Feasibility of a Health Coaching and Home-Based Rehabilitation Intervention With Remote Monitoring for COPD

Experiences of Home-Based Pulmonary Rehabilitation With mHealth and Centre-Based Pulmonary Rehabilitation in People With Chronic Obstructive Pulmonary Disease: A Qualitative Study

BACKGROUND

Mobile health (mHealth) provides innovative solutions to improve access to pulmonary rehabilitation (PR). This study aimed to explore the experiences of people with chronic obstructive pulmonary disease (COPD) who undertook either an 8-week home-based PR with a mHealth application (app) (m-PR) or centre-based PR (CB-PR).

METHODS

Convenience then purposive sampling was used to recruit participants enrolled in a randomised controlled trial after completion or withdrawal from either m-PR or CB-PR. Participants undertook individual, semi-structured interviews. Interview transcripts were inductively coded and thematically analysed using a critical realist approach.

RESULTS

Thirteen m-PR and 12 CB-PR participants were interviewed (mean age (SD) 75 (8) years, 52% male). Four themes were conceptualised: internal motivators influence uptake and adherence, external motivators influence uptake and adherence, programme structure impacts practicality and experience, and living with and managing COPD and other health issues. Motivators for both programmes included improved fitness levels, feeling accountable to the programme and reinforcement from staff and peers. The m-PR in-app functionalities such as the daily task list were additionally motivational. m-PR participants arranged the programme around their schedule while centred-based participants arranged their schedule around the programme. Multi-morbidity and illness were barriers to adherence in both programmes. The social network, environment and resources available to participants impacted their enjoyment.

CONCLUSION

This study adds important information for service providers considering implementation of mHealth PR models.

PATIENT OR PUBLIC CONTRIBUTION

Consumers co-designed and user-tested the m-PR app. The qualitative data presented in this manuscript was obtained through interviews with consumers.

Assessment of Home-based Monitoring in Adults with Chronic Lung Disease: An Official American Thoracic Society Research Statement

Background: There is increasing interest in the use of home-based monitoring in people with chronic lung diseases to improve access to care, support patient self-management, and facilitate the collection of information for clinical care and research. However, integration of home-based monitoring into clinical and research settings requires careful consideration of test performance and other attributes. There is no published guidance from professional respiratory societies to advance the science of home-based monitoring for chronic lung disease. Methods: An international multidisciplinary panel of 32 clinicians, researchers, patients, and caregivers developed a multidimensional framework for the evaluation of home-based monitoring in chronic lung disease developed through consensus using a modified Delphi survey. We also present an example of how the framework could be used to evaluate home-based monitoring using spirometry and pulse oximetry in adults with asthma, bronchiectasis/cystic fibrosis, chronic obstructive pulmonary disease, and interstitial lung disease. Results: The PANACEA framework includes seven domains (test Performance, disease mANAgement, Cost, patient Experience, clinician Experience, researcher Experience, and Access) to assess the degree to which home-based monitoring assessments meet the conditions for clinical and research use in chronic lung disease. Knowledge gaps and recommendations for future research of home spirometry and pulse oximetry in asthma, bronchiectasis/cystic fibrosis, chronic obstructive pulmonary disease, and interstitial lung disease were identified. Conclusions: The development of the PANACEA framework allows standardized evaluation of home-based monitoring in chronic lung diseases to support clinical application and future research.

Factors influencing adherence to home based pulmonary rehabilitation programme by high risk patients awaiting lung surgery: mixed methods study

OBJECTIVE

Preoperative home based pulmonary rehabilitation (HPR) can reduce postoperative complications in lung surgery patients. This study aimed to investigate the level of adherence to a preoperative HPR programme in high risk patients awaiting lung surgery, and factors influencing adherence.

DESIGN

A mixed methods explanatory sequential design consisting of a quantitative questionnaire survey and a qualitative interview study.

SETTING

The study was conducted at a tertiary hospital in Chongqing, China.

PARTICIPANTS

186 high risk patients awaiting lung surgery were enrolled in the preoperative HPR programme. All 186 patients participated in the quantitative questionnaire survey. 13 of the 186 patients were selected to participate in the qualitative interview study.

RESULTS

Quantitative questionnaire results revealed an adherence rate of 52.3%. Marital status, residence location, exercise habit, smoking index and pulmonary function were identified as independent influencers of adherence (p<0.05). Qualitative interviews identified poor health, lack of family and social support, adverse weather condition, arduous preoperative examination and unfit exercise intensity as barriers to adherence, and perceived health benefits, family support, and flexibility and convenience in exercise time and space as factors encouraging adherence.

CONCLUSIONS

High risk patients awaiting lung surgery adhered to preoperative HPR at a moderate level. A tiered approach can be used to develop personalised HPR protocols based on patients' individual needs and situations to improve adherence and maximise the benefits of HPR.

Risk Factors for Adults with Chronic Obstructive Pulmonary Disease in the United States, Utilizing State-Based Surveillance

Chronic Obstructive Pulmonary Disease (COPD) is a complex and heterogeneous condition. Exposure to tobacco smoke and air pollutants are key risk factors for COPD development; however, other risk factors include race/ethnicity, sex of adults, a history of asthma, occupational exposures, and chronic respiratory infections. Data for the current study were from the 2022 Behavioral Risk Factor Surveillance Survey. Chi-squares and multinomial logistic regression analyses, adjusted with the survey's sampling weight, were used to examine how critical health indicators impacted a COPD diagnosis. Participants (N = 311,175) were adults aged 45 years and older. Adjusted multinomial regression analyses showed adults who reported asthma, current and former smoking, poor physical health, depression, less physical activity, and fatigue were more likely to report COPD. Those with COPD were more likely to be male than female. Moreover, those with COPD reported higher rates of health insurance coverage, and yet had lower income and more financial difficulty affording a doctor for health services. In a follow up regression analysis, examining racial differences in COPD for participants, American Indian adults had a higher odds of reporting COPD than the "other" race groups. Because COPD remains a leading cause of death and disability in the U.S., and racial disparities persist in respiratory outcomes, continuing to identify risk factors for vulnerable groups could assist health program planners with development of successful health messaging.

Research Priorities in Pulmonary Rehabilitation: The Urgent Need to Increase the Portfolio of Rehabilitation Options for Chronic Lung Disease

Pulmonary rehabilitation (PR) plays a crucial role in improving outcomes for individuals with chronic respiratory diseases. The most outstanding challenge in PR is the low referral, uptake, and adherence that is dramatically low in the post-hospitalization period in rural, minority, and low-income populations. Research efforts to increase the portfolio of PR through the testing and implementation of new and effective options for home-based and community-based programs are potential research targets. Other potential foci of research efforts are the pursuit of behavior-change techniques to achieve a lifestyle change during PR and the referral process to increase uptake and adherence rates. Creating new rehabilitation options for chronic lung disease that can reach more people may require expanding the definition of PR for chronic lung disease to one more flexible and perhaps concordant with the World Health Organization's definition of rehabilitation as "a set of interventions designed to optimize functioning and reduce disability in individuals with health conditions in interaction with their environment." While efforts to augment access to conventional PR are warranted, it is time to devote research efforts to reach many more individuals with chronic lung disease, particularly minorities, rural, and low-income individuals that currently have no access to any rehabilitation, a social injustice that requires action. This manuscript outlines suggested future directions in rehabilitation research with the pursuit of evidence to support feasible and effective programs that may increase the rehabilitation portfolio to accommodate most individuals with chronic lung disease.

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

PURPOSE

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

REVIEW METHODS

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

SUMMARY

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

The experiences of people with chronic obstructive pulmonary disease (COPD) using activity monitors in everyday life: an interpretative phenomenological study

PURPOSE

Understanding the experiences of people with Chronic Obstructive Pulmonary Disease (COPD) using activity monitors in daily life could support the utilisation of technology within healthcare to increase physical activity and support self-management. This qualitative study aimed to explore the experiences of people with COPD using activity monitors at home in everyday life.

METHODS

Semi-structured face-to-face or telephone interviews were conducted with seven people with COPD between August 2018 and June 2020. Participants had all used an activity monitor within the last year (Fitbit, Garmin, or Apple Watch). Interviews were analysed in-depth using Interpretative Phenomenological Analysis (IPA).

RESULTS

Four themes, developed using IPA, highlight participants' engagement with activity monitors and integrating them into their lives: (1) Motivational features to monitor activity, (2) Importance of setting achievable goals, (3) Developing knowledge and awareness, and (4) Integration into everyday life for self-management.

CONCLUSION

Activity monitors were perceived to be beneficial and useful to people with COPD, not just for monitoring their activity, but also helping to self-manage their condition. Activity monitors may be a useful tool within rehabilitation and healthcare services for COPD.

Effect of telemonitoring and telerehabilitation on physical activity, exercise capacity, health-related quality of life and healthcare use in patients with chronic lung diseases or COVID-19: A scoping review

BACKGROUND

Telemonitoring and telerehabilitation can support home-based pulmonary rehabilitation (PR) and benefit patients with lung diseases or COVID-19. This study aimed to (1) identify which telemonitoring and telerehabilitation interventions (e.g. videoconferencing) are used to provide telehealth care for people with chronic respiratory conditions or COVID-19, and (2) provide an overview of the effects of telemonitoring and telerehabilitation on exercise capacity, physical activity, health-related QoL (HRQoL), and healthcare use in patients with lung diseases or COVID-19.

METHODS

A search was performed in the electronic databases of Ovid MEDLINE, EMBASE, and Cinahl through 15 June 2021. Subject heading and keywords were used to reflect the concepts of telemonitoring, telerehabilitation, chronic lung diseases, and COVID-19. Studies that explored the effect of a telerehabilitation and/or telemonitoring intervention, in patients with a chronic lung disease such as asthma, chronic obstructive pulmonary diseases (COPD), or COVID-19, and reported the effect of the intervention in one or more of our outcomes of interest were included. Excluding criteria included evaluation of new technological components, teleconsultation or one-time patient assessment.

RESULTS

This scoping review included 44 publications reporting the effect of telemonitoring (25 studies), telerehabilitation (8 studies) or both (11 studies) on patients with COPD (35 studies), asthma (5 studies), COPD and asthma (1 study), and COVID-19 (2 studies). Patients who received telemonitoring and/or telerehabilitation had improvements in exercise capacity in 9 out of 11 (82%) articles, better HRQoL in 21 out of 25 (84%), and fewer health care use in 3 out of 3 (100%) articles compared to pre-intervention. Compared to controls, no statistically significant differences were found in the intervention groups' exercise capacity in 5 out 6 (83%) articles, physical activity in 3 out of 3 (100%) articles, HRQoL in 21 out of 25 (84%) articles, and healthcare use in 15 out of 20 (75%) articles. The main limitation of the study was the high variability between the characteristics of the studies, such as the number and age of the patients, the outcome measures, the duration of the intervention, the technological components involved, and the additional elements included in the interventions that may influence the generalization of the results.

CONCLUSION

Telemonitoring and telerehabilitation interventions had a positive effect on patient outcomes and appeared to be as effective as standard care. Therefore, they are promising alternatives to support remote home-based rehabilitation in patients with chronic lung diseases or COVID-19.

Patient Engagement in Health Coaching and Self-Management Abilities in Chronic Obstructive Pulmonary Disease

Objective: Health coaching has the potential to improve self-management abilities (SM) in patients with Chronic Obstructive Pulmonary Disease (COPD). Patient engagement with health care providers has a beneficial effect on patient outcomes. We examined the association of patient engagement with the health coach on SM abilities in patients with COPD. Methods: We analyzed the association between the degree of engagement measured by the Working Alliance Inventory (WAI-SR) and the SM measured by the Self-Management-Ability-Scale-30 (SMAS-30) at the end of a COPD health coaching intervention. Results: The cohort included 146 moderate to severe COPD patients. The WAI-SR total score was 85% of the maximum possible scores indicating a high degree of engagement between the health coach and the patients. The WAI-SR Task and Bond domains were positively associated with SM abilities after adjusting for lung function (FEV1 %) and depression symptoms (PHQ-2). Conclusion: The degree of engagement between a health coach and patients is associated with the perception of SM abilities in patients with COPD. Our results may inform self-management intervention and clinical practice.

Feasibility Trial of a Comprehensive, Highly Patient-Centered COPD Self-Management Support Program

Purpose

To test the feasibility of a novel self-management support intervention for people with chronic obstructive pulmonary disease (COPD).

Methods

We conducted a feasibility randomized controlled trial involving patients ≥40 years with severe or very severe COPD in New York, New York (n=59). Community health workers screened patients and addressed barriers to COPD self-management. Patients were also offered home-based pulmonary rehabilitation (HBPR) and an antibiotic and steroid rescue pack. Control patients received general COPD education. Clinical outcomes for intervention and control were compared by difference-in-differences (DiD) at baseline and 6 months. The study was not powered for statistically significant differences for any measure. Feasibility measures were collected at 6 months.

Results

There were high rates of completion of intervention activities, including 75% of patients undergoing evaluation for and participating in HBPR. Most (92%) intervention patients said the program was very or extremely helpful and 96% said they would participate again. Clinical outcomes generally favored the intervention: COPD assessment test, DiD -1.1 (95% confidence interval [CI] -5.9 to 3.6); 6-minute walk test distance, DiD 7.4 meters (95% CI -45.1 to 59.8); self-reported hospitalizations, DiD -9.8% (95% CI -42.3% to 22.8%); medication adherence, DiD 7.7% (-29.6%, 45.0%), and Physical Activity Adult Questionnaire, DiD 86 (95% CI -283 to 455). Intervention patients reported more emergency department visits, DiD 10.6% (95% CI 17.7% to 38.8%).

Conclusions

A highly patient-centered, self-management support intervention for people with COPD was well received by patients and associated with potential improvements in clinical and self-management outcomes. A fully powered study of the intervention is warranted.

Using concepts from trauma-informed care: Potential to inform health and wellness coaching for college students

College students are struggling to maintain well-being, with mental health challenges becoming exceedingly disruptive. Health and wellness coaching can be utilized in the college setting in addition to counseling to connect college students with resources, provide support through accountability and unconditional positive regard, and promote personal growth. Trauma-informed care is an effective approach for supporting those who may be or are experiencing trauma and is shown to be relevant in the college setting. This paper describes a rationale for integrating trauma-informed care and health and wellness coaching to enhance overall college student well-being, foster academic achievement, and create a safe, inclusive environment for growth.

Digital empowerment in long-term condition management: A systematic review and narrative synthesis of the experiences and perceptions of home-based digital health coaching interventions

Objectives

Globally, the prevalence of long-term conditions (LTCs) continues to rise. The impact of LTCs presents significant challenges for international health and social care systems and continues to be a leading cause of mortality. Despite this, digital health coaching interventions (DHCIs) appear to be a promising strategy for managing chronic disease. The aims of this systematic review and narrative synthesis were to explore the barriers and enablers for the use of DHCIs and to gather valuable information to inform the development of a new DHCI for LTC management.

Methods

Six major databases were searched for studies published in the English language between January 2012 and December 2022. Qualitative and mixed methods studies were included if there was an intervention of digital health coaching alongside the use of a digital component. Interventions were suitable if completed in community settings, amongst adults aged over 18 with a LTC, or amongst informal carers, health coaches, or health and care professionals. Included studies were assessed for quality, and results were analysed with narrative synthesis.

Results

Ten studies met the inclusion criteria, covering a range of LTCs and interventions which included digital health coaching (telephone, video, online, text) and the use of a digital component (online, application-based). Results showed that DHCIs require personalisation and feedback, and cannot be overcomplex. Importantly, an element of human connection is favourable.

Conclusions

The acceptability of DHCIs is variable- and context-dependent. Further research is needed to focus on the breadth of LTCs in order to generalise findings.

The impact of health and wellness coaching on patient-important outcomes in chronic illness care: A systematic review and meta-analysis

BACKGROUND

Health and Wellness Coaching (HWC) may be beneficial in chronic condition care. We sought to appraise its effectiveness on quality of life (QoL), self-efficacy (SE), depression, and anxiety.

METHODS

We searched MEDLINE, EMBASE, CINAHL, PsycINFO, and Cochrane CENTRAL for randomized trials published January 2005 - March 2023 that compared HWC to standard clinical care or another intervention without coaching. We examined QoL, SE, depression, or anxiety outcomes. Meta-analysis utilizing the random-effects model was used to estimate the pooled standardized mean difference (SMD).

RESULTS

Thirty included studies demonstrated that HWC improved QoL within 3 months (SMD 0.62 95 % CI 0.22-1.02, p = 0.002), SE within 1.5 months (SMD 0.38, 95 % CI 0.03-0.73, p = 0.03), and depression at 3, 6, and 12 months (SMD 0.67, 95 % CI 0.13-1.20, p = 0.01), (SMD 0.72, 95 % CI 0.19-1.24, p = 0.006), and (SMD 0.41, 95 % CI 0.09-0.73, p = 0.01) Certainty in the evidence for most outcomes was either very low or low primarily due to the high risk of bias, heterogeneity, and imprecision.

CONCLUSION

HWC improves QoL, SE, and depression across chronic illness populations. Future research needs to standardize intervention reporting and outcome collection.

PRACTICE IMPLICATIONS

Future HWC studies should standardize intervention components, reporting, and outcome measures, apply relevant chronic illness theories, and aim to follow participants for greater than one year.

Wearable technology interventions in patients with chronic obstructive pulmonary disease: a systematic review and meta-analysis

Chronic obstructive pulmonary disease (COPD) is the third leading cause of death and is associated with multiple medical and psychological comorbidities. Therefore, future strategies to improve COPD management and outcomes are needed for the betterment of patient care. Wearable technology interventions offer considerable promise in improving outcomes, but prior reviews fall short of assessing their role in the COPD population. In this systematic review and meta-analysis we searched ovid-MEDLINE, ovid-EMBASE, CINAHL, CENTRAL, and IEEE databases from inception to April 2023 to identify studies investigating wearable technology interventions in an adult COPD population with prespecified outcomes of interest including physical activity promotion, increasing exercise capacity, exacerbation detection, and quality-of-life. We identified 7396 studies, of which 37 were included in our review. Meta-analysis showed wearable technology interventions significantly increased: the mean daily step count (mean difference (MD) 850 (494-1205) steps/day) and the six-minute walk distance (MD 5.81 m (1.02-10.61 m). However, the impact was short-lived. Furthermore, wearable technology coupled with another facet (such as health coaching or pulmonary rehabilitation) had a greater impact that wearable technology alone. Wearable technology had little impact on quality-of-life measures and had mixed results for exacerbation avoidance and prediction. It is clear that wearable technology interventions may have the potential to form a core part of future COPD management plans, but further work is required to translate this into meaningful clinical benefit.

Urban Zen integrative therapy: Understanding intervention delivery adherence

BACKGROUND

Complementary health approaches have shown therapeutic benefits in symptom reduction and improved patients' quality of life for chronic debilitating conditions such as cancer and pulmonary hypertension. Urban Zen Integrative Therapy (UZIT) is a mindfulness-based multicomponent complementary intervention shown to improve symptom management and quality of life in patients with pulmonary hypertension. Consistent intervention delivery across interventionists is critical to test mindfulness-based multicomponent interventions on a larger scale and further implementations as an augmented practice in routine care.

OBJECTIVE

The purpose of the study is to explore interventionists' perspectives of UZIT delivery to gain an in-depth understanding of subjective interventionist-related variables that may influence intervention fidelity beyond objective measurements.

METHODS

Two trained Urban Zen Integrative Therapy interventionists provided their perspectives via joint interviews after delivering 78 one-on-one UZIT sessions to 14 pulmonary hypertension patients. A UZIT session incorporates essential oil, gentle movement, positioning, and meditation.

RESULTS

Qualitative analysis revealed four main contextual themes related to UZIT delivery adherence: (1) balancing between tailoring and standardization, (2) challenges with delivery, (3) the need for teamwork, and (4) clients' application of UZIT.

CONCLUSION

When mindfulness-based complementary intervention is aimed at affecting behavioral health practice outcomes, comprehensive contextual insights from interventionists' point-of-view can enhance intervention fidelity and help researchers strengthen the conduct of rigorous research.

Home-Based Physical Activity Program With Health Coaching for participants With Chronic Obstructive Pulmonary Disease in Sweden: A Proof-of-Concept Pilot Study

Home-based interventions are at the center stage of current health care demands. There is a clear need to translate pulmonary rehabilitation into a home-based setting. This 8-week pilot study aimed to determine the feasibility of a home-based physical activity program for participants with chronic obstructive pulmonary disease (COPD) in Sweden. Patients with COPD, aged 40 years or older and clinically stable in the past 3 months, were recruited. The program used a fitness tracker to monitor step count, weekly health coaching calls using motivational interviewing, and video-guided mindful movements. The outcome measures were adherence to the 8-week program's video-guided exercises (number of times videos were watched), adherence to health coaching calls (minimum 8), monthly and daily step count, and quality of life (QoL) using the chronic respiratory questionnaire. Thirteen participants were enrolled, and 12 participants adhered to health coaching calls and step monitoring. We had 643 video-exercise views, which exceeded the minimum standard (576 views). The mean difference comparing total monthly steps from baseline and the 8-week time point was 47,039 steps (95% CI, -113,625 to 1623.5; P=.06). The minimal clinical improvement of 500 daily steps was found for 8 of the patients. No significant improvement was found in the QoL measures and mental health. We found the home-based physical activity program to be a feasible intervention. Patients reported high adherence to tracking step counts, health coaching calls, and video-guided exercise. No improvements in QoL or monthly step count emerged; however, we found high adherence and a positive trend in the number of monthly step counts, and improvements of at least 500 daily step counts improved in most patients with this small sample size.

Understanding the Patient Experience of Home-Based Pulmonary Rehabilitation with Health Coaching for COPD: A Qualitative Interview Study

Background

We recently reported on a randomized trial of home-based pulmonary rehabilitation (PR) for chronic obstructive pulmonary disease (COPD) that showed improvement in all domains of quality of life, accelerometry-measured physical activity, and self-management. In this current study, we used a theoretical framework to help us gain an in-depth understanding of how patients experience complex, multi-component programs to help uncover factors related to behavior change and to inform program scale-up in other populations.

Study Design and Methods

The parent trial was conducted with COPD patients receiving care at an academic medical center and a community health system in the upper Midwest. The 12-week PR intervention included 3 daily video-guided exercises, activity monitors, and weekly telephonic health coaching. Trial participants were eligible to participate in an individual phone interview about their experience if they completed the intervention within the prior 12 months.. Analysis of verbatim transcripts followed an inductive thematic approach followed by deductive categorization and interpretation using a theoretical model: the Capability, Opportunity, Motivation-Behavior (COM-B) model developed for linking intervention functions to aspects of behavioral change.

Results

Among 32 eligible program participants,32 were approached, and 15 completed interviews between October 19, 2021, and January 13, 2022. The COM-B model and recommendations for program improvement were observed in the primary findings.

Discussion

Participants' feedback highlighted how the health coaching bolstered skills and confidence among individuals with the poorest function at program enrollment and how improved physical function and mood led to motivation. It also highlighted the roles of technology and telephonic support in a home-based program. Suggestions for improvement included providing exercise variations.

Benefits and Harms of Digital Health Interventions Promoting Physical Activity in People With Chronic Conditions: Systematic Review and Meta-Analysis

BACKGROUND

Digital health interventions for managing chronic conditions have great potential. However, the benefits and harms are still unclear.

OBJECTIVE

This systematic review and meta-analysis aimed to investigate the benefits and harms of digital health interventions in promoting physical activity in people with chronic conditions.

METHODS

We searched the MEDLINE, Embase, CINAHL, and Cochrane Central Register of Controlled Trials databases from inception to October 2022. Eligible randomized controlled trials were included if they used a digital component in physical activity promotion in adults with ≥1 of the following conditions: depression or anxiety, ischemic heart disease or heart failure, chronic obstructive pulmonary disease, knee or hip osteoarthritis, hypertension, or type 2 diabetes. The primary outcomes were objectively measured physical activity and physical function (eg, walk or step tests). We used a random effects model (restricted maximum likelihood) for meta-analyses and meta-regression analyses to assess the impact of study-level covariates. The risk of bias was assessed using the Cochrane Risk of Bias 2 tool, and the certainty of the evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation.

RESULTS

Of 14,078 hits, 130 randomized controlled trials were included. Compared with usual care or minimal intervention, digital health interventions increased objectively measured physical activity (end of intervention: standardized mean difference [SMD] 0.29, 95% CI 0.21-0.37; follow-up: SMD 0.17, 95% CI 0.04-0.31) and physical function (end of intervention: SMD 0.36, 95% CI 0.12-0.59; follow-up: SMD 0.29, 95% CI 0.01-0.57). The secondary outcomes also favored the digital health interventions for subjectively measured physical activity and physical function, depression, anxiety, and health-related quality of life at the end of the intervention but only subjectively measured physical activity at follow-up. The risk of nonserious adverse events, but not serious adverse events, was higher in the digital health interventions at the end of the intervention, but no difference was seen at follow-up.

CONCLUSIONS

Digital health interventions improved physical activity and physical function across various chronic conditions. Effects on depression, anxiety, and health-related quality of life were only observed at the end of the intervention. The risk of nonserious adverse events is present during the intervention, which should be addressed. Future studies should focus on better reporting, comparing the effects of different digital health solutions, and investigating how intervention effects are sustained beyond the end of the intervention.

TRIAL REGISTRATION

PROSPERO CRD42020189028; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=189028.

Home-Based Pulmonary Rehabilitation and Health Coaching in Fibrotic Interstitial Lung Disease: IMPLEMENTATION AND QUALITATIVE ASSESSMENT OF A PILOT TELEHEALTH PROGRAM

PURPOSE

Pulmonary rehabilitation is a behavioral modification intervention shown to improve exercise tolerance and patient-reported quality of life in patients with fibrotic interstitial lung disease. Home-based rehabilitation may provide easier access for those who struggle to complete center-based rehabilitation programs due to increased symptom burden or frailty.

METHODS

We present the quantitative and qualitative findings of a pilot study of 21 patients with fibrotic interstitial lung disease who participated in a 12-wk home-based pulmonary rehabilitation program with activity monitoring and health coaching.

RESULTS

Pre- and post-intervention patient-reported outcome questionnaires suggested improvements in dyspnea and respiratory-related quality of life but were underpowered to meet statistical significance. Half had increases in mean daily step counts while a quarter declined because of disease progression. Qualitative analysis of semistructured participant interviews suggested a significant baseline disease burden with related secondary impacts, including anxiety regarding disease progression and prognosis. Many who participated had no specific program expectations or self-determined goals but still found the program impactful, particularly on their abilities to adapt and cope with the disease.

CONCLUSION

Our study suggests feasibility in a diverse set of patients with varying severity and diagnostic subtypes. We also provide quantitative and qualitative aspects of program impact on patient well-being and highlight the complex interaction between measured physical and self-reported outcomes and disease experience.

Pulmonary Rehabilitation in Persons With COPD

Pulmonary rehabilitation (PR) is a high-value intervention for persons with COPD and other chronic lung diseases. It is associated with improvement in exercise capacity, dyspnea, health-related quality of life, and depression as well as a reduction in hospitalization and improved survival when PR follows COPD-related hospitalizations. PR is underused in the United States and other countries despite strong evidence of both clinical effectiveness and cost-effectiveness. Additional challenges include a lack of equitable reimbursement and poor access, particularly in rural settings. Models, for example, virtual PR, may be an option for improving access but coverage in the United States by Medicare is tenuous. In addition, virtual PR models have considerable heterogeneity, which challenges uniform efficacy and selection of optimal candidates.

COPD: Providing the right treatment for the right patient at the right time

Chronic Obstructive Pulmonary Disease (COPD) is a common disease associated with significant morbidity and mortality that is both preventable and treatable. However, a major challenge in recognizing, preventing, and treating COPD is understanding its complexity. While COPD has historically been characterized as a disease defined by airflow limitation, we now understand it as a multi-component disease with many clinical phenotypes, systemic manifestations, and associated co-morbidities. Evidence is rapidly emerging in our understanding of the many factors that contribute to the pathogenesis of COPD and the identification of "early" or "pre-COPD" which should provide exciting opportunities for early treatment and disease modification. In addition to breakthroughs in our understanding of the origins of COPD, we are optimizing treatment strategies and delivery of care that are showing impressive benefits in patient-centered outcomes and healthcare utilization. This special issue of Respiratory Medicine, "COPD: Providing the Right Treatment for the Right Patient at the Right Time" is a summary of the proceedings of a conference held in Stresa, Italy in April 2022 that brought together international experts to discuss emerging evidence in COPD and Pulmonary Rehabilitation in honor of a distinguished friend and colleague, Claudio Ferdinando Donor (1948-2021). Claudio was a true pioneer in the field of pulmonary rehabilitation and the comprehensive care of individuals with COPD. He held numerous leadership roles in in the field, provide editorial stewardship of several respiratory journals, authored numerous papers, statement and guidelines in COPD and Pulmonary Rehabilitation, and provided mentorship to many in our field. Claudio's most impressive talent was his ability to organize spectacular conferences and symposia that highlighted cutting edge science and clinical medicine. It is in this spirit that this conference was conceived and planned. These proceedings are divided into 4 sections which highlight crucial areas in the field of COPD: (1) New concepts in COPD pathogenesis; (2) Enhancing outcomes in COPD; (3) Non-pharmacologic management of COPD; and (4) Optimizing delivery of care for COPD. These presentations summarize the newest evidence in the field and capture lively discussion on the exciting future of treating this prevalent and impactful disease. We thank each of the authors for their participation and applaud their efforts toward pushing the envelope in our understanding of COPD and optimizing care for these patients. We believe that this edition is a most fitting tribute to a dear colleague and friend and will prove useful to students, clinicians, and researchers as they continually strive to provide the right treatment for the right patient at the right time. It has been our pleasure and a distinct honor to serve as editors and oversee such wonderful scholarly work.

Physical activity promotion interventions in chronic airways disease: a systematic review and meta-analysis

Physical inactivity is common in people with chronic airways disease (pwCAD) and associated with worse clinical outcomes and impaired quality of life. We conducted a systematic review and meta-analysis to characterise and evaluate the effectiveness of interventions promoting step-based physical activity (PA) in pwCAD. We searched for studies that included a form of PA promotion and step-count outcome measure. A random-effects model was used to determine the overall effect size using post-intervention values. 38 studies (n=32 COPD; n=5 asthma; n=1 bronchiectasis; study population: n=3777) were included. Overall, implementing a form of PA promotion resulted in a significant increase in step-count: median (IQR) 705 (183-1210) when compared with usual standard care: -64 (-597-229), standardised mean difference (SMD) 0.24 (95% CI: 0.12-0.36), p<0.01. To explore the impact of specific interventions, studies were stratified into subgroups: PA promotion+wearable activity monitor-based interventions (n=17) (SMD 0.37, p<0.01); PA promotion+step-count as an outcome measure (n=9) (SMD 0.18, p=0.09); technology-based interventions (n=12) (SMD 0.16, p=0.01). Interventions promoting PA, particularly those that incorporate wearable activity monitors, result in a significant and clinically meaningful improvement in daily step-count in pwCAD.

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.

Promoting Chronic Obstructive Pulmonary Disease Wellness through Remote Monitoring and Health Coaching: A Clinical Trial

Rationale: Quality of life (QoL) matters the most to patients with chronic obstructive pulmonary disease (COPD) and is associated with healthcare usage and survival. Pulmonary rehabilitation is the most effective intervention in improving QoL but has low uptake and adherence. Home-based programs are a proposed solution. However, there is a knowledge gap on effective and sustainable home-based programs impacting QoL in patients with COPD. Objectives: To determine whether remote patient monitoring with health coaching improves the physical and emotional disease-specific QoL measured by the Chronic Respiratory Questionnaire (CRQ). Methods: This multicenter clinical trial enrolled 375 adult patients with COPD, randomized to a 12-week remote patient monitoring with health coaching (n = 188) or wait-list usual care (n = 187). Primary outcomes include physical and emotional QoL measured by the CRQ summary scores. Prespecified secondary outcomes included the CRQ domains: dyspnea, CRQ-fatigue, CRQ-emotions, CRQ-mastery, daily physical activity, self-management abilities, symptoms of depression/anxiety, emergency room/hospital admissions, and sleep. Results: Participant age: 69 ± 9 years; 59% women; forced expiratory volume in 1 second percent predicted: 45 ± 19. At 12 weeks, there was a significant and clinically meaningful difference between the intervention versus the control group in the physical and emotional CRQ summary scores: change difference (95% confidence interval): 0.54 points (0.36-0.73), P < 0.001; 0.51 (0.39-0.69), P < 0.001, respectively. In addition, all CRQ domains, self-management, daily physical activity, sleep, and depression scores improved (P < 0.01). CRQ changes were maintained at 24 weeks. Conclusions: Remote monitoring with health coaching promotes COPD wellness and behavior change, given its effect on all aspects of QoL, self-management, daily physical activity, sleep, and depression scores. It represents an effective option for home-based rehabilitation. Clinical trial registered with clinicaltrials.gov (NCT03480386).

Home-Based Respiratory Care for COPD Patients

Despite significant advances in pharmacological treatment over the last few decades, COPD remains a heavy burden on the health systems around the world, affecting approximately 210 million people, with elevated morbimortality and socioeconomic impact. Barriers to healthcare access were even more evident during the coronavirus disease 19 (COVID-19) pandemic and increased patients’ vulnerability to physical deconditioning, depression, and social isolation. Home-based respiratory care in patients with COPD provides a valuable contribution to effective disease management, with potential advantages for monitoring, treatment adherence, and cost reduction. Technological innovation allows clinical markers of interest, such as respiratory frequency, pulmonary function, and oxygen saturation, to be tracked remotely from the patients’ homes, providing a better understanding of their real needs. Home-based telerehabilitation can also be a viable alternative to hospital-based programs. Here, we highlight the full extent of health benefits of HRC in COPD, particularly for patients with a higher risk of exacerbations, multiple comorbidities, and limited access to health services.

Design and delivery of home-based telehealth pulmonary rehabilitation programs in COPD: A systematic review and meta-analysis

RATIONALE

Home-based telehealth pulmonary rehabilitation (HTPR) for chronic obstructive pulmonary disease (COPD) is increasingly common partly due to the COVID-19 pandemic. However, optimal HTPR programming has not been described. This review provides a comprehensive overview of the design, delivery, and effects of HTPR for people with COPD.

METHODS

Relevant databases were searched to July 2021 for studies on adults with COPD utilizing information or communication technology to monitor or deliver HTPR. A meta-analysis was performed on a subset of randomized controlled trials.

RESULTS

Of 3124 records retrieved, 38 studies evaluating 1993 individuals with stable COPD (age 54-75 and FEV1 31-92% predicted) were included. Program components included exercise and education (n = 17) or exercise alone (n = 15) with in-clinic baseline assessments commonly conducted (n = 26). Few trials (n = 7) featured synchronous virtual exercise supervision. Aerobic exercise commonly involved walking (n = 14) and cycling (n = 11) and most programs included resistance training (n = 25). Exercise progressions and emergency action plans were inconsistently reported. Meta-analysis demonstrated HTPR was comparable to outpatient PR and had a greater effect than usual care for the modified Medical Research Council dyspnea scale (mean difference [95 %CI]: -0.49 [-0.77, -0.22], p < 0.01) and COPD Assessment Test score (-4.90 [-7.13, -2.67], p < 0.01). Neither HTPR nor outpatient PR impacted sedentary time or step count. Only 6% of studies reported race and no studies reported participant ethnicity.

CONCLUSION

This review revealed the heterogeneity of HTPR program designs in COPD. HTPR programs had similar effects to outpatient PR programs and greater effects than usual care for people with COPD.

Pulmonary rehabilitation in a postcoronavirus disease 2019 world: feasibility, challenges, and solutions

PURPOSE OF REVIEW

Pulmonary rehabilitation improves clinical outcomes in patients with chronic obstructive pulmonary disease (COPD). Traditional centre-based (in-person) pulmonary rehabilitation was largely shut down in response to the COVID-19 pandemic, forcing many centres to rapidly shift to remote home-based programs in the form of telerehabilitation (tele-pulmonary rehabilitation). This review summarizes the recent evidence for the feasibility and effectiveness of remote pulmonary rehabilitation programs, and their implications for the delivery of pulmonary rehabilitation in a postpandemic world.

RECENT FINDINGS

A number of innovative adaptations to pulmonary rehabilitation in response to COVID-19 have been reported, and the evidence supports tele-pulmonary rehabilitation as a viable alternative to traditional centre-based pulmonary rehabilitation. However, these studies also highlight the challenges that must be surmounted in order to see its widespread adoption.

SUMMARY

There are outstanding questions regarding the optimal model for tele-pulmonary rehabilitation. In the post-COVID-19 world, a 'hybrid' model may be more desirable, with some components held in person and others via telehealth technology. This would be determined by the infrastructure and expertise of individual centres, and the needs of their patients. In order to achieve a truly patient-centred pulmonary rehabilitation program, high-quality studies addressing these outstanding questions, as well as multidisciplinary collaboration, are required.

Digital healthcare in COPD management: a narrative review on the advantages, pitfalls, and need for further research

Chronic obstructive pulmonary disease (COPD) remains a leading cause of morbidity and mortality despite current treatment strategies which focus on smoking cessation, pulmonary rehabilitation, and symptomatic relief. A focus of COPD care is to encourage self-management, particularly during COVID-19, where much face-to-face care has been reduced or ceased. Digital health solutions may offer affordable and scalable solutions to support COPD patient education and self-management, such solutions could improve clinical outcomes and expand service reach for limited additional cost. However, optimal ways to deliver digital medicine are still in development, and there are a number of important considerations for clinicians, commissioners, and patients to ensure successful implementation of digitally augmented care. In this narrative review, we discuss advantages, pitfalls, and future prospects of digital healthcare, which offer a variety of tools including self-management plans, education videos, inhaler training videos, feedback to patients and healthcare professionals (HCPs), exacerbation monitoring, and pulmonary rehabilitation. We discuss the key issues with sustaining patient and HCP engagement and limiting attrition of use, interoperability with devices, integration into healthcare systems, and ensuring inclusivity and accessibility. We explore the essential areas of research beyond determining safety and efficacy to understand the acceptability of digital healthcare solutions to patients, clinicians, and healthcare systems, and hence ways to improve this and sustain engagement. Finally, we explore the regulatory challenges to ensure quality and engagement and effective integration into current healthcare systems and care pathways, while maintaining patients' autonomy and privacy. Understanding and addressing these issues and successful incorporation of an acceptable, simple, scalable, affordable, and future-proof digital solution into healthcare systems could help remodel global chronic disease management and fractured healthcare systems to provide best patient care and optimisation of healthcare resources to meet the global burden and unmet clinical need of COPD.