Home or community-based pulmonary rehabilitation for individuals with chronic obstructive pulmonary disease: a systematic review and meta-analysis

User experience testing of the mobile pulmonary rehabilitation (m-PR™) app in people with chronic obstructive pulmonary disease

Objective

Mobile health (mHealth) technologies are emerging to support the delivery of pulmonary rehabilitation (PR). This study aimed to explore the ease of use, satisfaction and acceptability of an Australian mobile pulmonary rehabilitation app (m-PR™) in people with chronic obstructive pulmonary disease (COPD).

Methods

In this mixed methods observational study, participants with COPD were recruited following PR assessment. Participants were educated on m-PR™ which contained symptom monitoring, individualised exercise training with exercise videos, education videos, goal setting, health notifications and medication action plan. Participants used m-PR™ for 4-8 weeks. At baseline, participants were surveyed to assess level of technology engagement. At follow-up, participants completed the system usability survey (SUS), a satisfaction survey and a semi-structured interview.

Results

Fifteen participants (mean age 70 [SD 10] years, 53% female) completed the study. Technology usage was high with 73% (n = 11) self-rating their technology competence as good or very good. The SUS score of 71 (SD 16) demonstrated above average perceived usability of m-PR™. The satisfaction survey indicated that 67% (n = 10) enjoyed m-PR™ and 33% (n = 5) were neutral. Most participants found the different m-PR™ components somewhat easy or very easy to use (range 69-100%) and somewhat helpful or very helpful (range 76-100%). Interview responses revealed that m-PR™ elicited divergent feelings among participants, who reported both positive and negative feelings towards the app's features, the effort required to use it and data security.

Conclusion

The majority of participants found m-PR™ enjoyable, easy to use and helpful in managing their COPD. Further research is warranted to understand the effectiveness of mHealth to deliver PR.

Effects of exercise-based home pulmonary rehabilitation on patients with chronic obstructive pulmonary disease: An overview of systematic review

BACKGROUND

Clinical research on exercise-based home pulmonary rehabilitation (HPR) effectiveness in chronic obstructive pulmonary disease (COPD) treatment is rising, as are associated systematic reviews/meta-analyses (SRs/MAs). However, different SRs/MAs vary in outcome indicators, analysis methodologies, literature quality, and findings. This overview aimed to describe the findings of these SRs/MAs and assess their methodological quality.

METHODS

From inception until April 2022, we searched PubMed, Web of Science, Cochrane Library, EMBASE, China National Knowledge Infrastructure (CNKI), and Wan Fang. Two researchers searched these SRs/MAs separately, collected the data, and cross-checked it using predetermined rules. The Assessing the Methodological Quality of Systematic Reviews 2 (AMSTAR 2) was used to evaluate the methodological quality of each contained SR/MA. The evidence was assessed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2009 (PRISMA-2009). The Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) was used to determine the validity of the results.

RESULTS

A total of 433 records were found, with 44 chosen for full-text review. There were 11 SRs/MAs that matched the inclusion criteria. Our overview included studies published from 2010 to 2022. According to the AMSTAR 2 tool, one had low methodological quality, while the other 10 SRs/MAs had very low quality. The PRISMA statement revealed a low rate of complete reporting for eight items. The GRADE tool, on the other hand, revealed that the evidence quality for most outcomes was very low to moderate.

CONCLUSION

According to current research, exercise-based HPR may benefit COPD patients. Nevertheless, this finding is restricted by the low quality of the included SRs/MAs. And more high-quality and large-sample studies are needed in the future.

PROSPERO

ID: CRD42022322768. https://www.crd.york.ac.uk/prospero/#recordDetails.

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.

Research Trends on Pulmonary Rehabilitation: A Bibliometric Analysis From 2011 to 2020

Background and Objective

A mounting body of evidence suggests that lung function may deteriorate over time with the development of chronic lung diseases (CRDs). Pulmonary rehabilitation has been proved to improve exercise capacity and quality of life in individuals with CRDs. However, PR remains grossly underutilized all around the world. This study aimed to analyze the research trends on PR over the past 10 years.

Methods

The publications related to pulmonary rehabilitation in the Web of Science Core Collection (WoSCC) from 2011 to 2020 were searched. VOSviewer (1.6.15) and CiteSpace Software (5.5.R2) were used to analyze authors and co-cited authors, countries and institutions, journals and co-cited journals, co-cited references, and keywords.

Results

A total of 4,521 publications were retrieved between 2011 and 2020, and the number of annual publications on pulmonary rehabilitation has shown an overall upward trend in the past decade. The USA was the most productive country, the University of Toronto from Canada was both the first in publications and citations. Spruit MA was both the most productive author and the one with the highest number of co-citations. The first productive journal was the International Journal of Chronic Obstructive Pulmonary Disease, while the first co-cited journal was the American Journal of Respiratory and Critical Care Medicine. The hot keywords were grouped into three clusters, while “Asthma” and “Respiratory society statement” were determined as the frontier topics.

Conclusions

The present study successfully revealed the research status and development trends of pulmonary rehabilitation from 2011 to 2020 by using bibliometric analysis, which may help researchers explore and discover new research directions in the future.

Use of Singing for Lung Health as an alternative training modality within pulmonary rehabilitation for COPD: a randomised controlled trial

BACKGROUND

Pulmonary rehabilitation (PR) is a cornerstone in chronic obstructive pulmonary disease (COPD) management. However, PR adherence is generally low, and barriers include availability, economic issues, motivation and an inability to attend or perform physical training. Therefore, alternative, evidence-based PR activities are required. Singing may have benefits for quality of life (QoL), respiratory control and well-being in COPD, but the impact on the PR key outcome, physical exercise capacity, is uncertain.

METHODS

In this randomised controlled trial (NCT03280355), we investigated the effectiveness of 10 weeks of PR, including either "Singing for Lung Health" (SLH) training or standard physical exercise training (PExT). The primary outcome was a change in exercise capacity (6-min walk distance (6MWD)) from baseline to post-PR. Secondary outcomes were changes in QoL (St George's Respiratory Questionnaire (SGRQ)), Hospital Anxiety and Depression Score (HADS), lung function, dyspnoea and adherence.

RESULTS

We included 270 COPD patients, and 195 completed the study. Demographics across groups were comparable, and both groups improved significantly in 6MWD and SGRQ score. SLH was non-inferior to PExT in improving 6MWD (mean±sd 13.1±36.3 m versus 14.1±32.3 m, p=0.81; difference 1.0 m, 95% CI -7.3-9.3 m) with 21.8% and 25.0%, respectively (p=0.57), reaching the 6MWD minimal important difference of 30 m. We found no significant between-group differences concerning SGRQ, HADS, lung function, dyspnoea or adherence.

CONCLUSION

Our study suggests that SLH is non-inferior to PExT in improving 6MWD during a 10-week PR programme. Future studies addressing reproducibility, long-term effects and health economics are needed.

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.

Clinical effectiveness and components of Home-pulmonary rehabilitation for people with chronic respiratory diseases: a systematic review protocol

INTRODUCTION

Chronic respiratory diseases (CRDs) are common and disabling conditions that can result in social isolation and economic hardship for patients and their families. Pulmonary rehabilitation (PR) improves functional exercise capacity and health-related quality of life (HRQoL) but practical barriers to attending centre-based sessions or the need for infection control limits accessibility. Home-PR offers a potential solution that may improve access. We aim to systematically review the clinical effectiveness, completion rates and components of Home-PR for people with CRDs compared with Centre-PR or Usual care.

METHODS AND ANALYSIS

We will search PubMed, CINAHL, Cochrane, EMBASE, PeDRO and PsycInfo from January 1990 to date using a PICOS search strategy (Population: adults with CRDs; Intervention: Home-PR; Comparator: Centre-PR/Usual care; Outcomes: functional exercise capacity and HRQoL; Setting: any setting). The strategy is to search for 'Chronic Respiratory Disease' AND 'Pulmonary Rehabilitation' AND 'Home-PR', and identify relevant randomised controlled trials and controlled clinical trials. Six reviewers working in pairs will independently screen articles for eligibility and extract data from those fulfilling the inclusion criteria. We will use the Cochrane risk-of-bias tool and Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to rate the quality of evidence. We will perform meta-analysis or narrative synthesis as appropriate to answer our three research questions: (1) what is the effectiveness of Home-PR compared with Centre-PR or Usual care? (2) what components are used in effective Home-PR studies? and (3) what is the completion rate of Home-PR compared with Centre-PR?

ETHICS AND DISSEMINATION

Research ethics approval is not required since the study will review only published data. The findings will be disseminated through publication in a peer-reviewed journal and presentation in conferences.

PROSPERO REGISTRATION NUMBER

CRD42020220137.

Community-based intervention for prevention and management of chronic obstructive pulmonary disease in Nepal (COBIN-P trial): study protocol for a cluster-randomized controlled trial

Background

Chronic obstructive pulmonary disease (COPD) is one of the leading causes of death worldwide and the commonest of non-communicable diseases (NCDs) in Nepal. Risk factors like indoor and outdoor air pollution, a high prevalence of smoking, and the lack of awareness of COPD make it a serious public health concern. However, no attempt has been made in Nepal to estimate its burden and address the disease at the community level.

Method

This study aims to evaluate the effect of a community-based health educational intervention administered by Female Community Health Volunteers (FCHVs) on the prevention and management of COPD. An open-label, two-group, community-based, cluster-randomized controlled trial will be implemented in the semi-urban area of Pokhara Metropolitan city (former Lekhnath Municipality) located in the Kaski district of Nepal. The estimated sample size of the intervention will be 1143. The unit of randomization is the ward (administrative unit) of the study area. The follow-up survey will be conducted immediately after 12 months of FCHVs-led interventions. The difference in the rate of decline of forced expiratory volume in 1 s (FEV₁) and FEV₁/FVC (forced vital capacity) ratio are the primary outcomes and the change in the proportion of modifiable risk factors of COPD, health-related quality of life scores, and change in knowledge of COPD will be secondary outcomes.

Discussion

This study will estimate the burden of COPD, the magnitude of risk factors and generate evidence to mobilize community health workers for COPD prevention and management at the community level in Nepal.

Trial registration

ClinicalTrials.gov NCT03797768. Registered on January 9, 2019.

Perfil sociodemográfico e qualidade de vida de mulheres com doenças cardiovasculares e respiratórias: estudo de base populacional

RESUMO O objetivo do estudo é descrever o perfil de três grupos de mulheres: aparentemente saudáveis (não doentes-ND); com doenças cardiovasculares (DC); e com doenças respiratórias (DR) crônicas. A pesquisa comparou esses grupos conforme variáveis sociodemográficas (faixa etária, escolaridade, etnia e renda familiar) e dados sobre qualidade de vida (QV), segundo domínios: físico, psicológico, relações sociais e meio ambiente. Este estudo é caracterizado como quantitativo, analítico, observacional e transversal de base populacional, com informações extraídas do Inquérito de Saúde da Mulher, realizado na cidade de Uberaba-MG. Foram entrevistadas 1.387 mulheres, com o objetivo de coletar informações sobre DC, DR, idade, escolaridade, etnia e renda familiar. A QV foi estudada por meio do WHOQOL - Bref, segundo os quatro domínios. Foi realizado levantamento estatístico, descritivo e inferencial. Identificou-se que o grupo com DC é formado por mulheres com idade a partir de 50 anos e baixa escolaridade, em oposição ao grupo de mulheres com DR, que são mais jovens e possuem escolaridade superior. Quanto à QV, as mulheres com DC (31,65%) apresentaram níveis inferiores em relação às mulheres com DR (19,10%), nos domínios: físico (50,6;54,0;<0,0001), psicológico (55,1;58,7;<0,0001), relações sociais (75,8;77,2;0,0055) e meio ambiente (41,7;43,0;0,0173), valores em média. Portanto, o domínio de QV que obteve menor pontuação para todos os grupos foi o meio ambiente e as mulheres com DC apresentaram valores mais baixos, estatisticamente significativos, para todas as categorias.

Effects of a Home-Based Pulmonary Rehabilitation Program in Patients with Chronic Obstructive Pulmonary Disease in GOLD B Group: A Pilot Study

Patients with chronic obstructive pulmonary disease (COPD) in the Global Initiative for Chronic Obstructive Lung Disease (GOLD) B group can be included in pulmonary rehabilitation (PR) settings outside the hospitals. This study aimed to explore the feasibility of a home-based pulmonary rehabilitation (HBPR) program and assess its impact on patients with COPD in the GOLD B group. A real-world, pre–post intervention study was conducted with 12 weeks of HBPR (presential home visits and phone calls) using the self-management program Living Well with COPD. The 1-min sit-to-stand test (1MSTS), modified Medical Research Council Questionnaire (mMRC), COPD Assessment Test (CAT), Hospital Anxiety and Depression Scale (HADS), and London Chest Activity of Daily Living (LCADL) were used to assess the impact. Pre–post differences and correlations between changes in outcomes were calculated. In 30 patients (71.6 years, FEV₁ (%) 52.8), significant improvements (p < 0.05) were observed on 1MSTS (Pre 17.2, Post 21.2), mMRC (Pre 2.0, Post 1.0), CAT (Pre 16.3, Post 9.9), HADS (Pre 14.4, Post 9.6), and LCADL (Pre 21.0, Post 15.8), with no adverse events reported. When significant, correlations between changes in outcomes were moderate or strong (0.48 ≤ ρ ≤ 0.66). HBPR can be feasible and safe, and it shows the potential to significantly improve outcomes of patients with COPD in the GOLD B group.

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.

Advanced telehealth technology improves home-based exercise therapy for people with stable chronic obstructive pulmonary disease: a systematic review

QUESTIONS

How effective is home-based exercise therapy delivered using advanced telehealth technology (ATT-ET) for people with chronic obstructive pulmonary disease (COPD) compared with: no exercise therapy (ET), in/outpatient ET, and home-based ET without ATT?

DESIGN

Systematic review and meta-analysis of randomised trials.

PARTICIPANTS

People with stable COPD referred for ET.

INTERVENTION

ATT-ET.

OUTCOME MEASURES

Exercise capacity, quality of life, functional dyspnoea, cost-effectiveness and various secondary outcomes.

RESULTS

Fifteen eligible trials involved 1,522 participants. Compared with no ET, ATT-ET improved exercise capacity (four studies, 6-minute walk test MD 15 m, 95% CI 5 to 24) and probably improved quality of life (four studies, SMD 0.22, 95% CI 0.00 to 0.43) and functional dyspnoea (two studies, Chronic Respiratory Questionnaire-Dyspnoea MD 2, 95% CI 0 to 4). ATT-ET had a similar effect as in/outpatient ET on functional dyspnoea (two studies, SMD -0.05, 95% CI -0.39 to 0.29) and a similar or better effect on quality of life (two studies, SMD 0.23, 95% CI -0.04 to 0.50) but its relative effect on exercise capacity was very uncertain (three studies, 6-minute walk test MD 6 m, 95% CI -26 to 37). ATT-ET had a similar effect as home-based ET without ATT on exercise capacity (three studies, 6-minute walk test MD 2 m, 95% CI -16 to 19) and similar or better effects on quality of life (three studies, SMD 0.79, 95% CI -0.04 to 1.62) and functional dyspnoea (two studies, Chronic Respiratory Questionnaire-Dyspnoea MD 2, 95% CI 0 to 4). ATT-ET had effects on most secondary outcomes that were similar to or better than each comparator.

CONCLUSION

ATT-ET improves exercise capacity, functional dyspnoea and quality of life compared with no ET, although some benefits may be small. Its benefits are generally similar to in/outpatient ET and similar to or better than home-based ET without ATT.

REGISTRATION

PROSPERO CRD42020165773.

Measurement properties of step tests for exercise capacity in COPD: A systematic review

Objective:

To determine the level of evidence of the measurement properties (validity, reliability, and responsiveness) and interpretability of the step tests available for assessing the exercise capacity in patients with chronic obstructive pulmonary disease.

Data sources:

The data sources Web of Science, MEDLINE, PubMed, PEDro, CENTRAL of Cochrane Library, and Scopus were searched up to June 26, 2020.

Review methods:

Studies of any design that reported results for any measurement property of the step tests for assessing the exercise capacity in COPD patients were selected. One reviewer extracted the data, and two reviewers independently rated the level of evidence by using the Consensus-Based Standards for the Selection of Health Measurements Instruments recommendations.

Results:

Thirty-one studies were included in the data synthesis. Chester Step Test, Modified Incremental Step Test, two-, three-, four-, and six-Minute Step Test, Paced Step Test, and six-Minute Stepper Test were identified. A step test protocol was also found. The level of evidence of their results for the measurement properties was mostly determined as “low” to “very low.” The best level of evidence found was for the six-minute stepper test: “high” on construct validity (r = 0.56–0.71); and “moderate” on criterion validity (r = 0.36–0.69), and responsiveness (r = 0.26–0.34).

Conclusion:

The general level of evidence of the measurement properties of the step tests is “low” to “very low” for assessing exercise capacity in patients with chronic obstructive pulmonary disease, which can limit their application in clinical practice. The six-minute Stepper Test is currently the most appropriate step test available.

The effect of participating in MedEx Wellness, a community-based chronic disease exercise rehabilitation programme, on physical, clinical and psychological health: A study protocol for a cohort trial

Background

Community-based exercise rehabilitation programmes for chronic disease are an effective alternative to traditional hospital-based programmes. MedEx Wellness is a novel community-based exercise rehabilitation programme that integrates a range of chronic diseases. The aim of this trial was to investigate the effect of participating in MedEx Wellness on physical, clinical and psychological health.

Methods

A prospective cohort study was conducted. Participants were recruited at induction to the MedEx Wellness programme following referral from healthcare professionals. Participants underwent a baseline assessment before commencing the exercise programme and repeat assessments at 3, 6 and 12 months. The primary outcome was cardiorespiratory fitness (6 minute- time trial) at 12 months. Secondary outcomes included health-related quality of life (EuroQoL-5D, Satisfaction with Life Scale, Warwick Edinburgh Mental Wellbeing Scale, Patient Health Questionnaire8, Functional Assessment of Cancer Therapy Questionnaire), free living activity behavior (accelerometer) and healthcare utilization (recall questionnaire). Tertiary outcomes included blood pressure (24 h), biomarkers (lipids, glucose and C-reactive protein), other components of physical fitness, including strength (handgrip test, sit-to-stand test), flexibility (sit-and-reach test), body composition (body mass index and waist-to-hip ratio), and falls risk (timed up and go test), and claudication time (incremental treadmill walking test), cognitive function, including attention (Attention Network Task), memory (Luck & Vogel Visual Working Memory Task) and cognitive reserve. Exploratory outcomes included psychosocial determinants of physical activity (self-efficacy, social support, intentions).

Discussion

This trial will evaluate whether participation in the MedEx Wellness programme has positive effects on physical, clinical and psychological health in individuals with a range of chronic diseases.

Trial registration

ISRCTN Registry ISRCTN10351412.

The COVID-19 Pandemic Confronts the Motivation Fallacy within Pulmonary Rehabilitation Programs

Social distancing and quarantines have been implemented worldwide to reduce the spread of Coronavirus Disease (COVID-19). However, social distancing has had far-reaching health consequences, considering that the COVID-19 pandemic has exposed people to the hazard of physical inactivity and sedentary behavior. For patients with Chronic Obstructive Pulmonary Disease (COPD), which is one of the main diseases at risk for COVID-19, the impact is even greater since outpatient pulmonary rehabilitation (PR) programs are temporarily closed. More than ever, patients' behavior change to exercise calls for urgent debate. We propose a theoretical discussion in light of Self-Determination Theory, aiming to make PR a setting that supports autonomous forms of motivation. The scenario will not be changed in the short-term; but if other conditions hinder the development of PR in its most traditional form, the PR community will be better prepared to overcome the barriers to maintain physical exercise.

Improving access to community-based pulmonary rehabilitation: 3R protocol for real-world settings with cost-benefit analysis

Background

Pulmonary rehabilitation (PR) has demonstrated patients’ physiological and psychosocial improvements, symptoms reduction and health-economic benefits whilst enhances the ability of the whole family to adjust to illness. However, PR remains highly inaccessible due to lack of awareness of its benefits, poor referral and availability mostly in hospitals. Novel models of PR delivery are needed to enhance its implementation while maintaining cost-efficiency. We aim to implement an innovative community-based PR programme and assess its cost-benefit.

Methods

A 12-week community-based PR will be implemented in primary healthcare centres where programmes are not available. Healthcare professionals will be trained. 73 patients with CRD and their caregivers (dyads patient-caregivers) will compose the experimental group. The control group will include dyads age- and disease-matched willing to collaborate in data collection but not in PR. Patients/family-centred outcomes will be dyspnoea (modified Medical Research Council Questionnaire), fatigue (Checklist of individual strength and Functional assessment of chronic illness therapy – fatigue), cough and sputum (Leicester cough questionnaire and Cough and sputum assessment questionnaire), impact of the disease (COPD Assessment Test), emotional state (The Hospital Anxiety and Depression Scale), number of exacerbations, healthcare utilisation, health-related quality of life and family adaptability/cohesion (Family Adaptation and Cohesion Scale). Other clinical outcomes will be peripheral (biceps and quadriceps-hand held dynamometer, 1 or 10 repetition-maximum) and respiratory (maximal inspiratory and expiratory pressures) muscle strength, muscle thickness and cross sectional area (biceps brachialis, rectus femoris and diaphragm-ultrasound imaging), exercise capacity (six-minute walk test and one-minute sit to stand test), balance (brief-balance evaluation systems test) and physical activity (accelerometer). Data will be collected at baseline, at 12 weeks, at 3- and 6-months post-PR.

Changes in the outcome measures will be compared between groups, after multivariate adjustment for possible confounders, and effect sizes will be calculated. A cost-benefit analysis will be conducted.

Discussion

This study will enhance patients access to PR, by training healthcare professionals in the local primary healthcare centres to conduct such programmes and actively involving caregivers. The cost-benefit analysis of this intervention will provide an evidence-based insight into the economic benefit of community-based PR in chronic respiratory diseases.

Trial registration

The trial was registered in the ClinicalTrials.gov U.S. National Library of Medicine, on 10th January, 2019 (registration number: NCT03799666).

Electronic supplementary material

The online version of this article (10.1186/s12889-019-7045-1) contains supplementary material, which is available to authorized users.

Pulmonary rehabilitation for obstructive lung disease

Pulmonary rehabilitation (PR) is a highly effective, established therapy to improve exercise intolerance, impaired quality of life and limb muscle weakness associated with a range of chronic respiratory diseases. The evidence base for PR is largest in the area of chronic obstructive pulmonary disease (COPD), yet its role in other obstructive lung diseases such as asthma is less well defined. Despite several features being common across both COPD and asthma, factors such as younger age or employment may affect the potential applicability of traditional PR models for patients with asthma. This review examines the current evidence regarding PR for the obstructive lung diseases of COPD and asthma. It offers appraisal of some of the strengths and weaknesses of existing literature, identifies areas in need of future research and details some of the issues facing clinicians responsible for the clinical management and rehabilitation of patients with these diseases.

Triangulated perspectives on outcomes of pulmonary rehabilitation in patients with COPD: a qualitative study to inform a core outcome set

Introduction:

Pulmonary rehabilitation implies a comprehensive assessment. Although several outcomes are commonly measured, those are selected mainly by health professionals and researchers, with the voice of patients and informal caregivers being minimally captured. Qualitative studies are fundamental to enhance our knowledge on perspectives of different stakeholders involved in pulmonary rehabilitation.

Objective:

This study aimed to explore the views of different stakeholders on outcomes of pulmonary rehabilitation, contributing to one of the stages of a core outcome set for pulmonary rehabilitation in patients with chronic obstructive pulmonary disease (COPD).

Methods:

Semi-structured interviews were conducted with 12 patients with COPD, 11 informal carers and 10 health professionals. Data were analysed with content analysis, followed by thematic analysis to gain deeper understanding of the different perspectives.

Results:

A total of 44 outcomes were identified, being the most reported ‘improving functional performance’ (67%) and ‘reducing and taking control over dyspnoea’ (64%). Five relevant themes across stakeholders were generated: having a healthy mind in a healthy body; I can(’t) do it; feeling fulfilled; knowing more, doing better and avoiding doctors and expenses. Although perspectives were mostly consensual, some outcomes were only valued by health professionals (e.g. pulmonary function) or by patients and informal carers (e.g. quality of sleep).

Conclusion:

Views of the different stakeholders on outcomes of pulmonary rehabilitation were similar although, some specificities existed. Comprehensive assessments are needed to reflect what is valued by the different stakeholders in pulmonary rehabilitation. This study contributed to a future core outcome set in this field.

Factors associated with hospital emergency readmission and mortality rates in patients with heart failure or chronic obstructive pulmonary disease: a national observational study

Background

Heart failure (HF) and chronic obstructive pulmonary disease (COPD) lead to unplanned hospital activity, but our understanding of what drives this is incomplete.

Objectives

To model patient, primary care and hospital factors associated with readmission and mortality for patients with HF and COPD, to assess the statistical performance of post-discharge emergency department (ED) attendance compared with readmission metrics and to compare all the results for the two conditions.

Design

Observational study.

Setting

English NHS.

Participants

All patients admitted to acute non-specialist hospitals as an emergency for HF or COPD.

Interventions

None.

Main outcome measures

One-year mortality and 30-day emergency readmission following the patient’s first unplanned admission (‘index admission’) for HF or COPD.

Data sources

Patient-level data from Hospital Episodes Statistics were combined with publicly available practice- and hospital-level data on performance, patient and staff experience and rehabilitation programme website information.

Results

One-year mortality rates were 39.6% for HF and 24.1% for COPD and 30-day readmission rates were 19.8% for HF and 16.5% for COPD. Most patients were elderly with multiple comorbidities. Patient factors predicting mortality included older age, male sex, white ethnicity, prior missed outpatient appointments, (long) index length of hospital stay (LOS) and several comorbidities. Older age, missed appointments, (short) LOS and comorbidities also predicted readmission. Of the practice and hospital factors we considered, only more doctors per 10 beds [odds ratio (OR) 0.95 per doctor;p < 0.001] was significant for both cohorts for mortality, with staff recommending to friends and family (OR 0.80 per unit increase;p < 0.001) and number of general practitioners (GPs) per 1000 patients (OR 0.89 per extra GP;p = 0.004) important for COPD. For readmission, only hospital size [OR per 100 beds = 2.16, 95% confidence interval (CI) 1.34 to 3.48 for HF, and 2.27, 95% CI 1.40 to 3.66 for COPD] and doctors per 10 beds (OR 0.98;p < 0.001) were significantly associated. Some factors, such as comorbidities, varied in importance depending on the readmission diagnosis. ED visits were common after the index discharge, with 75% resulting in admission. Many predictors of admission at this visit were as for readmission minus comorbidities and plus attendance outside the day shift and numbers of admissions that hour. Hospital-level rates for ED attendance varied much more than those for readmission, but the omega statistics favoured them as a performance indicator.

Limitations

Data lacked direct information on disease severity and ED attendance reasons; NHS surveys were not specific to HF or COPD patients; and some data sets were aggregated.

Conclusions

Following an index admission for HF or COPD, older age, prior missed outpatient appointments, LOS and many comorbidities predict both mortality and readmission. Of the aggregated practice and hospital information, only doctors per bed and numbers of hospital beds were strongly associated with either outcome (both negatively). The 30-day ED visits and diagnosis-specific readmission rates seem to be useful performance indicators.

Future work

Hospital variations in ED visits could be investigated using existing data despite coding limitations. Primary care management could be explored using individual-level linked databases.

Funding

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

Outcome Measures Used in Pulmonary Rehabilitation in Patients With Acute Exacerbation of Chronic Obstructive Pulmonary Disease: A Systematic Review

BACKGROUND

Conflicting results about the effects of community-based pulmonary rehabilitation in acute exacerbations of chronic obstructive pulmonary disease (AECOPD) exist, possibly because the variety of outcome measures used and the lack of appropriate measurement properties hinder the development of pulmonary rehabilitation guidelines.

PURPOSE

The purpose of this study was to identify and review the measurement properties of patient-reported outcome measures (PROMs) and clinical outcome measures of AECOPD that are used in pulmonary rehabilitation and that can be easily applied in a community setting.

DATA SOURCES

PubMed, Web of Science, Scopus, and CINAHL were searched up to July 1, 2016.

STUDY SELECTION

Phase 1 identified outcome measures used in pulmonary rehabilitation for AECOPD. Phase 2 reviewed the measurement properties of the identified outcome measures.

DATA EXTRACTION

One reviewer extracted the data and 2 reviewers independently assessed the methodological quality of the studies and the measurement properties of the outcome measures by using the Consensus-Based Standards for the Selection of Health Status Measurement Instruments (COSMIN) recommendations.

DATA SYNTHESIS

Twenty-three PROMs and 18 clinical outcome measures were found. The outcome measures most used were the St George Respiratory Questionnaire (n = 15/37 studies) and the 6-minute walk test (n = 21/37 studies). Thirty-two studies described the measurement properties of 22 PROMs and 7 clinical outcome measures. The methodological quality of the studies was mostly poor, and the measurement properties were mostly indeterminate. The outcome measure exhibiting more robust properties was the COPD Assessment Test.

LIMITATIONS

A Number of studies were not found with the validated search strategy used and were included a posteriori; the fact that 3 studies presented combined results- for patients who were stable and patients with exacerbation-affected the conclusions that can be drawn.

CONCLUSIONS

A Large variety of outcome measures have been used; however, studies on their measurement properties are needed to enhance the understanding of community pulmonary rehabilitation for AECOPD.