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Spitzer KA, Stefan MS, Priya A, Pack QR, Pekow PS, Lagu T, Mazor K, Pinto-Plata VM, Bradley K, Heineman B, ZuWallack RL, Lindenauer PK. Promoting Participation in Pulmonary Rehabilitation after Hospitalization for Chronic Obstructive Pulmonary Disease, Strategies of Top-performing Systems: A Qualitative Study. Ann Am Thorac Soc 2023; 20:532-538. [PMID: 36449407 PMCID: PMC10112402 DOI: 10.1513/annalsats.202203-237oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 11/30/2022] [Indexed: 12/03/2022] Open
Abstract
Rationale: Pulmonary rehabilitation (PR) after hospitalization for chronic obstructive pulmonary disease (COPD) is recommended by guidelines; however, few patients participate, and rates vary between hospitals. Objectives: To identify contextual factors and strategies that may promote participation in PR after hospitalization for COPD. Methods: Using a positive-deviance approach, we calculated hospital-specific rates of PR after hospitalization for COPD among a cohort of Medicare beneficiaries. At a purposive sample of high-performing and innovative hospitals in the United States, we conducted in-depth interviews with key stakeholders. We defined high-performing hospitals as having a PR rate above the 95th percentile, at least 6.58%. To learn from hospitals that demonstrated a commitment to improving rates of PR, regardless of PR rates after discharge, we identified innovative hospitals on the basis of a review of American Thoracic Society conference research presentations from prior years. Interviews were audio-recorded and transcribed verbatim. Using a directed content analysis approach, transcripts were coded iteratively to identify themes. Results: Interviews were conducted with 38 stakeholders at nine hospitals (seven high-performers and two innovators). Hospitals were diverse regarding size, teaching status, PR program characteristics, and geographic location. Participants included PR medical directors, PR managers, respiratory therapists, inpatient and outpatient providers, and others. We found that high-performing hospitals were broadly focused on improving care for patients with COPD, and several had recently implemented new initiatives to reduce rehospitalizations after admission for COPD in response to the Centers for Medicare and Medicaid Services/Medicare's Hospital Readmission Reduction Program. Innovative and high-performing hospitals had systems in place to identify patients with COPD that enabled them to provide patient education and targeted discharge planning. Strategies took several forms, including the use of a COPD navigator or educator. In addition, we found that high-performing hospitals reported effective interprofessional and patient communication, had clinical champions or external change agents, and received support from hospital leadership. Specific strategies to promote PR included education of referring providers, education of patients to increase awareness of PR and its benefits, and direct assistance in overcoming barriers. Conclusions: Our findings suggest that successful efforts to increase participation in PR may be most effective when part of a larger strategy to improve outcomes for patients with COPD. Further research is necessary to test the generalizability of our findings.
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Affiliation(s)
| | - Mihaela S. Stefan
- Department of Healthcare Delivery and Population Sciences and
- Department of Medicine, University of Massachusetts Chan Medical School–Baystate, Springfield, Massachusetts
| | - Aruna Priya
- School of Public Health and Health Sciences, University of Massachusetts, Amherst, Massachusetts
- Department of Healthcare Delivery and Population Sciences and
| | - Quinn R. Pack
- Department of Healthcare Delivery and Population Sciences and
- Department of Medicine, University of Massachusetts Chan Medical School–Baystate, Springfield, Massachusetts
- Division of Cardiovascular Medicine and
| | - Penelope S. Pekow
- School of Public Health and Health Sciences, University of Massachusetts, Amherst, Massachusetts
- Department of Healthcare Delivery and Population Sciences and
| | - Tara Lagu
- Department of Healthcare Delivery and Population Sciences and
- Department of Medicine, University of Massachusetts Chan Medical School–Baystate, Springfield, Massachusetts
| | - Kathy Mazor
- Meyers Primary Care Institute, Worcester, Massachusetts
- Department of Medicine and
| | | | - Kolbi Bradley
- Department of Healthcare Delivery and Population Sciences and
| | - Brent Heineman
- Department of Healthcare Delivery and Population Sciences and
| | | | - Peter K. Lindenauer
- Department of Healthcare Delivery and Population Sciences and
- Department of Medicine, University of Massachusetts Chan Medical School–Baystate, Springfield, Massachusetts
- Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, Massachusetts; and
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Tang CY, Lavercombe M, Southcott AM, Taylor NF, Blackstock FC. Access to pulmonary rehabilitation for people from culturally and linguistically diverse communities: A cohort study. HEALTH & SOCIAL CARE IN THE COMMUNITY 2022; 30:e4133-e4143. [PMID: 35352435 DOI: 10.1111/hsc.13807] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 01/11/2022] [Accepted: 03/15/2022] [Indexed: 06/14/2023]
Abstract
Little is known about the extent of cultural and linguistic diversity among people with chronic obstructive pulmonary disease (COPD) in Australia and if ethno-cultural factors influence engagement in pulmonary rehabilitation (PR). We conducted a prospective cohort study to evaluate the extent of cultural and linguistic diversity among people with COPD and identify variables that influence engagement in PR. Patients with COPD attending the respiratory outpatient clinic at a metropolitan health service completed a study-specific questionnaire with results descriptively analysed. Access issues of awareness, referrals, attendance and completion of PR were examined. A multiple regression analysis was conducted to identify variables that influenced engagement in PR. Ninety-seven participants were recruited, of whom 36 (37%) self-identified a culturally and linguistically diverse (CALD) community. While participants from CALD communities had less awareness of PR as compared with the English Australian group (χ2 (df) = 5.3 (1), p = 0.02), there were no significant between-group differences in number of observed referrals (p = 0.30), attendance (p = 0.50) and completions of PR (p = 0.90). Only 11 (11%) out of 97 participants completed PR. Age (p = 0.006) and being from a CALD community (p = 0.03) were independent factors impacting on the awareness of PR while English proficiency (p = 0.04) was an independent factor impacting on referrals to PR. While older age and being from a CALD community were associated with having less awareness in PR, referrals to, attendance and completion rates of PR were similar regardless of ethnicity.
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Affiliation(s)
- Clarice Y Tang
- Physiotherapy Department, Western Health, St Albans, Victoria, Australia
- Physiotherapy, School of Health Sciences, Western Sydney University, Penrith, New South Wales, Australia
- School of Allied Health, Human Services and Sport, La Trobe University, Bundoora, Victoria, Australia
| | - Mark Lavercombe
- Department of Respiratory & Sleep Disorders Medicine, Western Health, St Albans, Victoria, Australia
- Department of Medical Education, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Medicine, Western Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - Anne M Southcott
- Department of Respiratory & Sleep Disorders Medicine, Western Health, St Albans, Victoria, Australia
- Department of Medicine, Western Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - Nicholas F Taylor
- School of Allied Health, Human Services and Sport, La Trobe University, Bundoora, Victoria, Australia
| | - Felicity C Blackstock
- Physiotherapy, School of Health Sciences, Western Sydney University, Penrith, New South Wales, Australia
- School of Allied Health, Human Services and Sport, La Trobe University, Bundoora, Victoria, Australia
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Valeiro B, Rodríguez E, Pérez P, Gómez A, Mayer AI, Pasarín A, Ibañez J, Ferrer J, Ramon MA. Promotion of physical activity after hospitalization for COPD exacerbation: A randomized control trial. Respirology 2022; 28:357-365. [PMID: 36270673 DOI: 10.1111/resp.14394] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 10/06/2022] [Indexed: 01/21/2023]
Abstract
BACKGROUND AND OBJECTIVE Physical activity worsens during exacerbations of chronic obstructive pulmonary disease (COPD) and notably after hospitalizations. Pedometer-based interventions are useful to increase physical activity in stable patients with COPD. However, there is little information concerning the implementation of such programs following severe exacerbation. This study assessed the efficacy of a physical activity program after hospitalization for a COPD exacerbation. METHODS We performed a prospective, 12-week, parallel group, assessor-blinded, randomized control trial in COPD patients hospitalized for an exacerbation. After discharge, physical activity and other secondary variables were assessed. Patients were allocated (1:1) to a physical activity promotion program (intervention group, IG) or usual care (control group, CG). Based on a motivational interview and accelerometer physical activity assessment, a patient-tailored, pedometer-based, progressive and target-driven program was designed. Linear mixed effect models were used to analyse between-group differences. RESULTS Forty-six out of 61 patients recruited were randomized and 43 (IG = 20, CG = 23) completed the study. In-hospital and baseline characteristics were similar in both groups. After 12 weeks of intervention, the mean steps difference between groups was 2093 steps/day, p = 0.018, 95% CI 376-4012, favouring the IG. Only the IG significantly increased the number of steps/day compared to baseline (mean difference [95% CI] 2932 [1069-4795] steps; p = 0.004). There were no other between-group differences. CONCLUSION After hospitalization for a COPD exacerbation, a patient-tailored physical activity program based on a motivational interview and the use of pedometers, with progressive and customized targets, improved the number of steps/day.
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Affiliation(s)
- Beatriz Valeiro
- Servicio de Neumología, Hospital Universitari Vall d'Hebron, Departamento de Medicina, Universidad Autónoma de Barcelona (UAB), Barcelona, Spain
| | - Esther Rodríguez
- Servicio de Neumología, Hospital Universitari Vall d'Hebron, Departamento de Medicina, Universidad Autónoma de Barcelona (UAB), Barcelona, Spain.,CIBER Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Paula Pérez
- Servicio de Neumología, Hospital Universitari Vall d'Hebron, Departamento de Medicina, Instituto de Investigación Vall d'Hebron (VHIR), Barcelona, Spain
| | - Alba Gómez
- Servicio de Rehabilitación, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Ana Isabel Mayer
- Servicio de Rehabilitación, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Alejandro Pasarín
- Servicio de Rehabilitación, Sant Rafael Hospital, Germanes Hospitalaries, Barcelona, Spain
| | - Jordi Ibañez
- Servicio de Medicina Interna, Sant Rafael Hospital, Germanes Hospitalaries, Barcelona, Spain
| | - Jaume Ferrer
- Servicio de Neumología, Hospital Universitari Vall d'Hebron, Departamento de Medicina, Universidad Autónoma de Barcelona (UAB), Barcelona, Spain.,CIBER Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Maria Antonia Ramon
- Servicio de Neumología, Hospital Universitari Vall d'Hebron, Departamento de Medicina, Universidad Autónoma de Barcelona (UAB), Barcelona, Spain.,CIBER Enfermedades Respiratorias (CIBERES), Madrid, Spain
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Bickton FM, Shannon H. Barriers and Enablers to Pulmonary Rehabilitation in Low- and Middle-Income Countries: A Qualitative Study of Healthcare Professionals. Int J Chron Obstruct Pulmon Dis 2022; 17:141-153. [PMID: 35046649 PMCID: PMC8763198 DOI: 10.2147/copd.s348663] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 12/24/2021] [Indexed: 01/17/2023] Open
Abstract
Introduction Low- and middle-income countries bear a disproportionately high burden of global morbidity and mortality caused by chronic respiratory diseases. Pulmonary rehabilitation is recommended as a core intervention in the management of people with chronic respiratory diseases. However, the intervention remains poorly accessed/utilised globally, especially in low- and middle-income countries. Aim This qualitative study explored barriers and enablers to pulmonary rehabilitation in low- and middle-income countries from the perspective of healthcare professionals with pulmonary rehabilitation experience in these settings. Methods Online-based semi-structured in-depth interviews with healthcare professionals were undertaken to data saturation, exploring lived barriers and enablers to pulmonary rehabilitation in their low- or middle-income country. Anonymised interviews were audio-recorded, transcribed verbatim, and analysed using thematic analysis. Results A total of seven healthcare professionals from seven low- and middle-income countries representing Africa, Asia, and South America were interviewed. They included five physiotherapists (four females), one family physician (male), and one pulmonologist (female). Themes for barriers to pulmonary rehabilitation included limited resources, low awareness, coronavirus disease 2019, and patient access-related costs. Themes for enablers included local adaptation, motivated patients, coronavirus disease 2019 (which spanned both enablers and barriers), better awareness/recognition, provision of PR training, and resource support. Conclusion Barriers to pulmonary rehabilitation in low- and middle-income countries include limited resources, low awareness, coronavirus disease 2019, and patient access-related costs. Enablers include local adaptation, motivated patients, coronavirus disease 2019 (which spanned both enablers and barriers), better awareness/recognition, provision of PR training, and resource support. Successful implementation of these enablers will require engagement with multiple stakeholders. The findings of this study are a necessary step towards developing strategies that can overcome the existing pulmonary rehabilitation evidence-practice gap in low- and middle-income countries and alleviating the burden of chronic respiratory diseases in these countries.
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Affiliation(s)
- Fanuel Meckson Bickton
- UCL Great Ormond Street Institute of Child Health, London, UK
- Lung Health Research Group, Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Harriet Shannon
- UCL Great Ormond Street Institute of Child Health, London, UK
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Benzo RP, Ridgeway J, Hoult JP, Novotny P, Thomas BE, Lam NM, V Benzo M, Kramer K, Seifert S. Feasibility of a Health Coaching and Home-Based Rehabilitation Intervention With Remote Monitoring for COPD. Respir Care 2021; 66:960-971. [PMID: 33906954 PMCID: PMC10027177 DOI: 10.4187/respcare.08580] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Pulmonary rehabilitation is an effective treatment for patients with COPD, but patient uptake and adherence to the current offering of center-based pulmonary rehabilitation is modest due to transportation, access, poverty, and frailty, and even more so in the context of the COVID pandemic. Home-based options have been proposed and were found noninferior to center-based rehabilitation; however, there is a lack of home-based programs, and more understanding is needed. We aimed to test the feasibility, uptake, and adherence to a home-based program for COPD rehabilitation with health coaching. METHODS We conducted a randomized trial with a wait-list controlled design to evaluate the effects of a home-based program with health coaching on breathlessness in subjects with moderate to severe COPD unable to attend the regular pulmonary rehabilitation program. The 8-week intervention consisted of video-guided exercises to be done 6 times a week and captured with a computer tablet. Health coaching was done weekly over the telephone to review subject activity and symptoms and to provide an opportunity for the subject to define their weekly goals. The primary outcomes were uptake, adherence, and Chronic Respiratory Questionnaire (CRQ) Dyspnea Domain. Secondary outcomes were self-management abilities and CRQ Emotions-Mastery-Fatigue. RESULTS 154 subjects with moderate to severe COPD were randomized. Subject adherence was 86% to the proposed 6-times a week exercise routine. There (P = .062) was no significant difference in breathlessness (CRQ dyspnea). There was a significant improvement in self-management abilities (P < .001). The results of the qualitative interviews showed high levels of acceptability of the program. CONCLUSIONS The tested home-based rehabilitation program with health coaching was feasible, highly acceptable, showed a high degree of adherence, and improved self-management abilities. This study offers seminal information for home-based rehabilitation programs to design alternative options of rehabilitation to individuals with COPD that cannot attend to the well-established center-based pulmonary rehabilitation. (ClinicalTrials.gov registration NCT02557178.).
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Affiliation(s)
- Roberto P Benzo
- Department of Pulmonary and Critical Care Medicine, Mindful Breathing Laboratory, Mayo Clinic, Rochester, Minnesota.
| | | | - Johanna P Hoult
- Department of Pulmonary and Critical Care Medicine, Mindful Breathing Laboratory, Mayo Clinic, Rochester, Minnesota
| | - Paul Novotny
- Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | - Benjamin E Thomas
- Department of Pulmonary and Critical Care Medicine, Mindful Breathing Laboratory, Mayo Clinic, Rochester, Minnesota
| | - Nyanjok M Lam
- Department of Pulmonary and Critical Care Medicine, Mindful Breathing Laboratory, Mayo Clinic, Rochester, Minnesota
| | - Maria V Benzo
- Department of Pulmonary and Critical Care Medicine, Mindful Breathing Laboratory, Mayo Clinic, Rochester, Minnesota
| | - Kevin Kramer
- Minnesota Health Solutions, Minneapolis, Minnesota
| | - Sara Seifert
- Minnesota Health Solutions, Minneapolis, Minnesota
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