Alternative Modes of Delivery in Pulmonary Rehabilitation: A Critical Appraisal of the Literature

PURPOSE

This review presents an overview of the safety and efficacy of alternative modes of pulmonary rehabilitation (PR) in people with chronic obstructive pulmonary disease (COPD).

REVIEW METHODS

We identified recently published systematic reviews, meta-analyses, and guidelines, as well as relevant studies, exploring the safety and effectiveness of community-based PR, home-based PR, telerehabilitation, and web-based rehabilitation in people with COPD. A narrative summary of the main findings is presented.

SUMMARY

Although evidence suggests that community-based PR, home-based PR, telerehabilitation, and web-based rehabilitation are effective alternatives to center-based PR, it requires a careful interpretation as several of these programs do not comply with PR definition and have been compared with center-based PR programs that do not reach the minimal clinically important differences. Moreover, there is a huge heterogeneity among programs, and the confidence and quality of the evidence is mostly low. Hence, these novel modes of PR and center-based PR are not interchangeable. Instead, these are alternative modes aiming to increase access to PR. Questions remain regarding the most efficient way of implementing each PR mode, level of access, reimbursement policies, and data privacy in the use of technology. Standard protocols on how to set up each alternative PR mode need to be developed. Future research needs to explore how to use the treatable traits approach in combination with individual preferences and needs, program availability, safety, social support network, digital literacy, and health system context to identify the optimal PR program for each patient.

Chronic obstructive pulmonary disease features in patients visiting primary respiratory clinic and tertiary hospital in Japan

Pulmonologists in primary care clinics are positioned between those in tertiary hospitals and general practitioners in clinics and are anticipated to promote hospital-clinic collaboration for patients with chronic obstructive pulmonary disease (COPD). However, the clinical features of patients in primary respiratory clinics are unclear. This multicenter study cross-sectionally compared the characteristics of patients with COPD in a respiratory clinic (n = 69) with those in a university hospital (n = 124). More patients visited the clinic for symptom relief without a referral, whereas more visited the hospital for consultation of abnormal spirometry/computed tomography (CT). The patients in the clinic showed female predilection, higher prevalence of current smokers, severe dyspnea, and concomitant heart failure, and higher CT-measured cross-sectional area ratio of pectoralis muscle to adjacent subcutaneous adipose tissue compared to those in the hospital (all p < 0.05). The observed differences between the two groups suggest the need to establish the role of primary pulmonologists in hospital-clinic collaboration for better COPD management.

Embedding Pulmonary Rehabilitation for Chronic Obstructive Pulmonary Disease in the Home and Community Setting: A Rapid Review

This paper presents a rapid review of the literature for the components, benefits, barriers, and facilitators of pulmonary rehabilitation for chronic obstructive pulmonary disease (COPD) people in-home and community-based settings. seventy-six studies were included: 57 home-based pulmonary rehabilitation (HBPR) studies and 19 community-based pulmonary rehabilitation (CBPR) studies. The benefits of HBPR on exercise capacity and health-related quality of life were observed in one-group studies, studies comparing HBPR to usual care, and studies comparing to hospital-based pulmonary rehabilitation, although the benefits were less pronounced in the latter. HBPR reduced hospital admissions compared to usual care and was more cost-effective than hospital pulmonary rehabilitation. Most HBPRs were designed with low-density or customized equipment, are minimally supervised, and have a low intensity of training. Although the HBPR has flexibility and no travel burden, participants with severe disease, physical frailty, and complex comorbidities had barriers to complying with HBPR. The telerehabilitation program, a facilitator for HBPR, is feasible and safe. CBPR was offered in-person supervision, despite being limited to physical therapists in most studies. Benefits in exercise capacity were shown in almost all studies, but the improvement in health-related quality of life was controversial. Patients reported the benefits that facilities where they attended the CBPR including social support and the presence of an instructor. They also reported barriers, such as poor physical condition, transport difficulties, and family commitments. Despite the minimal infrastructure offered, HBPR and CBPR are feasible, safe, and provide clinical benefits to patients with COPD. Home and community settings are excellent opportunities to expand the offer of pulmonary rehabilitation programs, as long as they follow protocols that ensure quality and safety following current guidelines.

Effects of community-based pulmonary rehabilitation in 33 municipalities in Denmark - results from the KOALA project

Background

The positive impact of pulmonary rehabilitation (PR) in patients with COPD is well documented. However, little is known regarding the effect of this treatment in community-based settings. Since 2007, all Danish municipalities have been offering PR to patients with moderate to severe COPD, whereas patients with very severe disease or those suffering from many comorbidities were referred to outpatient hospital-based PR.

Objective

To analyze the effect of a standardized PR program conducted in a community-based setting on exercise capacity and health-related quality of life (HRQoL).

Methods

This is a real-life study including data from patients attending PR at one of the 33 healthcare centers in Denmark during the period 2011–2012. For the purpose of registration and for quality assurance, the KOALA database was established and this web-based registration instrument was offered free of charge to every municipality. Measures included sociodemographic and health-related variables and outcomes were exercise capacity and HRQoL assessed by 6-minute walking distance (6MWD) and the 15D questionnaire, respectively, at the beginning (baseline) and after completion of PR. Relative improvements in 6MWD and 15D were analyzed with multivariable linear models in patients who attended >50% of the sessions.

Results

A total of 581 patients completed the PR (72% of those included). We found statistically significant and clinically meaningful differences between baseline and end of rehabilitation values for both main outcomes with a mean change in 6MWD of 45 m, and the magnitude of improvement corresponds to other findings. Furthermore, relative improvements in 6MWD and 15D were correlated, as was the relative change in 15D and baseline Medical Research Council scores.

Conclusion

Standardized, multidisciplinary PR conducted in a community-based setting showed good adherence to the program and produced effects on exercise capacity and HRQoL that were clinically meaningful and comparable in size to hospital-based PR.

Burden of COPD in patients treated in different care settings in the Netherlands

INTRODUCTION

Care for patients with chronic obstructive pulmonary disease (COPD) can be provided in primary, secondary or tertiary care. Whether and to what extent patients with COPD treated in various healthcare settings differ in disease burden and healthcare utilization remains unknown. Therefore, daily symptoms, functional mobility, mood status, health status and healthcare utilization were compared between COPD patients in various care settings, to explore possibilities for healthcare-optimization.

METHODS

Current data are part of the Chance study. Demographics, functional mobility (Care Dependency Scale (CDS); Timed-Up-and-Go (TUG) test), mood status (Hospital Anxiety and Depression scale (HADS)), health status (COPD Assessment test (CAT); Clinical COPD questionnaire (CCQ); COPD specific St. George Respiratory questionnaire (SGRQ-C)), received treatments and severity of physical and psychological symptoms were assessed in subjects with and without COPD.

RESULTS

836 subjects (100 primary care patients, 100 secondary care patients, 518 tertiary care patients and 118 non-COPD subjects) were included. The burden of disease significantly increased from primary care to tertiary care. However, in all three healthcare settings a high percentage of patients with an impaired health status was observed (i.e. CAT ≥10 points, 68.0% vs. 91.0% vs. 94.5%, respectively). Furthermore, many patients treated in secondary care remain highly symptomatic despite treatment, while others with low burden of disease would allow for de-intensification of care.

CONCLUSION

This study revealed important shortcomings and challenges for the care of COPD patients in the Netherlands. It emphasizes the need for detailed patient characterization and more individualized treatment, independent of the healthcare setting.

Use of exercise testing in the evaluation of interventional efficacy: an official ERS statement

This document reviews 1) the measurement properties of commonly used exercise tests in patients with chronic respiratory diseases and 2) published studies on their utilty and/or evaluation obtained from MEDLINE and Cochrane Library searches between 1990 and March 2015.

Exercise tests are reliable and consistently responsive to rehabilitative and pharmacological interventions. Thresholds for clinically important changes in performance are available for several tests. In pulmonary arterial hypertension, the 6-min walk test (6MWT), peak oxygen uptake and ventilation/carbon dioxide output indices appear to be the variables most responsive to vasodilators. While bronchodilators do not always show clinically relevant effects in chronic obstructive pulmonary disease, high-intensity constant work-rate (endurance) tests (CWRET) are considerably more responsive than incremental exercise tests and 6MWTs. High-intensity CWRETs need to be standardised to reduce interindividual variability. Additional physiological information and responsiveness can be obtained from isotime measurements, particularly of inspiratory capacity and dyspnoea. Less evidence is available for the endurance shuttle walk test. Although the incremental shuttle walk test and 6MWT are reliable and less expensive than cardiopulmonary exercise testing, two repetitions are needed at baseline. All exercise tests are safe when recommended precautions are followed, with evidence suggesting that no test is safer than others.

A randomised trial of telemedicine-based treatment versus conventional hospitalisation in patients with severe COPD and exacerbation - effect on self-reported outcome

We investigated self-reported outcome in patients with COPD and exacerbation. Consecutive patients were randomised to an intervention group with home telemedicine and a control group who had conventional hospital admission. We assessed Health-Related Quality of Life (HRQoL) using the St George's Respiratory Questionnaire, daily activity using Instrumental Activity of Daily Living, anxiety and depression using the Hospital Anxiety and Depression Scale, and self-assessed cognitive decline using Subjective Cognitive Functioning. Data were collected at 3 days, 6 weeks and 3 months after discharge. There were 22 patients in each group. Their baseline characteristics were similar: a mean age of 70 years, FEV₁ 42% predicted and oxygen saturation 95%. After 6 weeks, FEV₁ had improved in both groups, to 1.2 L in the intervention group and 1.0 L in the control group. Oxygen saturation had improved in the intervention group from 94% to 96%. Regarding HRQoL, there was a non-significant (P = 0.05) improvement in the symptom score in favour of the control group, but the improvement was not maintained after three months. However, there were no significant differences in self-reported outcomes in COPD patients with exacerbation treated at home via telemedicine versus conventionally in hospital.