Effect of a rehabilitation-based chronic disease management program targeting severe COPD exacerbations on readmission patterns

Virtual reality for COPD exacerbation: A randomized controlled trial

BACKGROUND

Pulmonary rehabilitation (PR) is an effective treatment method for chronic obstructive pulmonary disease (COPD). However, individuals with chronic diseases that require lifelong treatment and experience exacerbations need motivational methods.

OBJECTIVES

The aim of this study was to examine the effects of virtual reality on symptoms, daily living activity, functional capacity, anxiety and depression levels in COPD exacerbation.

METHODS

Fifty patients hospitalized for COPD exacerbation were included in the study. They were randomly assigned to two groups. Twenty-five patients participated in a traditional PR (once-daily until discharge), including pedaling exercises. The second/25 patients followed the same protocol but experienced cycling simulation in the forest via virtual reality (VR + PR). All patients were evaluated using 1-minute/Sit-to-Stand test (STST), modified-Medical Research Council (mMRC) scale, COPD Assessment test (CAT), Hospital Anxiety and Depression Scale (HADS), and London Chest Activities of Daily Living (LCADL) before and after the treatment.

RESULTS

The STST showed an increase in both groups post-treatment, notably higher in the VR + PR (p = 0.037). Dyspnea levels and CAT scores decreased in all patients, but the decrease was greater in the PR + VR group for both parameters (p = 0.062, p = 0.003; respectively). Both groups experienced a reduction in the HADS scores compared to the pre-treatment, with a more significant decrease in depression and the total score in the VR + PR (p < 0.05). LCADL's sub-parameters and total score, excluding household, decreased in both groups after treatment (p < 0.05). The improvement was more substantial in the VR + PR.

CONCLUSIONS

Virtual reality provides benefits in the management of COPD exacerbations and can be used safely.

CLINICAL TRIAL REGISTIRATION

Registered at clinicaltrials.gov, registration ID: NCT05687396, URL: www.

CLINICALTRIALS

gov.

Predictors of Readmission, for Patients with Chronic Obstructive Pulmonary Disease (COPD) - A Systematic Review

Introduction

Chronic obstructive pulmonary disease (COPD) is the third-leading cause of death globally and is responsible for over 3 million deaths annually. One of the factors contributing to the significant healthcare burden for these patients is readmission. The aim of this review is to describe significant predictors and prediction scores for all-cause and COPD-related readmission among patients with COPD.

Methods

A search was conducted in Ovid MEDLINE, Ovid Embase, Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials, from database inception to June 7, 2022. Studies were included if they reported on patients at least 40 years old with COPD, readmission data within 1 year, and predictors of readmission. Study quality was assessed. Significant predictors of readmission and the degree of significance, as noted by the p-value, were extracted for each study. This review was registered on PROSPERO (CRD42022337035).

Results

In total, 242 articles reporting on 16,471,096 patients were included. There was a low risk of bias across the literature. Of these, 153 studies were observational, reporting on predictors; 57 studies were observational studies reporting on interventions; and 32 were randomized controlled trials of interventions. Sixty-four significant predictors for all-cause readmission and 23 for COPD-related readmission were reported across the literature. Significant predictors included 1) pre-admission patient characteristics, such as male sex, prior hospitalization, poor performance status, number and type of comorbidities, and use of long-term oxygen; 2) hospitalization details, such as length of stay, use of corticosteroids, and use of ventilatory support; 3) results of investigations, including anemia, lower FEV1, and higher eosinophil count; and 4) discharge characteristics, including use of home oxygen and discharge to long-term care or a skilled nursing facility.

Conclusion

The findings from this review may enable better predictive modeling and can be used by clinicians to better inform their clinical gestalt of readmission risk.

Effectiveness of home-based pulmonary rehabilitation programs for patients with chronic obstructive pulmonary disease (COPD): systematic review

BACKGROUND

Although pulmonary rehabilitation (PR) is considered a key component in managing chronic obstructive pulmonary disease (COPD) patients, uptake remains suboptimal. This systematic review aimed to determine the effectiveness of home-based PR (HBPR) programs for COPD patients.

METHODS

A systematic review of scholarly literature published within the last 10 years from the conception of this project was conducted using internationally recognized guidelines. Search strategies were applied to electronic databases and clinical trial registries through March 2020 and updated in November 2021 to identify studies comparing HBPR with 'usual care' or outpatient pulmonary rehabilitation (OPR). To critically appraise randomized studies, the Cochrane Collaboration risk of bias tool (ROB) was used. The quality of non-randomized studies was evaluated using the ACROBAT-NRSI tool. The quality of evidence relating to key outcomes was assessed using Grading of Recommendations, Assessment, Development and Evaluations (GRADE) on health-related quality of life (HRQoL), exacerbation frequencies, COPD-related hospital admissions, and program adherence. Three independent reviewers assessed methodologic quality and reviewed the studies.

RESULTS

Twelve randomized controlled trials (RCTs) and 2 comparative observational studies were included. While considerable evidence relating to the effectiveness of HBPR programs for COPD patients exist, overall quality is low. There were no differences between HBPR and OPR in terms of safety, HRQoL, functional exercise capacity and health care resource utilization. Compared to usual care, functional exercise capacity seemed to significantly improve after HBPR. While patient compliance with HBPR is good, two factors appeared to increase the 'risk' of non-compliance: expectations of patients to 1) complete daily diaries/activity logs and 2) engage in solely unsupervised exercise sessions.

CONCLUSION

The overall quality for most outcomes was low to very low; however, HBPR seems to offer comparable short-term benefits to OPR.

Pulmonary Rehabilitation for Patients After COPD Exacerbation

BACKGROUND

The aim of this study was to clarify the effectiveness of pulmonary rehabilitation in patients after exacerbations of COPD and to explore the initiation timing of pulmonary rehabilitation.

METHODS

Systematic review and meta-analysis were performed to assess the effects of pulmonary rehabilitation in subjects with exacerbations of COPD on mortality and readmission compared with usual care. We searched for studies published up to October 2020 in MEDLINE, Embase, Cochrane Library, and other sources. Risk of bias was assessed for the randomization process, deviations from intended interventions, missing outcome data, outcome measurements, and selection of the reported result using the Risk of Bias 2 tool. We pooled mortality and readmission data and performed comparisons between pulmonary rehabilitation and usual care. The subgroup analysis compared pulmonary rehabilitation at different start times (early: ≤ 1 week from admission; and late: > 1 week from admission).

RESULTS

We identified 10 randomized trials (1,056 participants). Our meta-analysis showed a clinically relevant reduction in readmission up to 3-6 months after pulmonary rehabilitation in both early group (4 trials, 190 subjects; risk ratio [RR] 0.58, [95% CI 0.34-0.99]) and late group (3 trials, 281 subjects; RR 0.48, [95% CI 0.32-0.71]). However, pulmonary rehabilitation had no significant effect on mortality 1 y later compared with usual care (4 trials, 765 subjects; RR 1.27, [95% CI 0.91-1.79]).

CONCLUSIONS

Pulmonary rehabilitation showed short-term effects for subjects with exacerbations of COPD even if initiated within 1 week; however, further study is required to determine its long-term effects.

Strategies to Prevent Readmissions to Hospital for COPD: A Systematic Review

Patients with chronic obstructive pulmonary disease (COPD) experience high rates of hospital readmissions, placing substantial clinical and economic strain on the healthcare system. Therefore, it is essential to implement evidence-based strategies for preventing these readmissions. The primary objective of our systematic review was to identify and describe the domains of existing primary research on strategies aimed at reducing hospital readmissions among adult patients with COPD. We also aimed to identify existing gaps in the literature to facilitate future research efforts. A total of 843 studies were captured by the initial search and 96 were included in the final review (25 randomized controlled trials, 37 observational studies, and 34 non-randomized interventional studies). Of the included studies, 72% (n = 69) were considered low risk of bias. The majority of included studies (n = 76) evaluated patient-level readmission prevention strategies (medication and other treatments (n = 25), multi-modal (n = 19), follow-up (n = 16), telehealth (n = 8), education and coaching (n = 8)). Fewer assessed broader system- (n = 13) and policy-level (n = 7) strategies. We observed a trend toward reduced all-cause readmissions with the use of medication and other treatments, as well as a trend toward reduced COPD-related readmissions with the use of multi-modal and broader scale system-level interventions. Notably, much of this evidence supported shorter-term (30-day) readmission outcomes, while little evidence was available for longer-term outcomes. These findings should be interpreted with caution, as considerable between-study heterogeneity was also identified. Overall, this review identified several evidence-based interventions for reducing readmissions among patients with COPD that should be targeted for future research.Supplemental data for this article is available online at https://doi.org/10.1080/15412555.2021.1955338 .

Timing of Pulmonary Rehabilitation in Readmitted Patients with Severe Chronic Obstructive Pulmonary Disease: A Randomized Clinical Trial

Early pulmonary rehabilitation (PR), started during hospitalization or within the first month after discharge, has been shown to reduce exacerbations and improve health-related-quality of life (HRQoL) and exercise capacity. However, no randomized clinical trials (RCT) have compared the efficacy of PR started during hospitalization (DHPR) to PR initiated one month post-hospitalization (PHPR). We conducted an RCT to compare DHPR to PHPR in severe patients with COPD readmitted for exacerbations in a tertiary hospital setting. Patients were randomized to receive three months of DHPR or PHPR. Outcomes were assessed at completion of the PR programme and at months 3 and 9. A total of 53 patients (26 DHPR and 27 PHPR) were included. There were no between-group differences in the number of exacerbations (mean, 3.62 vs. 3.04 in the DHPR and PHPR groups, respectively; p = 0.403). Dyspnea in activities of daily living, exercise capacity, and all HRQoL parameters improved in the PHPR group. In the DHPR group, improvement was observed only for some HRQoL parameters. All gains in both groups were lost during follow-up. More adverse events were observed in the DHPR group (20 vs 5, p = 0.023), although none of these were clinically significant. In this sample of patients with severe COPD readmitted to the hospital for exacerbations, both approaches to PR were safe, but PHPR yielded better outcomes overall. These findings suggest that, PR should be initiated in patients with severe COPD only after hospital discharge when the patients' clinical condition has stabilized.

Nutritional status and muscle dysfunction in chronic respiratory diseases: stable phase versus acute exacerbations

Nutritional abnormalities are frequent in different chronic respiratory diseases such as chronic obstructive pulmonary disease (COPD), bronchiectasis, cystic fibrosis (CF), interstitial fibrosis and lung cancer, having important clinical consequences. However, nutritional abnormalities often remained underdiagnosed due to the relative lack of awareness of health professionals. Therefore, systematic anthropometry or even better, assessment of body composition, should be performed in all patients with chronic respiratory conditions, especially following exacerbation periods when malnutrition becomes more accentuated. Nutritional abnormalities very often include the loss of muscle mass, which is an important factor for the occurrence of muscle dysfunction. The latter can be easily detected with the specific assessment of muscle strength and endurance, and also negatively influences patients' quality of life and prognosis. Both nutritional abnormalities and muscle dysfunction result from the interaction of several factors, including tobacco smoking, low physical activity-sedentarism, systemic inflammation and the imbalance between energy supply and requirements, which essentially lead to a negative balance between protein breakdown and synthesis. Therapeutic approaches include improvements in lifestyle, nutritional supplementation and training. Anabolic drugs may be administered in some cases.

Magnetic Stimulation Therapy in Patients with COPD: A Systematic Review

Magnetotherapy (MT) is a therapeutic treatment based on the use of magnetic fields (MF) that can have an anti-inflammatory and analgesic effect. MT represents a possible treatment or an ancillary therapeutic intervention for a wide range of diseases and it is often used in the field of physiotherapeutic practices. A crucial point in the treatment of chronic obstructive pulmonary disease (COPD) patients, to counteract muscular depletion and respiratory symptoms, is represented by physiotherapy. Nevertheless, the knowledge about the application of MF as a therapeutic option in COPD patients is very limited. The purpose of the present study was to define what is currently known about the use of MF in patients with COPD. A systematic review of the literature was conducted during the month of October 2017, searching three main databases. Only those citations providing detailed informations about the use of MF to treat COPD symptoms either during an acute or a chronic phase of the disease, were selected. Following the selection process three articles were included in the final analysis. The present review focused on a total of thirty-six patients with COPD, and on the effects of the application of MF. In the majority of cases, the treatment sessions with MF were carried-out in an outpatient setting, and they differed with regard to the duration; frequency of application; dosage; intensity of the applied MF. Basing on the available informations, it seems that MF is a feasible, well tolerated, safe therapeutic option, for the treatment of motor-related COPD symptoms.