Factors in maintaining long-term improvements in health-related quality of life after pulmonary rehabilitation for COPD

Development and Preliminary Evaluation of the Effects of an mHealth Web-Based Platform (HappyAir) on Adherence to a Maintenance Program After Pulmonary Rehabilitation in Patients With Chronic Obstructive Pulmonary Disease: Randomized Controlled Trial

Background

Pulmonary rehabilitation is one of the main interventions to reduce the use of health resources, and it promotes a reduction in chronic obstructive pulmonary disease (COPD) costs. mHealth systems in COPD aim to improve adherence to maintenance programs after pulmonary rehabilitation by promoting the change in attitude and behavior necessary for patient involvement in the management of the disease.

Objective

This study aimed to assess the effects of an integrated care plan based on an mHealth web-based platform (HappyAir) on adherence to a 1-year maintenance program applied after pulmonary rehabilitation in COPD patients.

Methods

COPD patients from three hospitals were randomized to a control group or an intervention group (HappyAir group). Patients from both groups received an 8-week program of pulmonary rehabilitation and educational sessions about their illness. After completion of the process, only the HappyAir group completed an integrated care plan for 10 months, supervised by an mHealth system and therapeutic educator. The control group only underwent the scheduled check-ups. Adherence to the program was rated using a respiratory physiotherapy adherence self-report (CAP FISIO) questionnaire. Other variables analyzed were adherence to physical activity (Morisky-Green Test), quality of life (Chronic Obstructive Pulmonary Disease Assessment Test, St. George’s Respiratory Questionnaire, and EuroQOL-5D), exercise capacity (6-Minute Walk Test), and lung function.

Results

In total, 44 patients were recruited and randomized in the control group (n=24) and HappyAir group (n=20). Eight patients dropped out for various reasons. The CAP FISIO questionnaire results showed an improvement in adherence during follow-up period for the HappyAir group, which was statistically different compared with the control group at 12 months (56.1 [SD 4.0] vs 44.0 [SD 13.6]; P=.004) after pulmonary rehabilitation.

Conclusions

mHealth systems designed for COPD patients improve adherence to maintenance programs as long as they are accompanied by disease awareness and patient involvement in management.

Trial Registration

ClinicalTrials.gov NCT04479930; https://clinicaltrials.gov/ct2/show/NCT04479930

A three-year follow-up of a nurse-led multidisciplinary pulmonary rehabilitation programme in primary health care: a quasi-experimental study

AIMS AND OBJECTIVES

To investigate the effects of a nurse-led multidisciplinary pulmonary rehabilitation programme conducted in primary health care on functional capacity, quality of life and exacerbation frequency over three years among patients with Chronic Obstructive Pulmonary Disease.

BACKGROUND

Although Chronic Obstructive Pulmonary Disease is a chronic respiratory disease, it has been established that pulmonary rehabilitation has positive effects on patients' everyday functioning. However, the duration of these functional improvements, especially when the rehabilitation programmes are provided in primary health care settings, remains to be established.

DESIGN

A quasi-experimental design.

METHOD

Primary health care patients with Chronic Obstructive Pulmonary Disease (GOLD stages II and III) were included; 49 in the intervention group and 54 in the control group. The intervention comprised a six-week pulmonary rehabilitation programme. Functional capacity was assessed using a six-minute walking test and quality of life by the Clinical COPD Questionnaire at baseline, after one year and three years. Exacerbation frequency was calculated from one year before to three years after the programme.

RESULTS

No significant differences between the groups were observed in the six-minute walking-test or the Clinical COPD Questionnaire after one year and three years. On average, there were significant improvements in the six-minute walking-test and the Clinical COPD Questionnaire from baseline to the one-year follow-up. Exacerbation frequency tended to decrease in the intervention group and increase in the control group (interaction test was p = 0·091) but increased again in both groups after three years.

CONCLUSION

There was no evidence of the benefit of the nurse-led multidisciplinary pulmonary rehabilitation programme, although the exacerbation frequency tended to decrease in the intervention group after one year. There is a need for support and coaching at regular follow-ups in primary health care.

RELEVANCE TO CLINICAL PRACTICE

There is a need to support and coach patients with Chronic Obstructive Pulmonary Disease in primary health care by means of regular follow-ups.

Maintenance of a physically active lifestyle after pulmonary rehabilitation in patients with COPD: a qualitative study toward motivational factors

OBJECTIVES

To explore determinants of behavior change maintenance of a physically active lifestyle in patients with chronic obstructive pulmonary disease (COPD) 8-11 months after completion of a 4-month outpatient pulmonary rehabilitation program.

DESIGN

A qualitative descriptive study of semistructured interviews.

SETTING

Pulmonary rehabilitation assessment center.

PARTICIPANTS

Patients with COPD.

MEASUREMENTS

Semistructured interviews until data saturation, coded by 2 independent researchers. Patients were classified as responder (maintenance or improvement) or nonresponder (relapse or decrease), based on 3 quantitative variables reflecting exercise capacity (Constant Work Rate Test), health-related quality of life (Short-Form health survey [SF-36]), and self-management abilities (Self-Management Ability Scale [SMAS-30/Version 2]).

RESULTS

Mean (SD) forced expiratory volume in the first second (FEV1) among interviewees was 52.5% (14.4%) predicted and the mean age was 63.5 years (range: 45-78). The group consisted of 15 responders and 7 nonresponders. Physical limitations reduced competence to engage in an active lifestyle and responders appeared to experience higher levels of perceived competence. Social support was found important and the experienced understanding from fellow patients made exercising together enjoyable. Particularly, responders expressed autonomous motivation and said they exercised because of the benefits they gain from it. Unexpectedly, only responders also experienced controlled motivation.

CONCLUSION

Perceived competence and autonomous motivation are important determinants for maintenance of an active lifestyle in patients with COPD. In contrast to common theoretical assumptions, a certain threshold level of controlled motivation may remain important in maintaining a physically active lifestyle after a pulmonary rehabilitation program.

Seasonal variation and living alone are related to pulmonary rehabilitation non-completion

AIM: To identify baseline characteristics that independently predict pulmonary rehabilitation non-completion and compare these findings against the participant’s reasons for non-completion.

METHODS: Participants with chronic obstructive pulmonary disease (COPD) who attended a standardised twice weekly, eight week pulmonary rehabilitation program (located in the sub-tropics, latitude 27°29’ South) between 2010 and 2012 were recruited. The baseline characteristics of program completers and non-completers were compared in a case-controlled design. Participants who attended < 12/16 sessions were classified as a non-completer. Non-completers (those who missed > 4 sessions of the program) were asked by one independent investigator to participate in a survey about their pulmonary rehabilitation experience. Baseline characteristics were assessed for differences between program completers and non-completers. The baseline characteristics included disease severity, exercise capacity, smoking history, participant’s social support and the season when each participant commenced rehabilitation. Non-completers that agreed to participate in the survey were asked to indicate what personal factors or external factors contributed to their program non-completion. Comparisons of completers and non-completers baseline characteristics were performed using cross-tabulations and t-tests, with significant measures analysed in a multivariate binary logistic regression model. Non-completers survey responses were compared to the identified independent predictors using cross-tabulations.

RESULTS: Twenty-six participants (23.4%) of the 111 participants with COPD [(mean ± SD) age was 67.4 ± 9.2 years and FEV1 54.6% ± 22.3%)], were classified as non-completers. Forty-five participants (40.5%) commenced pulmonary rehabilitation during winter. Thirty-six participants (32.4%) were living alone at program commencement. In the multivariate analysis (n = 111), only programs that commenced in winter (Exp B: 0.255, 95%CI: 0.090-0.727, P = 0.011) and participants that lived alone (Exp B: 2.925, 95%CI: 1.039-8.229, P = 0.042) were identified as independent predictors of program non-completion. Twenty participants of the twenty-six non-completers agreed to participate in the survey about their pulmonary rehabilitation experience. The reasons given for non-completion were grouped into: medical reasons (75%), other personal reasons (30%) and external barriers (45%), with ten non-completers reporting more than one reason. No participant reported living alone or that the program commenced during winter as a reason for non-completion. There was no relationship between illness being the participant’s reason for non-completion and the programs that commenced in winter (P = 0.135).

CONCLUSION: Despite winter commencing programs and participants who lived alone being independent predictors of program non-completion, neither measure was reported by participants as a reason for non-completion.

Health-related quality of life and chronic obstructive pulmonary disease in North Carolina

Background:

Comparisons of health-related quality of life (HRQOL) between persons with chronic obstructive pulmonary disease (COPD) and adults in the general population are not well described.

Aims:

To examine associations between COPD and four measures of HRQOL in a population-based sample.

Patients & Methods:

These relationships were examined using data from 13,887 adults aged >18 years who participated in the 2007 Behavioral Risk Factor Surveillance System (BRFSS) conducted in North Carolina (NC). Logistic regression was used to obtain adjusted relative odds (aOR).

Results:

The age-adjusted prevalence of COPD among NC adults was 5.4% (standard error 0.27). Nearly half of adults with COPD reported fair/poor health compared with 15% of those without the condition (age-aOR, 5.5; 95% confidence interval [ CI] , 4.4 to 6.8). On average, adults with COPD reported twice as many unhealthy days (physical/mental) as those without the condition. The age-adjusted prevalence of >14 unhealthy days during the prior 30 days was 45% for adults with COPD and 17% for those without. The aOR of >14 unhealthy days was 1.7 (95% CI, 1.4 to 2.2) times greater among adults with COPD compared with those without.

Conclusions:

These results suggest COPD is independently associated with lower levels of HRQOL and reinforce the importance of preventing COPD and its complications through health education messages stressing efforts to reduce total personal exposure to tobacco smoke, occupational dusts and chemicals, and other indoor and outdoor air pollutants linked to COPD and early disease recognition. Our findings represent one of the few statewide efforts in the US and provide guidance for disease management and policy decision making.

Defining patient-reported outcomes in chronic obstructive pulmonary disease: the patient-centered experience

Patients with COPD have reduced HRQOL, and HRQOL worsens as COPD progresses.Although long-term interventions such as smoking cessation, supplemental oxygen therapy for hypoxemia, LVRS, and lung transplantation may save lives, these and other therapies have variable but important effects on PROs. Measures of HRQOL can serve as measures of disease severity and predict outcome. Moreover, these measures are sensitive to change following interventions, and can thus be used as measures of intervention effect. Future research will provide a better understanding of the effects of COPD on HRQOL and the impact of various interventions.

Learning to manage COPD

The aim of this article is to understand the reasons for attending a chronic obstructive pulmonary disease (COPD)-specific self-management (SM) programme and how attendance at such programmes might be improved. A total of 20 qualitative semistructured interviews were carried out with patients and with lay programme tutors involved in the Better Living with Long term Airways disease (BELLA) pilot trial. Thematic framework data analysis was used. Common reasons for participant attendance arising from patients and tutors include (1) desire to learn about SM, (2) social benefits of meeting others with COPD and (3) altruism. Patients' reasons for poor attendance include (1) being too ill or not feeling ill enough and (2) practical, physical and emotional barriers. Tutor’s explanations for patients’ poor attendance were (1) failure to accept their condition, (2) fear of making a change, (3) lack of adequate support, (4) guilt about smoking and (5) the ‘scripted’ nature of the course. Suggestions for improving programme participation included (1) having choice of several start dates, (2) minimal delay inviting participant onto courses, (3) planning for ‘special needs’. Participation may be better amongst those who have accepted their condition or who are motivated towards improving their condition or to help others. Providing solutions for practical barriers may improve participation. However, alternatives to group-based interventions need to be developed for people with functional and emotional barriers to attendance.

Improvements in quadriceps force and work efficiency are related to improvements in endurance capacity following pulmonary rehabilitation in COPD patients

BACKGROUND AND OBJECTIVE

The endurance time has been reported to be the most sensitive measure of improved exercise capacity in response to a variety of interventions for COPD. The aim of the present study was to determine whether the improvements in quadriceps force and measures obtained from a symptom-limited maximal test contributed to the improvements in endurance time following pulmonary rehabilitation.

METHODS

Fifty-seven consecutive COPD subjects completed a 10-week pulmonary rehabilitation program. The subjects completed a symptom-limited incremental cycle ergometry test and a constant work rate test before and after pulmonary rehabilitation. Peripheral and respiratory muscle strength was also measured. The relationships between the change in endurance time and the changes obtained from the incremental test and muscle strength test were investigated.

RESULTS

The endurance time showed the greatest improvement among the exercise capacity indices. The changes in endurance time were significantly correlated to changes in quadriceps force, peak work rate, anaerobic threshold and work efficiency on the incremental load test. In the multiple stepwise regression analysis, changes in quadriceps force and work efficiency measured on the maximal exercise test were selected.

CONCLUSION

These findings suggest that the improvements in endurance time after pulmonary rehabilitation may be explained by increased quadriceps force and improvements in peak work rate and work efficiency.

Self-efficacy as a predictor of improvement in health status and overall quality of life in pulmonary rehabilitation--an exploratory study

OBJECTIVE

To evaluate developments in health status (HS) and overall quality of life (QOL), and the impact of self-efficacy on HS and QOL in relation to COPD pulmonary rehabilitation (PR).

METHODS

A longitudinal study of 100 COPD patients before and up to 3 months after COPD PR. Self-efficacy was measured by the COPD self-efficacy scale, HS by the St. George Respiratory Questionnaire and QOL by the Quality of Life Scale. Mixed effect models were used.

RESULTS

Patients reported significantly reduced psychosocial impact of disease (estimate=-4.05, p=0.019) immediately after the PR programme. Higher levels of self-efficacy at baseline predicted significantly reduced psychosocial impact of disease and improved physical activity, total HS and QOL (p<0.05). Better exercise capacity at baseline predicted significantly reduced psychosocial impact of disease, improved physical activity and QOL (p<0.05). Older age at baseline predicted significantly fewer respiratory symptoms and improved total HS (p<0.05).

CONCLUSIONS

Patients reported significantly reduced psychosocial impact of disease immediately after a COPD PR, and better exercise capacity and higher self-efficacy at baseline predicted significantly improved HS and QOL.

PRACTICE IMPLICATIONS

Increasing self-efficacy is suggested to be an important aim in relation to COPD PR.

Factors associated with the minimal clinically important difference for health-related quality of life after physical conditioning in patients with COPD

OBJECTIVE

To identify factors associated with the minimal clinically important difference (MCID) for health-related quality of life (HRQoL) after physical conditioning in patients with COPD.

METHODS

Thirty-five patients were submitted to a 12-week program of physical conditioning (strength training plus low-intensity aerobic exercise). Body composition, incremental treadmill test results, endurance treadmill test results, six-minute walk test results, peripheral muscle strength, MIP, baseline dyspnea index (BDI) and Saint George's Respiratory Questionnaire (SGRQ) scores were assessed at baseline and after the program, thus allowing the variations (Delta) to be calculated. The MCID for HRQoL was defined as a reduction of > 4% in the SGRQ total score. Subjects who responded to the program, achieving the MCID for HRQoL, were allocated to the responders (R) group (n = 24), and the remainder were allocated to the non-responders (NR) group (n = 11).

RESULTS

The values obtained for the following variables were significantly higher in group R than in group NR (p < 0.05): FEV1 (1.48 + or - 0.54 L vs. 1.04 + or - 0.34 L); VEF1/FVC (47.9 + or - 11.7% vs. 35.5 + or - 10.7%); PaO2 (74.1 + or - 9.7 mmHg vs. 65.0 + or - 8.9 mmHg); and DeltaBDI, expressed as median and interquartile range (2.0 [0.0-3.5] vs. 0.0 [0.0-1.0]). The DeltaBDI correlated significantly with the DeltaSGRQ symptoms domain score, activity domain score and total score (r = 0.44, 0.60 and 0.62, respectively, p < 0.01 for all). After logistic regression, only DeltaBDI remained as a predictor of MCID for HRQoL.

CONCLUSIONS

Achieving the MCID for HRQoL after physical conditioning is associated with dyspnea reduction in COPD patients. Therefore, there is a need to develop treatment strategies designed to interrupt the dyspnea-inactivity-dyspnea cycle in such patients.

Drop-out and attendance in pulmonary rehabilitation: the role of clinical and psychosocial variables

BACKGROUND

In spite of the well-demonstrated benefits for patients with COPD, pulmonary rehabilitation programmes show considerable drop-out and suboptimal attendance rates. The purpose of this prospective study is to examine causes for drop-out and non-attendance during a 12 week multidisciplinary pulmonary rehabilitation programme, and to investigate whether sociodemographic and medical factors as well as patients' perception of their illness are related to drop-out and non-attendance.

METHODS

Two hundred and seventeen patients with COPD who were referred to a rehabilitation centre participated in this multicentre study. Prior to treatment, patients received a questionnaire, which included the Illness Perception Questionnaire-Revised. Clinical data were drawn from medical records. Drop-out and attendance were recorded during the programme.

RESULTS

Fifty patients (23%) did not complete the rehabilitation course, of which half was due to medical reasons (e.g. exacerbations, hospitalisations). Non-completion could not be predicted by baseline sociodemographic, clinical or psychological variables. Patients who declined treatment did not differ from patients who dropped out due to medical reasons. On average, patients attended 92% of all scheduled appointments. Of all missed appointments, approximately 20% were accountable to factors beyond patients' control (e.g. absent therapists, hospitalisations). Smoking, living alone, a lower fat free mass and lower confidence in treatment increased the chance of patients not attending an appointment during rehabilitation.

CONCLUSION

In general, adherence in rehabilitation is high. However, paying attention to patients' nutritional status and creating a positive expectation of treatment during referral and intake appear to be important if one aims to optimise patients' attendance during rehabilitation.

A randomized clinical trial of an activity and exercise adherence intervention in chronic pulmonary disease

OBJECTIVES

To evaluate the effectiveness of an exercise adherence intervention to maintain daily activity, adherence to exercise, and exercise capacity over 1 year after completion of an outpatient pulmonary rehabilitation program.

DESIGN

A 2-group, experimental design was used with randomization into intervention and usual care groups.

SETTING

Outpatient pulmonary rehabilitation program in a university-affiliated medical center.

PARTICIPANTS

One hundred six subjects (98 men; 98 with chronic obstructive pulmonary disease) with a mean age of 67 years and chronic lung disease.

INTERVENTION

Twelve-week adherence intervention (weekly phone calls and home visit) including counseling on establishing, monitoring, and problem-solving in maintaining a home exercise program.

MAIN OUTCOME MEASURES

Primary outcomes included daily activity (accelerometer), exercise adherence (exercise diary), and exercise capacity (six-minute walk test). All measures were performed at baseline, after the pulmonary rehabilitation program (8 wk), after the adherence intervention (20 wk), and at 1 year.

RESULTS

A rank-based analysis of covariance showed less decline at 20 weeks in exercise adherence (intervention mean, +3 min; control mean, -13 min; P=.015) and exercise capacity (intervention mean, -10.7 m; control mean, -35.4 m; P=.023). There were no differences in daily activity at 20 weeks or any differences in any primary variable at 1 year.

CONCLUSIONS

The intervention enhanced exercise adherence and exercise capacity in the short term but produced no long-term benefit. These findings are in part attributed to the disappointing measurement characteristics of the accelerometer used to measure daily activity. The intervention was acceptable to participants. Further study is needed to fashion interventions that have more persistent benefit.

Hyperinflation and its management in COPD

Chronic obstructive pulmonary disease (COPD) is characterized by poorly reversible airflow limitation. The pathological hallmarks of COPD are inflammation of the peripheral airways and destruction of lung parenchyma or emphysema. The functional consequences of these abnormalities are expiratory airflow limitation and dynamic hyperinflation, which then increase the elastic load of the respiratory system and decrease the performance of the respiratory muscles. These pathophysiologic features contribute significantly to the development of dyspnea, exercise intolerance and ventilatory failure. Several treatments may palliate flow limitation, including interventions that modify the respiratory pattern (deeper, slower) such as pursed lip breathing, exercise training, oxygen, and some drugs. Other therapies are aimed at its amelioration, such as bronchodilators, lung volume reduction surgery or breathing mixtures of helium and oxygen. Finally some interventions, such as inspiratory pressure support, alleviate the threshold load associated to flow limitation. The degree of flow limitation can be assessed by certain spirometry indexes, such as vital capacity and inspiratory capacity, or by other more complexes indexes such as residual volume/total lung capacity or functional residual capacity/total lung capacity. Two of the best methods to measure flow limitation are to superimpose a flow–volume loop of a tidal breath within a maximum flow–volume curve, or to use negative expiratory pressure technique. Likely this method is more accurate and can be used during spontaneous breathing. A definitive definition of dynamic hyperinflation is lacking in the literature, but serial measurements of inspiratory capacity during exercise will document the trend of end-expiratory lung volume and allow establishing relationships with other measurements such as dyspnea, respiratory pattern, exercise tolerance, and gas exchange.