Systematic review of interventions to improve patient uptake and completion of pulmonary rehabilitation in COPD

A tailored psychological intervention for anxiety and depression management in people with chronic obstructive pulmonary disease: TANDEM RCT and process evaluation

Background

People with chronic obstructive pulmonary disease have high levels of anxiety and depression, which is associated with increased morbidity and poor uptake of effective treatments, such as pulmonary rehabilitation. Cognitive-behavioural therapy improves mental health of people with long-term conditions and could potentially increase uptake of pulmonary rehabilitation, enabling synergies that could enhance the mental health of people with chronic obstructive pulmonary disease.

Aim

Our aim was to develop and evaluate the clinical effectiveness and cost effectiveness of a tailored cognitive-behavioural approach intervention, which links into, and optimises the benefits of, routine pulmonary rehabilitation.

Design

We carried out a pragmatic multicentre randomised controlled trial using a 1.25 : 1 ratio (intervention : control) with a parallel process evaluation, including assessment of fidelity.

Setting

Twelve NHS trusts and five Clinical Commissioning Groups in England were recruited into the study. The intervention was delivered in participant's own home or at a local NHS facility, and by telephone.

Participants

Between July 2017 and March 2020 we recruited adults with moderate/very severe chronic obstructive pulmonary disease and mild/moderate anxiety and/or depression, meeting eligibility criteria for assessment for pulmonary rehabilitation. Carers of participants were invited to participate.

Intervention

The cognitive-behavioural approach intervention (i.e. six to eight 40- to 60-minute sessions plus telephone support throughout pulmonary rehabilitation) was delivered by 31 trained respiratory healthcare professionals to participants prior to commencing pulmonary rehabilitation. Usual care included routine pulmonary rehabilitation referral.

Main outcome measures

Co-primary outcomes were Hospital Anxiety and Depression Scale - anxiety and Hospital Anxiety and Depression Scale - depression at 6 months post randomisation. Secondary outcomes at 6 and 12 months included health-related quality of life, smoking status, uptake of pulmonary rehabilitation and healthcare use.

Results

We analysed results from 423 randomised participants (intervention, n = 242; control, n = 181). Forty-three carers participated. Follow-up at 6 and 12 months was 93% and 82%, respectively. Despite good fidelity for intervention delivery, mean between-group differences in Hospital Anxiety and Depression Scale at 6 months ruled out clinically important effects (Hospital Anxiety and Depression Scale - anxiety mean difference -0.60, 95% confidence interval -1.40 to 0.21; Hospital Anxiety and Depression Scale - depression mean difference -0.66, 95% confidence interval -1.39 to 0.07), with similar results at 12 months. There were no between-group differences in any of the secondary outcomes. Sensitivity analyses did not alter these conclusions. More adverse events were reported for intervention participants than for control participants, but none related to the trial. The intervention did not generate quality-of-life improvements to justify the additional cost (adjusted mean difference £770.24, 95% confidence interval -£27.91 to £1568.39) to the NHS. The intervention was well received and many participants described positive affects on their quality of life. Facilitators highlighted the complexity of participants' lives and considered the intervention to be of potential valuable; however, the intervention would be difficult to integrate within routine clinical services. Our well-powered trial delivered a theoretically designed intervention with good fidelity. The respiratory-experienced facilitators were trained to deliver a low-intensity cognitive-behavioural approach intervention, but high-intensity cognitive-behavioural therapy might have been more effective. Our broad inclusion criteria specified objectively assessed anxiety and/or depression, but participants were likely to favour talking therapies. Randomisation was concealed and blinding of outcome assessment was breached in only 15 participants.

Conclusions

The tailored cognitive-behavioural approach intervention delivered with fidelity by trained respiratory healthcare professionals to people with chronic obstructive pulmonary disease was neither clinically effective nor cost-effective. Alternative approaches that are integrated with routine long-term condition care are needed to address the unmet, complex clinical and psychosocial needs of this group of patients.

Trial registration

This trial is registered as ISRCTN59537391.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 13/146/02) and is published in full in Health Technology Assessment; Vol. 28, No. 1. See the NIHR Funding and Awards website for further award information.

A Systematic Review of the Effectiveness of Interventions to Promote Referral; Adherence; and Uptake of Pulmonary Rehabilitation for Patients with Chronic Obstructive Pulmonary Disease

Background

Pulmonary rehabilitation (PR) is an effective treatment for patients with chronic obstructive pulmonary disease (COPD). However, referral, uptake, and adherence remain low.

Objective

To determine effectiveness of interventions to increase patient referral, uptake, and adherence to PR programs for patients with COPD.

Methods

Randomized controlled trials (RCTs), non-randomized controlled trials, pre-post studies, and uncontrolled studies were sought from 7 databases and 3 clinical trial registries, to end August 2021. Full articles/conference abstracts were included if a coordinated set of activities was targeted to healthcare professionals (HCPs) caring for COPD patients, adults with COPD or their carers, to increase referral, uptake or adherence to any type of PR program. Two review authors independently screened titles, abstracts and full texts, extracted data and critically appraised studies using standard risk of bias tools.

Results

From 11,272 records, 30 studies (23 full-text; 7 abstracts) met inclusion criteria: study interventions and designs were varied and generally low quality, targeting patients (n=13), HCPs (n=14) or both (n=3 studies). A CCT of patient held evidence score cards increased referral by 7.3% compared to 1.3% for usual care (p-0.03). A cluster RCT involving COPD nurse home visits with individualized care plans increased uptake to 31% compared to 10% in usual care (p=0.002). For people with anxiety or depression, one RCT of cognitive behavioral therapy alongside PR increased adherence (mean sessions 14.0 (sd 1.7) compared to 12.4 (sd 2.6)).

Conclusion

Although a small number of studies, the weight of evidence suggested that interventions incorporating partnership working between patients and HCPs appeared to increase referral, uptake, and adherence with greater effectiveness than those targeting single populations. Increasing knowledge and empowering HCPs and patients may be important strategies. Concerns about study design and risk of bias suggest clear need for well-designed trials of interventions to report full pathway outcomes.

Telerehabilitation in pulmonary diseases

PURPOSE OF REVIEW

Telerehabilitation is an alternative delivery model for pulmonary rehabilitation, an evidence-based nonpharmacological intervention, in people with chronic pulmonary disease. This review synthesizes current evidence regarding the telerehabilitation model for pulmonary rehabilitation with an emphasis on its potential and implementation challenges, as well as the clinical experiences from the COVID-19 pandemic.

RECENT FINDINGS

Different models of telerehabilitation for delivering pulmonary rehabilitation exist. Current studies comparing telerehabilitation to centre-based pulmonary rehabilitation primarily focus on the evaluation in people with stable chronic obstructive pulmonary disease, which demonstrated equivalent improvements in exercise capacity, health-related quality of life and symptoms with improved programme completion rates. Although telerehabilitation may improve access to pulmonary rehabilitation by addressing travel burden, improving schedule flexibility and geographic disparity, there are challenges of ensuring satisfaction of healthcare interactions and delivering core components of initial patient assessment and exercise prescription remotely.

SUMMARY

Further evidence is needed on the role of telerehabilitation in various chronic pulmonary diseases, as well as the effectiveness of different modalities in delivering telerehabilitation programmes. Economic and implementation evaluation of currently available and emerging models of telerehabilitation in delivering pulmonary rehabilitation are needed to ensure sustainable adoption into clinical management for people with chronic pulmonary disease.

Factors which facilitate or impede patient engagement with pulmonary and cardiac rehabilitation: a rapid evaluation mapping review

Background

There is a considerable body of systematic review evidence considering the effectiveness of rehabilitation programmes on clinical outcomes. However, much less is known about effectively engaging and sustaining patients in rehabilitation. There is a need to understand the full range of potential intervention strategies.

Methods

We conducted a mapping review of UK review-level evidence published 2017-21. We searched MEDLINE, EMBASE and the Cumulative Index to Nursing and Allied Health (CINAHL) and conducted a narrative synthesis. Included reviews reported factors affecting commencement, continuation or completion of cardiac or pulmonary rehabilitation, or an intervention to facilitate these factors. Study selection was undertaken independently by two reviewers.

Results

In total, we identified 20 review papers that met our inclusion criteria. There was a bias towards reviews considering cardiac rehabilitation, with these numbering 16. An additional 11 unpublished interventions were also identified through internet searching of key websites. The reviews included 60 identifiable UK primary studies that considered factors which affected attendance at rehabilitation; 42 considered cardiac rehabilitation and 18 considering pulmonary rehabilitation. They reported on factors from the patients' point of view, as well as the views of professionals involved in referral or treatment. It was more common for factors to be reported as impeding attendance at rehabilitation rather than facilitating it. We grouped the factors into patient perspective (support, culture, demographics, practical, health, emotions, knowledge/beliefs and service factors) and professional perspective (knowledge: staff and patient, staffing, adequacy of service provision and referral from other services, including support and wait times). We found considerably fewer reviews (n = 3) looking at interventions to facilitate participation in rehabilitation. Although most of the factors affecting participation were reported from a patient perspective, most of the identified interventions were implemented to address barriers to access in terms of the provider perspective. The majority of access challenges identified by patients would not therefore be addressed by the identified interventions. The more recent unevaluated interventions implemented during the COVID-19 pandemic may have the potential to act on some of the patient barriers in access to services, including travel and inconvenient timing of services.

Conclusions

The factors affecting commencement, continuation or completion of cardiac or pulmonary rehabilitation consist of a web of complex and interlinked factors taking into consideration the perspectives of the patients and the service providers. The small number of published interventions we identified that aim to improve access are unlikely to address the majority of these factors, especially those identified by patients as limiting their access. Better understanding of these factors will allow future interventions to be more evidence based with clear objectives as to how to address the known barriers to improve access.

Limitations

Time limitations constrained the consideration of study quality and precluded the inclusion of additional searching methods such as citation searching and contacting key authors. This may have implications for the completeness of the evidence base identified.

Future work

High-quality effectiveness studies of promising interventions to improve attendance at rehabilitation, both overall and for key patient groups, should be the focus moving forward.

Funding

This report presents independent research funded by the National Institute for Health Research (NIHR). The views and opinions expressed by authors in this publication are those of the authors and do not necessarily reflect those of the NHS, the NIHR, NETSCC, the HSDR programme or the Department of Health.

Study registration

The study protocol is registered with PROSPERO [CRD42022309214].

Review of the British Thoracic Society Winter Meeting 23 November 2022 23-25 November 2022

The British Thoracic Society Winter Meeting at the QEII Centre in London provided the first opportunity for the respiratory community to meet and disseminate research findings face to face since the start of the COVID-19 pandemic. World-leading researchers from the UK and abroad presented their latest findings across a range of respiratory diseases. This article aims to represent the range of the conference and as such is written from the perspective of a basic scientist, a physiotherapist and two doctors. The authors reviewed showcase sessions plus a selection of symposia based on their personal highlights. Content ranged from exciting new developments in basic science to new and unpublished results from clinical trials, delivered by leading scientists from their fields including former deputy chief medical officer Professor Sir Jonathan Van-Tam and former WHO chief scientist Dr Soumya Swaminathan.

A mobile-based airway clearance care system using deep learning-based vision technology to support personalized home-based pulmonary rehabilitation for COAD patients: Development and usability testing

Background

Excessive mucus secretion is a serious issue for patients with chronic obstructive airway disease (COAD), which can be effectively managed through postural drainage and percussion (PD + P) during pulmonary rehabilitation (PR). Home-based (H)-PR can be as effective as center-based PR but lacks professional supervision and timely feedback, leading to low motivation and adherence. Telehealth home-based pulmonary (TH-PR) has emerged to assist H-PR, but video conferencing and telephone calls remain the main approaches for COAD patients. Therefore, research on effectively assisting patients in performing PD + P during TH-PR is limited.

Objective

This study developed a mobile-based airway clearance care for chronic obstructive airway disease (COAD-MoAcCare) system to support personalized TH-PR for COAD patients and evaluated its usability through expert validation.

Methods

The COAD-MoAcCare system uses a mobile device through deep learning-based vision technology to monitor, guide, and evaluate COAD patients' PD + P operations in real time during TH-PR programs. Medical personnel can manage and monitor their personalized PD + P and operational statuses through the system to improve TH-PR performance. Respiratory therapists from different hospitals evaluated the system usability using system questionnaires based on the technology acceptance model, system usability scale (SUS), and task load index (NASA-TLX).

Results

Eleven participant therapists were highly satisfied with the COAD-MoAcCare system, rating it between 4.1 and 4.6 out of 5.0 on all scales. The system demonstrated good usability (SUS score of 74.1 out of 100) and a lower task load (NASA-TLX score of 30.0 out of 100). The overall accuracy of PD + P operations reached a high level of 97.5% by comparing evaluation results of the system by experts.

Conclusions

The COAD-MoAcCare system is the first mobile-based method to assist COAD patients in conducting PD + P in TH-PR. It was proven to be usable by respiratory therapists, so it is expected to benefit medical personnel and COAD patients. It will be further evaluated through clinical trials.

Effectiveness of home-based pulmonary rehabilitation: systematic review and meta-analysis

INTRODUCTION

Despite proven effectiveness for people with chronic respiratory diseases, practical barriers to attending centre-based pulmonary rehabilitation (centre-PR) limit accessibility. We aimed to review the clinical effectiveness, components and completion rates of home-based pulmonary rehabilitation (home-PR) compared to centre-PR or usual care.

METHODS AND ANALYSIS

Using Cochrane methodology, we searched (January 1990 to August 2021) six electronic databases using a PICOS (population, intervention, comparison, outcome, study type) search strategy, assessed Cochrane risk of bias, performed meta-analysis and narrative synthesis to answer our objectives and used the Grading of Recommendations, Assessment, Development and Evaluations framework to rate certainty of evidence.

RESULTS

We identified 16 studies (1800 COPD patients; 11 countries). The effects of home-PR on exercise capacity and/or health-related quality of life (HRQoL) were compared to either centre-PR (n=7) or usual care (n=8); one study used both comparators. Compared to usual care, home-PR significantly improved exercise capacity (standardised mean difference (SMD) 0.88, 95% CI 0.32-1.44; p=0.002) and HRQoL (SMD -0.62, 95% CI -0.88--0.36; p<0.001). Compared to centre-PR, home-PR showed no significant difference in exercise capacity (SMD -0.10, 95% CI -0.25-0.05; p=0.21) or HRQoL (SMD 0.01, 95% CI -0.15-0.17; p=0.87).

CONCLUSION

Home-PR is as effective as centre-PR in improving functional exercise capacity and quality of life compared to usual care, and is an option to enable access to pulmonary rehabilitation.

“My life is not going to be the same, my health is going to improve”: a cross-sectional qualitative study of patients’ experiences of living with chronic respiratory symptoms and their views on a proposed pulmonary rehabilitation program at Queen Elizabeth Central Hospital, Blantyre, Malawi

Background: Malawi’s population has a substantial burden of chronic respiratory symptoms. Elsewhere, patients with these symptoms have benefited from pulmonary rehabilitation (PR), a program of exercise training, education, and behaviour management. Practically, PR in Malawi may not be delivered in the same format as elsewhere due to substantial contextual differences. These differences necessitate adaptation of the intervention to Malawi’s setting to be acceptable and effective. This study explored patients’ experiences of living with chronic respiratory symptoms and their views on a proposed PR program at Queen Elizabeth Central Hospital, Blantyre, Malawi, to inform the design of an individualized and culturally adapted PR program. Methods: This was a cross-sectional qualitative study. Face-to-face, one-to-one semi-structured in-depth interviews were undertaken to data saturation. Interviews were audio-recorded, transcribed verbatim, and Chichewa transcripts were translated into English. The transcripts were anonymized and thematically analysed using an inductive approach. Results: We recruited 10 patients (five males and five females) with functionally limiting chronic respiratory symptoms, with documented causes including chronic obstructive pulmonary disease, asthma, post-tuberculosis lung disease, and bronchiectasis. Symptoms most frequently included dyspnoea, with associated functional limitations including the reduced performance of activities of daily living. Participants’ coping strategies most frequently included the use of inhalers. Participants were motivated to undertake the PR program owing to its anticipated benefits including improved health. They perceived transport costs and competing commitments as barriers to participation. The participant group gender mix and public nature of the program were considered socio-culturally sensitive by some participants. Conclusions: The functionally limiting dyspnoea most frequently experienced by the study participants would be amenable to a PR program. To ensure participation by eligible patients, pre-program assessments should consider patient access to transport, suitability of the timing for the program’s sessions, and patient views on organizational aspects of the program considered social-culturally sensitive.

Satisfaction and Adherence of COPD Patients to a Conventional Training Associated with Functional Exercises and to a Conventional Training Isolated: A Qualiquantitative Study

PURPOSE

To verify, through quali-quantitative analysis, the satisfaction and adherence of patients with Chronic Obstructive Pulmonary Disease (COPD) to the insertion of functional circuit training into conventional training.

PATIENTS AND METHODS

23 patients with COPD from a randomized clinical trial were invited to participate in a quali-quantitative analysis after the training finalization, divided into FTG (Functional Training Group) and CTG (Conventional Training Group). A total of 21 patients participated [(FTG: n=10; 65.80±7.31 years; FEV₁/FVC: 56.44±12.67%) and CTG (n=11; 70.36±7.02 years; FEV₁/FVC: 55.89±8.20)]. For the qualitative evaluation, focus groups were performed, using a previously developed script. Adherence was verified by the presence in the training sessions that were prescribed, and the quantitative analysis was performed using questionnaires with multiple-choice questions (evaluation of the aspects that can interfere in a training). The participants were asked to define a grade between zero and ten regarding the aspects of the training (satisfaction).

RESULTS

In both groups, there was similar adherence (p=0.965) and satisfaction (p=0.341). The qualitative analysis identified seven themes and 17 codes, representing factors related to satisfaction and negative aspects, as follows: factors associated with satisfaction: self-efficacy management, physical and psychosocial improvement, interpersonal relationships, and proposed exercises. Negative aspects: pains, comorbidities, beliefs, and personal demotivation. In the quantitative analysis, was verified that an increase in the symptoms, the distance between home and training center, and personal problems were not factors that interfered in the adherence of the participants (p<0.05).

CONCLUSION

Similar satisfaction and adherence of patients with COPD were observed in the FTG and CTG and patients from FTG reported higher fatigue.

Listen to Me! - A Mixed-Methods Study of Thoughts and Attitudes Towards Participation in Pulmonary Telerehabilitation Among People with Severe and Very Severe COPD Who Declined Participation in Pulmonary Rehabilitation

INTRODUCTION

Pulmonary rehabilitation (PR) is a key standard treatment for people with chronic obstructive pulmonary disease (COPD) with documented effect on symptom relief, improved physical function, and quality of life. However, referral, uptake and adherence rates remain low. Pulmonary telerehabilitation (PTR) is a safe and effective alternative to conventional PR. This study explores associations, thoughts and attitudes towards PTR in patients with COPD who decline referral to outpatient hospital-based routine PR.

METHODS

A mixed-methods study with integration of survey data (n=84) and semi-structured interviews (n=9).

RESULTS

We found a significant association between belief of effect of PTR and willingness to participate. Increasing age was significantly associated with reduced odds of daily use of central processing unit (CPU) or tablet. One-third of the participants were undecided about potential participation in PTR. Qualitative findings highlight that participants perceived participating in PTR as more convenient and had preferences for individualized, supervised, and monitored rehabilitation.

CONCLUSION

Those willing to participate in a PTR program believed in the benefits, were comfortable with technological devices, had preferences for exercising at home, and saw opportunities in the social setting. Future PTR programs should include monitoring, preferably managed by a familiar health care professional (HCP).

A systematic review of the characteristics of interventions that promote physical activity in adults with asthma

Physical activity is promoted in the asthma population through pulmonary rehabilitation, but limited funding and facilities are available. This review aimed to examine the effectiveness of interventions that promote physical activity and identify the behaviour change techniques (BCTs) and other intervention components used. Five databases were searched, and 25 studies met the inclusion criteria. Interventions had a significant positive effect on physical activity, sedentary behaviour, quality of life and asthma symptoms. BCTs used across intervention and control groups were similar in studies that showed effects and those that did not. Future interventions should employ techniques that help to maintain behaviour change.

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.

The Need for Expanding Pulmonary Rehabilitation Services

Pulmonary rehabilitation is a strongly recommended and effective treatment for people with chronic lung disease. However, access to pulmonary rehabilitation is poor. Globally, pulmonary rehabilitation is accessed by less than 3% of people with chronic lung disease. Barriers to referral, uptake and completion of pulmonary rehabilitation are well documented and linked with organizational, practitioner and patient-related factors. Enhancing the knowledge of health care professionals, family carers, and people with chronic lung disease about the program and its benefits produces modest increases in referral and uptake rates, but evidence of the sustainability of such approaches is limited. Additionally, initiatives focusing on addressing organizational barriers to access, such as expanding services and implementing alternative models to the conventional center-based setting, are not yet widely used in clinical practice. The COVID-19 pandemic has highlighted the urgent need for health care systems to deliver pulmonary rehabilitation programs remotely, safely, and efficiently. This paper will discuss the pressing need to address the issue of the low accessibility of pulmonary rehabilitation. It will also highlight the distinctive challenges to pulmonary rehabilitation delivery in rural and remote regions, as well as low-income countries.

Development and validation of a prediction model for actionable aspects of frailty in the text of clinicians' encounter notes

OBJECTIVE

Frailty is a prevalent risk factor for adverse outcomes among patients with chronic lung disease. However, identifying frail patients who may benefit from interventions is challenging using standard data sources. We therefore sought to identify phrases in clinical notes in the electronic health record (EHR) that describe actionable frailty syndromes.

MATERIALS AND METHODS

We used an active learning strategy to select notes from the EHR and annotated each sentence for 4 actionable aspects of frailty: respiratory impairment, musculoskeletal problems, fall risk, and nutritional deficiencies. We compared the performance of regression, tree-based, and neural network models to predict the labels for each sentence. We evaluated performance with the scaled Brier score (SBS), where 1 is perfect and 0 is uninformative, and the positive predictive value (PPV).

RESULTS

We manually annotated 155 952 sentences from 326 patients. Elastic net regression had the best performance across all 4 frailty aspects (SBS 0.52, 95% confidence interval [CI] 0.49-0.54) followed by random forests (SBS 0.49, 95% CI 0.47-0.51), and multi-task neural networks (SBS 0.39, 95% CI 0.37-0.42). For the elastic net model, the PPV for identifying the presence of respiratory impairment was 54.8% (95% CI 53.3%-56.6%) at a sensitivity of 80%.

DISCUSSION

Classification models using EHR notes can effectively identify actionable aspects of frailty among patients living with chronic lung disease. Regression performed better than random forest and neural network models.

CONCLUSIONS

NLP-based models offer promising support to population health management programs that seek to identify and refer community-dwelling patients with frailty for evidence-based interventions.

Defining Modern Pulmonary Rehabilitation. An Official American Thoracic Society Workshop Report

Pulmonary rehabilitation is a highly effective treatment for people with chronic lung disease but remains underused across the world. Recent years have seen the emergence of new program models that aim to improve access and uptake, including telerehabilitation and low-cost, home-based models. This workshop was convened to achieve consensus on the essential components of pulmonary rehabilitation and to identify requirements for successful implementation of emerging program models. A Delphi process involving experts from across the world identified 13 essential components of pulmonary rehabilitation that must be delivered in any program model, encompassing patient assessment, program content, method of delivery, and quality assurance, as well as 27 desirable components. Only those models of pulmonary rehabilitation that have been tested in clinical trials are currently considered as ready for implementation. The characteristics of patients most likely to succeed in each program model are not yet known, and research is needed in this area. Health professionals should use clinical judgment to determine those patients who are best served by a center-based, multidisciplinary rehabilitation program. A comprehensive patient assessment is critical for personalization of pulmonary rehabilitation and for effectively addressing individual patient goals. Robust quality-assurance processes are important to ensure that any pulmonary rehabilitation service delivers optimal outcomes for patients and health services. Workforce capacity-building and training should consider the skills necessary for emerging models, many of which are delivered remotely. The success of all pulmonary rehabilitation models will be judged on whether the essential components are delivered and on whether the expected patient outcomes, including improved exercise capacity, reduced dyspnea, enhanced health-related quality of life, and reduced hospital admissions, are achieved.

The effect of pulmonary rehabilitation on physical performance and health related quality of life in patients with chronic lung disease

Pulmonary rehabilitation (PR) is a multidisciplinary approach that improves exercise capacity and health-related quality of life in patients with chronic lung disease. We retrospectively reviewed the medical records of the patients with chronic lung disease who participated in the PR program at University Medical Center in Lubbock, Texas, between 2014 and 2019. Clinical information, 6-min walk test (6 MW T) results, the number of emergency department (ED) visits and hospitalizations, and psychosocial questionnaires (CAT score, PHQ9 and mMRC dyspnea score) were recorded before and after the completion of the program. Multiple variable linear regression and logistic regression were used to analyze the relationships between patient characteristics and changes in the 6-min walk distance and the achievement of a minimal clinically important differences (MCID) in the 6-min walk distance, the CAT score, the PHQ-9, and the mMRC. 279 patients enrolled in pulmonary rehabilitation; 144 patients (52%) completed the program. After completion of the program, 84 patients increased their 6 MW T distance to exceed the MCID with a mean increase of 178 feet, and the number of ED visits and hospitalizations decreased from 0.80 ± 1.11 to 0.55 ± 0.87 (p < 0.05) in the six months before and after rehabilitation. There were statistically significant improvements in all three psychosocial scores. Factors associated with non-completion included younger age, female gender, and shorter baseline 6 MW T distances. The MCID helps evaluate patient outcomes following pulmonary rehabilitation and provide more definite assessment of benefits. The high dropout rate indicates that programs must continuously monitor patient participation and interest.

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.

Efficacy of unsupervised exercise in adults with obstructive lung disease: a systematic review and meta-analysis

INTRODUCTION

The benefits of unsupervised exercise programmes in obstructive lung disease are unclear. The aim of this systematic review was to synthesise evidence regarding the efficacy of unsupervised exercise versus non-exercise-based usual care in patients with obstructive lung disease.

METHODS

Electronic databases (MEDLINE, CINAHL, Embase, Allied and Complementary Medicine Database, Web of Science, Cochrane Central Register of Controlled Trials and Physiotherapy Evidence Database) and trial registers (ClinicalTrials.gov, Current Controlled Trials, UK Clinical Trials Gateway and WHO International Clinical Trials Registry Platform) were searched from inception to April 2020 for randomised trials comparing unsupervised exercise programmes with non-exercise-based usual care in adults with chronic obstructive pulmonary disease (COPD), non-cystic fibrosis bronchiectasis or asthma. Primary outcomes were exercise capacity, quality of life, mortality, exacerbations and respiratory cause hospitalisations.

RESULTS

Sixteen trials (13 COPD, 2 asthma, 1 chronic bronchitis: 1184 patients) met the inclusion criteria. Only data on COPD populations were available for meta-analysis. Unsupervised exercise resulted in a statistically but not clinically significant improvement in the 6-Minute Walk Test (n=5, MD=22.0 m, 95% CI 4.4 to 39.6 m, p=0.01). However, unsupervised exercise did lead to statistically significant and clinically meaningful improvements in St. George's Respiratory Questionnaire (n=4, MD=-11.8 points, 95% CI -21.2 to -2.3 points, p=0.01) and Chronic Respiratory Disease Questionnaire domains (dyspnoea: n=4, MD=0.5 points, 95% CI 0.1 to 0.8 points, p<0.01; fatigue: n=4, MD=0.7 points, 95% CI 0.4 to 1.0 points, p<0.01; emotion: n=4, MD=0.5 points, 95% CI 0.2 to 0.7 points, p<0.01; mastery: unable to perform meta-analysis) compared with non-exercise-based usual care.

DISCUSSION

This review demonstrates clinical benefits of unsupervised exercise interventions on health-related quality of life in patients with COPD. High-quality randomised trials are needed to examine the effectiveness of prescription methods.

How to Ensure Referral and Uptake for COPD Rehabilitation - Part 2: A Case of Integrated Care on How to Translate Findings of Cross-Sectorial Workflow to Improve Cross-Sectorial Rehabilitation

Background:

Patients with chronic obstructive pulmonary disease (COPD) can greatly benefit from rehabilitation initiatives, but referral to rehabilitation is sparse. Before we initiated activities to ensure hospital referrals for prevention initiatives at the municipality, we investigated referral patterns and relevant factors in the cross-sectorial workflow.

Objective:

To ensure referral to municipality COPD rehabilitation, by simplifying the referral procedures, and by facilitating relational coordination across the two health care settings.

Methods:

We simplified the referral procedure by initiating all referrals to contain standard wording, all send to the same electronic location, and assuring that all patients were referred to the same initial interview. We facilitated cross-sectorial relational coordination by establishing local- and cross-sectional network groups. We monitored the network groups, and send questionnaires to obtain knowledge of network activities. We used indicators to measure the cross-sectorial quality and questionnaires to measure the patient experienced quality.

Results:

We detected flaws in the referral system that meant that several referrals were neglected. Based on knowledge and experiences the networks called for adjustments. This led to adjustments in patient inclusion and data collection.

Conclusion:

We succeeded in simplifying referral procedures and facilitated cross-sectorial relational coordination. We had to make ongoing adjustments of procedures, information, content, population and data infrastructure.in simplifying referral procedures and facilitated cross-sectorial relational coordination. We had to make ongoing adjustments of procedures, information, content, population and data infrastructure.

Protocol for the cultural adaptation of pulmonary rehabilitation and subsequent testing in a randomised controlled feasibility trial for adults with chronic obstructive pulmonary disease in Sri Lanka

INTRODUCTION

International guidelines recommend pulmonary rehabilitation (PR) should be offered to adults living with chronic obstructive pulmonary disease (COPD), but PR availability is limited in Sri Lanka. Culturally appropriate PR needs to be designed and implemented in Sri Lanka. The study aims to adapt PR to the Sri Lankan context and determine the feasibility of conducting a future trial of the adapted PR in Sri Lanka.

METHODS AND ANALYSIS

Eligible participants will be identified and will be invited to take part in the randomised controlled feasibility trial, which will be conducted in Central Chest Clinic, Colombo, Sri Lanka. A total of 50 participants will be recruited (anticipated from April 2021) to the trial and randomised (1:1) into one of two groups; control group receiving usual care or the intervention group receiving adapted PR. The trial intervention is a Sri Lankan-specific PR programme, which will consist of 12 sessions of exercise and health education, delivered over 6 weeks. Focus groups with adults living with COPD, caregivers and nurses and in-depth interviews with doctors and physiotherapist will be conducted to inform the Sri Lankan specific PR adaptations. After completion of PR, routine measures in both groups will be assessed by a blinded assessor. The primary outcome measure is feasibility, including assessing eligibility, uptake and completion. Qualitative evaluation of the trial using focus groups with participants and in-depth interviews with PR deliverers will be conducted to further determine feasibility and acceptability of PR, as well as the ability to run a larger future trial.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the ethics review committee of Faculty of Medical Sciences, University of Sri Jayewardenepura, Sri Lanka and University of Leicester, UK. The results of the trial will be disseminated through patient and public involvement events, local and international conference proceedings, and peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ISRCTN13367735.

Pulmonary Rehabilitation

Pulmonary rehabilitation (PR) is an essential intervention in the management of patients with chronic obstructive pulmonary disease. To guide health care professionals in the implementation and evaluation of a PR program, this article discusses the current key concepts regarding exercise testing, prescription, and training, as well as self-management intervention as essential parts of PR and post-rehabilitation maintenance. Moreover, new approaches (alternative forms of organization and delivery, tele-rehabilitation, exercise adjuncts) and unique and challenging situations (patients experiencing acute exacerbations, advanced disease) are thoroughly reviewed. Finally, validated point-of-care resources and online tools are provided.

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.

Adherence to early pulmonary rehabilitation after COPD exacerbation and risk of hospital readmission: a secondary analysis of the COPD-EXA-REHAB study

Background

Early pulmonary rehabilitation after exacerbation of chronic obstructive pulmonary disease (COPD) has previously been shown to reduce the risk of hospital admission and improve physical performance and quality of life. However, the impact of attendance at early rehabilitation programmes has not been established.

Objectives

To evaluate the impact of increasing attendance to pulmonary rehabilitation on the risk of hospital admission, physical performance and quality of life in patients attending an early rehabilitation programme after an exacerbation of COPD.

Methods

This study was a secondary exploratory analysis of the randomised controlled trial COPD-EXA-REHAB study, involving patients hospitalised with an exacerbation of COPD. The COPD-EXA-REHAB study compared early pulmonary rehabilitation, starting within 2 weeks after an exacerbation, with standard treatment, that is, the same programme starting 2 months later. The present analysis included only the 70 patients allocated to early pulmonary rehabilitation.

Results

At 1-year follow-up, we found an association between the number of sessions attended and a reduction in hospital admissions (incidence rate ratio 0.93 (95% CI 0.88 to 0.99), p=0.02), corresponding to a 7% reduction for each session attended. Similarly, at 2-month follow-up, physical performance was positively associated with sessions attended: the mean Incremental Shuttle Walk Test result improved by 8 m with each session (95% CI 2.54 to 13.56, p=0.005) and the Endurance Shuttle Walk Test result by 44 s (95% CI 18.41 to 68.95, p=0.001). Quality of life, assessed using the COPD Assessment Test, was not significantly associated with the number of attended sessions, with the average score increasing by 0.15 points with each session (95% CI −0.35 to 0.65, p=0.55).

Conclusion

Increased attendance at early pulmonary rehabilitation after exacerbation of COPD was associated with reduced risk of hospital admission and improved physical performance.

Informal carers and peer support in pulmonary rehabilitation: an underutilized resource?

PURPOSE OF REVIEW

The aim of this review is to discuss the recent literature relating to the involvement of informal carers and peer support in pulmonary rehabilitation.

RECENT FINDINGS

Informal carers and peer support have been identified by both patients and healthcare workers as a crucial component in the care of those with chronic respiratory disease at home. Pulmonary rehabilitation, a cornerstone in the management of patients with breathlessness, is limited in its clinical effectiveness by poor referral, uptake and completion rates. Engagement of informal carers and support from peers may help maximize the utilization of pulmonary rehabilitation.

SUMMARY

This review highlights the need for more good-quality randomized controlled trials in identifying suitable interventions that may increase uptake and completion of pulmonary rehabilitation programmes. Qualitative studies have highlighted the potential for informal carers and peer support to play a key role in the design of research programmes, and in the delivery of pulmonary rehabilitation. This needs to be addressed in future research.

Evaluating an Intervention Program Using WeChat for Patients With Chronic Obstructive Pulmonary Disease: Randomized Controlled Trial

Background

The application of telemedicine in home pulmonary rehabilitation interventions for the management of patients with chronic obstructive pulmonary disease (COPD) has achieved promising results.

Objective

This study aimed to develop a WeChat official account (Pulmonary Internet Explorer Rehabilitation [PeR]) based on social media. It further evaluated the effect of PeR on the quality of life, symptoms, and exercise self-efficacy of patients with COPD.

Methods

The functional modules of PeR were developed by a multidisciplinary team according to the electronic health–enhanced chronic care model (eCCM) components. A total of 106 patients were randomly selected (53 in the PeR group and 53 in the outpatient face-to-face group [FtF]). Pulmonary rehabilitation intervention was conducted for 3 months, and the outcome was observed for 3 months. The primary outcome was patient quality of life measured with the COPD assessment test (CAT). The secondary outcomes were evaluated using the modified Medical Research Council scale (mMRC), exercise self-regulatory efficacy scale (Ex-SRES), and St George’s Respiratory Questionnaire (SGRQ).

Results

The intention-to-treat analysis was used in the study. A total of 94 participants completed the 6-month pulmonary rehabilitation program. No statistically significant differences were observed in CAT (F_1,3=7.78, P=.001), Ex-SRES (F_1,3=21.91, P<.001), and mMRC scores (F_1,3=29.64, P<.001) between the two groups with the variation in time tendency. The Ex-SRES score had a significant effect on the CAT score (P=.03). The partial regression coefficient of Ex-SRES to CAT was 0.81, and Exp (B) was 2.24.

Conclusions

The telemedicine technology was effective using the eCCM combined with a behavioral intervention strategy centering on self-efficacy. Pulmonary rehabilitation at home through PeR and FtF could improve the sense of self-efficacy and quality of life and alleviate symptoms in patients with COPD.

Trial Registration

Chinese Clinical Trial Registry ChiCTR1900022770; https://tinyurl.com/tmmvpq3

The lay health worker-patient relationship in promoting pulmonary rehabilitation (PR) in COPD: What makes it work?

Lay health workers (LHWs) can improve access to services and adherence to treatment, as well as promoting self-care and prevention. Their effect in promoting uptake and adherence in pulmonary rehabilitation (PR) for chronic obstructive pulmonary disease (COPD) has not been tested. PR is the most effective treatment for the symptoms and disability of COPD, but this effectiveness is undermined by poor rates of completion. Trained LHWs with COPD, who also have first-hand experience of PR, are well placed to help overcome the documented barriers to its completion. The relationship between LHWs and patients may be one of the keys to their effectiveness but it has been little explored. Semi-structured qualitative interviews were used with the aim of examining the LHW-patient partnership in a feasibility study of trained PR-experienced LHWs used to support COPD patients referred to PR. Twelve volunteers with COPD who completed LHW training supported 66 patients referred for PR. All 12 of these LHWs gave end-of-study interviews, 21 COPD patients supported by LHWs were also interviewed. Patients reported that the LHWs were keen to share their experiences of PR, and that this had a positive impact. The enthusiasm of the LHWs for PR was striking. The common bond between LHWs and patients of having COPD together with the LHWs positive, first-hand experience of PR were dominant and recurring themes in their relationship.

Implementation of interventions to reduce preventable hospital admissions for cardiovascular or respiratory conditions: an evidence map and realist synthesis

Background

In 2012, a series of systematic reviews summarised the evidence regarding interventions to reduce preventable hospital admissions. Although intervention effects were dependent on context, the reviews revealed a consistent picture of reduction across different interventions targeting cardiovascular and respiratory conditions. The research reported here sought to provide an in-depth understanding of how interventions that have been shown to reduce admissions for these conditions may work, with a view to supporting their effective implementation in practice.

Objectives

To map the available evidence on interventions used in the UK NHS to reduce preventable admissions for cardiovascular and respiratory conditions and to conduct a realist synthesis of implementation evidence related to these interventions.

Methods

For the mapping review, six databases were searched for studies published between 2010 and October 2017. Studies were included if they were conducted in the UK, the USA, Canada, Australia or New Zealand; recruited adults with a cardiovascular or respiratory condition; and evaluated or described an intervention that could reduce preventable admissions or re-admissions. A descriptive summary of key characteristics of the included studies was produced. The studies included in the mapping review helped to inform the sampling frame for the subsequent realist synthesis. The wider evidence base was also engaged through supplementary searching. Data extraction forms were developed using appropriate frameworks (an implementation framework, an intervention template and a realist logic template). Following identification of initial programme theories (from the theoretical literature, empirical studies and insights from the patient and public involvement group), the review team extracted data into evidence tables. Programme theories were examined against the individual intervention types and collectively as a set. The resultant hypotheses functioned as synthesised statements around which an explanatory narrative referenced to the underpinning evidence base was developed. Additional searches for mid-range and overarching theories were carried out using Google Scholar (Google Inc., Mountain View, CA, USA).

Results

A total of 569 publications were included in the mapping review. The largest group originated from the USA. The included studies from the UK showed a similar distribution to that of the map as a whole, but there was evidence of some country-specific features, such as the prominence of studies of telehealth. In the realist synthesis, it was found that interventions with strong evidence of effectiveness overall had not necessarily demonstrated effectiveness in UK settings. This could be a barrier to using these interventions in the NHS. Facilitation of the implementation of interventions was often not reported or inadequately reported. Many of the interventions were diverse in the ways in which they were delivered. There was also considerable overlap in the content of interventions. The role of specialist nurses was highlighted in several studies. The five programme theories identified were supported to varying degrees by empirical literature, but all provided valuable insights.

Limitations

The research was conducted by a small team; time and resources limited the team’s ability to consult with a full range of stakeholders.

Conclusions

Overall, implementation appears to be favoured by support for self-management by patients and their families/carers, support for services that signpost patients to consider alternatives to seeing their general practitioner when appropriate, recognition of possible reasons why patients seek admission, support for health-care professionals to diagnose and refer patients appropriately and support for workforce roles that promote continuity of care and co-ordination between services.

Future work

Research should focus on understanding discrepancies between national and international evidence and the transferability of findings between different contexts; the design and evaluation of implementation strategies informed by theories about how the intervention being implemented might work; and qualitative research on decision-making around hospital referrals and admissions.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Association of psychological flexibility with engagement in pulmonary rehabilitation following an acute exacerbation of chronic obstructive pulmonary disease

This study aimed to investigate (a) the association between psychological flexibility and engagement in pulmonary rehabilitation within 8 weeks following hospitalisation for an acute exacerbation of chronic obstructive pulmonary disease (AECOPD) and (b) how psychological (in)flexibility presents in this context. A mixed-methods study was conducted. Psychological flexibility during an AECOPD was assessed using The Acceptance and Action Questionnaire-II (AAQ-II) (n = 41) and the Engaged Living Scale (ELS) (n = 40). Engagement in post-AECOPD pulmonary rehabilitation was then recorded. Twenty-three patients also participated in cognitive interviews. Psychological flexibility was associated with a greater chance of accepting a pulmonary rehabilitation referral following an AECOPD. Small numbers prohibited analysis on attendance or completion. An AAQ-II score of 11 translated to a 60 (37–82)% probability of accepting a referral to pulmonary rehabilitation and an ELS score of 73 was associated with a 68 (46–91)% probability of accepting. Four themes were extracted from interviews: (1) family values, (2) self as abnormal, (3) ‘can’t do anything’ versus ‘I do what I can’ and (4) disability, and related emotions, as barriers to action. Randomised clinical trials are needed to evaluate interventions designed to increase psychological flexibility (i.e. acceptance and commitment therapy) to support acceptance of pulmonary rehabilitation post-AECOPD.

Is inspiratory muscle training (IMT) an acceptable treatment option for people with chronic obstructive pulmonary disease (COPD) who have declined pulmonary rehabilitation (PR) and can IMT enhance PR uptake? A single-group prepost feasibility study in a home-based setting

OBJECTIVES

This feasibility study aimed to assess the acceptability of inspiratory muscle training (IMT) in people with chronic obstructive pulmonary disease (COPD) who declined pulmonary rehabilitation (PR) as a potential treatment option or precursor to PR. Objectives were to assess attitudes to IMT, PR and alternatives to PR; factors influencing adherence with IMT and acceptability of outcome measures, research tools and study protocol.

DESIGN

A pragmatic, mixed methods, prepost feasibility study was conducted. Recruitment took place over a 4-month period. Participants were followed up for a period of 6 months.

SETTINGS

IMT sessions and assessments were conducted in the domiciliary setting.

PARTICIPANTS

Inclusion criteria: people over the age of 35, stable COPD, Medical Research Council Dyspnoea scale of 3 or above, declined PR.

EXCLUSION CRITERIA

history of spontaneous pneumothorax, incomplete recovery from a traumatic pneumothorax, asthma, known recently perforated eardrum, unstable angina, ventricular dysrhythmias, cerebrovascular event or myocardial infarction within the last 2 months. Participants were selected from a purposive sample. Of the 22 potential participants screened, 11 were recruited and interviewed. Ten participants commenced IMT. Seven participants completed the follow-up assessment.

INTERVENTION

Eight weeks of IMT twice a day, 5 days a week with visits once weekly by a physiotherapist. Unsupervised IMT twice a day three times a week until follow-up at 6 months.

OUTCOMES

Acceptability of IMT and the study process was explored via semi-structured interviews. Adherence with IMT was assessed by the Powerbreathe K3 device and participant diaries. Uptake of PR was identified.

RESULTS

IMT was found to be acceptable. Adherence was explored. Four people went on to participate in PR.

CONCLUSIONS

Feasibility was established. A randomised controlled trial is warranted to establish efficacy and cost-effectiveness of IMT in those who decline PR and IMT as an intervention to promote uptake of PR.

TRIAL REGISTRATION NUMBER

NCT01956565; Post-results.

A home-based lower limb-specific resistance training programme for patients with COPD: an explorative feasibility study

Peripheral muscle weakness leading to poor exercise tolerance is a significant problem in patients with chronic obstructive pulmonary disease (COPD). Increased lower limb strength following pulmonary rehabilitation (PR) has been shown to be associated with positive outcomes [1]. Despite this, access to and completion of PR remains problematic and alternative exercise interventions are sought. Elastic band resistance training has recently been shown to be as effective as conventional outpatient free-weight exercise training [2–4]. Elastic band resistance training may, therefore, provide an alternative home-based exercise intervention for patients with COPD who are unable or unwilling to participate in PR due to significant symptom burden or anxiety in attending group classes

It is feasible and acceptable to deliver a home-based lower limb-specific resistance training (LLSRT) programme to patients with COPD. Individual patient improvements in walking distance and breathlessness severity were observed post-LLSRT intervention.http://bit.ly/30xYpWI

Improving uptake and completion of pulmonary rehabilitation in COPD with lay health workers: feasibility of a clinical trial

Purpose

This study was designed to evaluate the feasibility of a cluster randomized controlled trial to test the efficacy of lay health workers (LHWs) in improving the uptake and completion of pulmonary rehabilitation (PR) in the treatment of COPD.

Materials and methods

LHWs, trained in confidentiality, role boundaries, and behavior change techniques, supported patients newly referred for PR. Interactions between LHWs and participants were recorded with smartphones. Outcomes were recruitment and retention rates of LHWs, questionnaire and interview-evaluated acceptability and analysis of intervention fidelity.

Results

Forty (36%) of 110 PR-experienced COPD patients applied to become LHWs. Twenty (18%) were selected for training. Twelve (11%) supported patients. Sixty-six COPD patients referred for PR received the intervention (5.5 participants per LHW). Ten LHWs were retained to the end of the study. Seventy-three percent of supported patients were satisfied or very satisfied with the intervention. LHWs delivered the intervention with appropriate style and variable fidelity. LHWs would welcome more intensive training. Based on this proof of concept, a cluster randomized controlled trial of an LHW intervention to improve uptake and completion of PR is feasible.

Conclusion

PR-experienced COPD patients can be recruited, trained, and retained as LHWs to support participation in PR, and can deliver the intervention. Participant COPD patients found the intervention acceptable. A cluster randomized controlled clinical trial is feasible.

Telemedicine and telerehabilitation: current and forthcoming applications in haemophilia

In persons with haemophilia (PWH), the importance of comprehensive disease management to prevent bleeding, joint damage and secondary diseases has been well established. However, because haemophilia is a chronic disease, intervention programmes carried out for prolonged periods of time may create problems of patient adherence. Driven by continuous technological innovation, telemedicine is being increasingly proposed as a way to provide PWH with a range of services designed to improve their health, saving the time and cost involved in going to the treatment centre, and increasing therapeutic adherence. The aim of this article is to identify and discuss the tools available for the management of PWH by means of telemedicine and information technology. Video conferences are helpful to obtain a rapid evaluation at a distance of the occurrence and severity of bleeding episodes by the personnel of the treatment centre. Cell phones and associated applications (apps) help to improve the regular implementation of replacement therapy and monitor any ensuing adverse effect. Portable sensors help to improve lifestyle and to monitor the degree of physical activity through the fulfilment of a given number of daily walking steps and other physical activities. In the context of telerehabilitation, exergames have the potential to improve the musculoskeletal function of PWH by exploiting the recreational features of videogames. Thus, telemedicine and its multiple applications may be useful in the management of haemophilia, especially for patients living far from specialised centres. However, since this is a recent and rapidly evolving field, published studies are few and have, so far, involved only a limited number of cases. Therefore, additional evidence needs to be obtained by means of accrual of cumulative data from multiple centres specialised in haemophilia.

Developing an intervention to increase REferral and uptake TO pulmonary REhabilitation in primary care in patients with chronic obstructive pulmonary disease (the REsTORE study): mixed methods study protocol

INTRODUCTION

Chronic obstructive pulmonary disease (COPD) is a progressive lung disease associated with breathlessness, inability to exercise, frequent infections, hospitalisation and reduced quality of life. Pulmonary rehabilitation (PR), providing supervised exercise and education, is an effective and cost-effective treatment for COPD but is significantly underused. Interventions to improve referral and uptake have been tested and some positive results reported. However, interventions are diverse and no clear recommendations for practice can be made. This study aims to understand the challenges to referral and uptake in primary care, where most referrals originate, and to develop a flexible toolkit of resources to support referral and uptake to PR in primary care in the UK.

METHODS AND ANALYSIS

This is a mixed methods study informed by normalisation process theory and burden of treatment theory. In the first phase, general practitioners, practice nurses and PR providers will be invited to complete an online survey to inform a broad exploration of the topic areas. In phase 2 interviews and focus groups will be conducted with patients, healthcare professionals (HCP) in primary care, PR providers and commissioners to gain an in-depth understanding of the issues and needs. Toolkit development in phase 3 will draw together the learning from phases 1 and 2 and employ an iterative development process to build the toolkit jointly with patients and HCPs. It will be tested in primary care for usability and acceptability.

ETHICS AND DISSEMINATION

The study has ethical and Health Research Authority approval (Research Ethics Committee reference number 17/EE/0136). It is registered with the International Standard Registered Clinical/Social Study Number (ISRCTN) registry (trial ID: ISRCTN20669629, assignment date 20 March 2018, trial start date 1 April 2016). Dissemination will be aimed at patients, carers/families, service providers, commissioners and national interest groups. Methods will include conferences, presentations, academic publications and plain English reports and will be supported by the British Lung Foundation.

TRIAL REGISTRATION NUMBER

ISRCTN20669629 ; Pre-results.

Contraction and nutrition interaction promotes anabolism in cachectic muscle

PURPOSE OF REVIEW

Cachexia is a disease-related multifactorial syndrome characterized by inflammation, massive muscle protein catabolism and carbohydrate and lipid metabolism disorder.Several studies tried to define the impact of either nutrition or physical exercise (single approach strategy) or their combination (multimodal approach strategy) on prevention and/or treatment of muscle wasting in cachectic patients.

RECENT FINDINGS

Single approach strategies (i.e. nutrition or physical exercise) have the potential of preventing and improving features of the cachexia syndrome possibly with a differential impact according to the underlying disease. Limited information is available on the beneficial effect of multimodal approach strategies.

SUMMARY

Multimodal approaches appear to be more effective than those based on single interventions in physiological condition and in cachectic patients with COPD or chronic kidney disease. Further studies, however, are required in cachexia induced by heart failure, cancer and critical illness.

Improving acceptance and uptake of pulmonary rehabilitation after acute exacerbation of COPD: Acceptability, feasibility, and safety of a PR "taster" session delivered before hospital discharge

The objectives of this study were to (1) assess the acceptability, feasibility, and safety of delivering a pulmonary rehabilitation (PR) "taster" session to patients hospitalized with acute exacerbations of chronic obstructive pulmonary disease; (2) evaluate the changes in patient knowledge and readiness to commence PR; and (3) make recommendations for future intervention iterations. Acceptability was measured by the proportion of patients that accepted to participate. Feasibility was measured by the proportion of eligible participants. Knowledge was evaluated using the modified versions of the Understanding COPD (UCOPD) and Bristol COPD Knowledge (BCKQ) questionnaires. Readiness to commence PR was measured by a modified version of the Readiness to Change Exercise Questionnaire. All measures were delivered pre- and post-intervention. Thirty-one of 34 eligible individuals were able to be approached. Prospective acceptability was low, with 24 individuals declining the intervention, 1 being discharged without making a decision, and only 6 participating. Positive median change was recorded in the modified UCOPD questionnaire (+8), but not the BCKQ (0). Three of the patients were already in the action phase pre-intervention, with all but one in that phase post-intervention. The delivery of a PR "taster" session was not prospectively acceptable to a large portion of patients and only feasible with modifications to the original protocol.

Interventions to increase referral and uptake to pulmonary rehabilitation in people with COPD: a systematic review

Pulmonary rehabilitation (PR) reduces the number and duration of hospital admissions and readmissions, and improves health-related quality of life in patients with COPD. Despite clinical guideline recommendations, under-referral and limited uptake to PR contribute to poor treatment access. We reviewed published literature on the effectiveness of interventions to improve referral to and uptake of PR in patients with COPD when compared to standard care, alternative interventions, or no intervention. The review followed recognized methods. Search terms included "pulmonary rehabilitation" AND "referral" OR "uptake" applied to MEDLINE, EMBASE, CINAHL, PsycINFO, ASSIA, BNI, Web of Science, and Cochrane Library up to January 2018. Titles, abstracts, and full papers were reviewed independently and quality appraised. The protocol was registered (PROSPERO # 2016:CRD42016043762). We screened 5,328 references. Fourteen papers met the inclusion criteria. Ten assessed referral and five assessed uptake (46,146 patients, 409 clinicians, 82 hospital departments, 122 general practices). One was a systematic review which assessed uptake. Designs, interventions, and scope of studies were diverse, often part of multifaceted evidence-based management of COPD. Examples included computer-based prompts at practice nurse review, patient information, clinician education, and financial incentives. Four studies reported statistically significant improvements in referral (range 3.5%-36%). Two studies reported statistically significant increases in uptake (range 18%-21.5%). Most studies had methodological and reporting limitations. Meta-analysis was not conducted due to heterogeneity of study designs. This review demonstrates the range of approaches aimed at increasing referral and uptake to PR but identifies limited evidence of effectiveness due to the heterogeneity and limitations of study designs. Research using robust methods with clear descriptions of intervention, setting, and target population is required to optimize access to PR across a range of settings.

Effect of Cardiac Rehabilitation on Quality of Life, Depression and Anxiety in Asian Patients

This study explored the effect of cardiac rehabilitation on quality of life, depression, and anxiety in Asian patients in Singapore. Out of the 194 patients who were recruited into the study, 139 patients (71.6%) completed both the pre- and post-cardiac rehabilitation questionnaires. Their ages ranged from 28 to 80 (M = 56.66, SD = 8.88), and 103 patients (74.1%) were males and 21 patients (15.1%) were females. As hypothesized, there was a statistically significant difference between the pre- and post-cardiac rehabilitation scores on the combined dependent variables, F (4, 135) = 34.84, p < 0.001; Wilks' Lambda = 0.49; partial eta squared = 0.51. An inspection of the mean scores indicated that patients reported higher levels of physical and mental quality of life and lower levels of depression post-cardiac rehabilitation. The findings were discussed in regards to implications in cardiac rehabilitation in Singapore.

Pulmonary rehabilitation in patients with an acute exacerbation of chronic obstructive pulmonary disease

Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) are one of the most common causes of emergency hospital admission and place great burden upon healthcare systems. Furthermore, AECOPD represent an important life event for patients, and are associated with significant reductions in physical activity, skeletal muscle function, exercise tolerance and health-related quality of life. Pulmonary rehabilitation, an intervention comprising supervised exercise-training and education, may counteract these negative consequences and target modifiable risk factors for hospital readmission. A recent Cochrane systematic review included 20 randomized controlled trials comparing pulmonary rehabilitation after exacerbation of COPD versus conventional care. Overall, the evidence supports moderate to large effects on health-related quality of life and exercise capacity. However, there is substantial heterogeneity across studies, and more recent studies have been more equivocal, including around hospital readmissions, particularly when rehabilitation is started in the inpatient setting. In this narrative review, we examine the rationale for pulmonary rehabilitation following AECOPD with a particular focus on skeletal muscle function, review the current evidence for pulmonary rehabilitation in the AECOPD setting, and identify areas that require future research, including the structure and nature of the intervention, improving uptake and adherence, and the role of alternative rehabilitation strategies for patients with AECOPD.

Motivational interviewing in respiratory therapy: What do clinicians need to make it part of routine care? A qualitative study

Motivational interviewing (MI) is a method for building motivation for behaviour change that has potential for use in respiratory contexts. There is a paucity of published research exploring the feasibility of this intervention from the clinicians’ perspective. This study aimed to explore respiratory clinicians' views of MI: Is it perceived as useful? Could it be integrated into practice? What training would be required to make it part of routine care? Nine respiratory clinicians attended a one-day MI workshop and a semi-structured face-to-face interview two weeks later. All interviews were audio-recorded, transcribed verbatim and analysed with thematic analysis. Four main themes are presented—1) MI’s suitability for use in respiratory contexts: participants saw potential in using MI to motivate their patients to engage with prescribed respiratory interventions, such as increased physical activity. Those who experimented with new skills post-workshop were encouraged by patient responsiveness and outcomes. 2) MI’s relationship with routine clinical practice: some believed they already used elements of MI, but most participants felt MI was fundamentally 'different' to their normal style of working. 3) Implementation issues: additional time would need to be made available to enable an appropriate depth of conversation. 4) Training issues: Participants sensed the complexity of MI could make it difficult to learn and that it would take them time to become competent. On-going supervision was perceived as necessary. One key challenge identified was how to suppress behaviours that are antithetical to MI. These findings lend support to the feasibility of using MI in respiratory contexts such as pulmonary rehabilitation programmes, but highlight implementation and training issues that would need to be overcome. The insights have informed the development of another study, testing the effect of a tailored training package on MI skill, specifically for respiratory clinicians delivering pulmonary rehabilitation programmes.

The role of tele-medicine in patients with respiratory diseases

INTRODUCTION

Tele-medicine is a clinical application connecting a patient with specialized care consultants by means of electronic platforms, potentially able to improve patients' self-management and allow for the care of patients with limited access to health services. This article summarizes the use of tele-medicine as a tool in managing patients suffering from some pathological respiratory conditions. Areas covered: We searched papers published between 1990 and 2017 dealing with tele-medicine and respiratory diseases, chronic obstructive pulmonary disease, asthma, interstitial lung disease, chronic respiratory failure, neuromuscular diseases, critical illness, home mechanical ventilation, and also legal and economic issues. Controlled trials report different results on feasibility, cost-effectiveness, and safety of tele-medicine. Expert commentary: Progress in tele-medicine widens the horizons in respiratory medicine: this tool may potentially reduce health care costs by moving some medical interventions from centralized locations in to patient's home, also allowing for the delivery of care in countries with limited access to it. Legal, safety, and privacy problems, as well as reimbursement issues, must still be defined and solved. At present time, we still need much more evidence to consider this modality as a real option in the management of these patients.