPD). Traditional outpatient pulmonary rehabilitation (PR) following an AECOPD has an established evidence-base, but there are issues with low referral, uptake and completion. One commonly cited barrier to PR post-hospitalisation relates to poor accessibility. To address this, the aim of this project was to enrol service users (patients with COPD and informal carers) and healthcare professionals to co-design a model of care that integrates home-based exercise training within a HaH scheme for patients discharged from hospital following AECOPD.

METHODS

This accelerated experience-based co-design project included three audio-recorded stakeholder feedback events, using key "touchpoints" from previous qualitative interviews and a recent systematic review. Audio-recordings were inductively analysed using directed content analysis. An integrated model of care was then developed and finalised through two co-design groups, with the decision-making process facilitated by the tables of changes approach.

RESULTS

Seven patients with COPD, two informal carers and nine healthcare professionals (from an existing outpatient PR service and HaH scheme) participated in the stakeholder feedback events. Four key themes were identified: 1) individualisation, 2) progression and transition, 3) continuity between services, and 4) communication between stakeholders. Two patients with COPD, one informal carer and three healthcare professionals participated in the first joint co-design group, with five healthcare professionals attending a second co-design group. These achieved a consensus on the integrated model of care. The agreed model comprised face-to-face supervised, individually tailored home-based exercise training one to three times a week, delivered during HaH scheme visits where possible by a healthcare professional competent to provide both home-based exercise training and usual HaH care.

CONCLUSION

An integrated model of care has been co-designed by patients with COPD, informal carers and healthcare professionals to address low uptake and completion of PR following AECOPD. The co-designed model of care has now been integrated within a well-established HaH scheme.

The Effects of a Video Intervention on Posthospitalization Pulmonary Rehabilitation Uptake. A Randomized Controlled Trial

Rationale: Pulmonary rehabilitation (PR) after hospitalizations for exacerbations of chronic obstructive pulmonary disease (COPD) improves exercise capacity and health-related quality of life and reduces readmissions. However, posthospitalization PR uptake is low. To date, no trials of interventions to increase uptake have been conducted.Objectives: To study the effect of a codesigned education video as an adjunct to usual care on posthospitalization PR uptake.Methods: The present study was an assessor- and statistician-blinded randomized controlled trial with nested, qualitative interviews of participants in the intervention group. Participants hospitalized with COPD exacerbations were assigned 1:1 to receive either usual care (COPD discharge bundle including PR information leaflet) or usual care plus the codesigned education video delivered via a handheld tablet device at discharge. Randomization used minimization to balance age, sex, FEV₁ % predicted, frailty, transport availability, and previous PR experience.Measurements and Main Results: The primary outcome was PR uptake within 28 days of hospital discharge. A total of 200 patients were recruited, and 196 were randomized (51% female, median FEV_1% predicted, 36 [interquartile range, 27-48]). PR uptake was 41% and 34% in the usual care and intervention groups, respectively (P = 0.37), with no differences in secondary (PR referral and completion) or safety (readmissions and death) endpoints. A total of 6 of the 15 participants interviewed could not recall receiving the video.Conclusions: A codesigned education video delivered at hospital discharge did not improve posthospitalization PR uptake, referral, or completion.

"You Leave There Feeling Part of Something": A Qualitative Study of Hospitalized COPD Patients' Perceptions of Pulmonary Rehabilitation

Rationale

Current guidelines recommend that patients hospitalized for acute exacerbations of chronic obstructive pulmonary disease (COPD) initiate pulmonary rehabilitation (PR) shortly after discharge from the hospital. However, fewer than 2 percent of Medicare beneficiaries do so. Few studies have examined hospitalized patients’ perceptions of the barriers and facilitators to enroll in PR. The aim of this study was to develop an understanding of these factors by interviewing patients.

Methods

We conducted semi-structured interviews with patients during a hospitalization for COPD exacerbation in a large teaching hospital. Directed content analysis was used to code and analyze interview transcripts.

Results

Of the 15 patients we interviewed, 9 had participated in PR prior to their hospitalization, 10 were women; 4 were black, and 1 was Hispanic. Facilitators of enrollment included a desire to learn more about the disease, social support, and trust in the health-care provider recommending PR. Barriers to enrollment included lack of awareness, family obligations, lack of motivation, and transportation. For those who had previous experience with PR, but who did not complete the program, another barrier was not feeling well enough. Facilitators to adherence included the educational component of the program; feeling better through exercise; and a social connection with both participants and staff. For some patients. PR contributed to a renewed sense of hope or meaning. Most interviewees expressed interest in a peer coaching program.

Conclusion

Our results highlight the importance of increasing awareness of PR and building trust between the provider and patients to facilitate initial enrollment. Future interventions to improve enrollment and adherence should address the need for education about the benefits of PR and the value of social support.

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A Geographic Analysis of Racial Disparities in Use of Pulmonary Rehabilitation After Hospitalization for COPD Exacerbation

BACKGROUND

Guidelines recommend pulmonary rehabilitation (PR) after hospitalization for an exacerbation of COPD, but few patients enroll in PR. We explored whether density of PR programs explained regional variation and racial disparities in receipt of PR.

METHODS

We used Centers for Medicare & Medicaid Services data from 223,832 Medicare beneficiaries hospitalized for COPD during 2012 who were eligible for PR postdischarge. We used Hospital-Referral Regions (HRR) as the unit of analysis. For each HRR, we calculated the density of PR programs as a measure of program access and estimated risk-standardized rates of PR within 6 months of discharge overall, and for non-Hispanic, white, and black beneficiaries. We used linear regression to examine the relationship between access to PR and HRR PR rates. We tested for racial disparity in PR rates among non-Hispanic white and black beneficiaries living in the same HRRs.

RESULTS

Across 306 HRRs, the median number of PR programs per 1,000 Medicare beneficiaries was 0.06 (interquartile range [IQR], 0.04-0.10). Risk-standardized rates of PR ranged from 0.53% to 6.67% (median, 1.93%). Density of PR programs was positively associated with PR rates overall and among non-Hispanic white beneficiaries (P < .001), but this relationship was not observed among black beneficiaries. Rates were higher among non-Hispanic white beneficiaries (median, 2.08%; IQR, 1.54%-2.87%) compared with black beneficiaries (median, 1.19%; IQR, 1.15%-1.20%).

CONCLUSIONS

Greater PR program density was associated with higher rates of PR for non-Hispanic white but not black beneficiaries. Further research is needed to identify reasons for this discrepancy and strategies to increase receipt of PR for black patients.

Pulmonary rehabilitation for people with chronic obstructive pulmonary disease: A protocol for an overview of Cochrane reviews

BACKGROUND

Pulmonary rehabilitation (PR) is an indispensable component in the nonpharmacological management of patients with chronic obstructive pulmonary disease (COPD) with significant improvements in quality of life and exercise capacity. It is strongly supported by systematic reviews (SR) as part of the treatment of these patients. However, it is not known which PR components are essential, such as duration, ideal locations, type and intensity of training, degree of supervision, adherence, cost-effectiveness challenge, and how long the program effects last. This overview aims to evaluate and describe different pulmonary rehabilitation interventions for individuals with COPD.

METHODS

Only systematic reviews of randomized controlled trials (RCTs) published in the Cochrane Database of Systematic Reviews will be included. The following results were analyzed: health-related quality of life, functional capacity, mortality, dyspnea, cost-effectiveness, and adverse events. The risk of bias will be assessed by the Risk of Bias in Systematic Reviews (ROBIS). The methodological quality will be analyzed through the Assessment of Multiple Systematic Reviews (AMSTAR-2). We will use the evaluations of the Classification of Recommendations, Evaluation, Development and Evaluation (GRADE) of the authors of the included systematic reviews. The screening of systematic reviews, eligibility evaluation, data extraction, methodological quality, and quality of evidence will be performed in pairs by independent reviewers. The results that have been reported in the included reviews will be summarized in an "Overview of Reviews" table. The main conclusions about the effects of the interventions studied in the included reviews will be summarized and organized in clinically meaningful categories.

RESULTS

The article in this overview will be submitted for publication in a peer-reviewed journal. The results will also be included in a doctoral thesis and disclosed in medical conferences.

CONCLUSIONS

We expect to compile evidence from multiple systematic reviews of pulmonary rehabilitation in people with COPD in an accessible and useful document.

REGISTRATION NUMBER PROSPERO

CRD42019111564.