Effects of a 10-week pulmonary rehabilitation program based on the 5A nursing model in patients with interstitial lung disease: a quasi-experimental study

BACKGROUND

Pulmonary rehabilitation (PR) is essential for treating interstitial lung disease (ILD). The 5A nursing model enhances patients' health-promoting behaviors by improving their self-management skills. The aim of this study is to examine and analyze the effectiveness of the PR program based on the 5A nursing model concerning lung function, dyspnea, anxiety, depression, self-efficacy, quality of life, and PR compliance in patients with ILD.

METHODS

64 hospitalized ILD patients were enrolled in this quasi-experimental study. Patients were randomly assigned to an intervention group (PR program based on the 5A nursing model) and a control group (conventional PR) on a ward-by-ward basis. The allocation was not concealed from the patients. A pre- and post-test design was used. An exercise training diary was utilized to evaluate PR compliance, data was gathered using the mMRC, HADS, PRAISE, and SGRQ, and lung function was assessed by a professional PR-trained nurse. SPSS 26.0 was used to analyze the data. For within/between-groups comparisons, the Wilcoxon signed-rank test, Fisher's exact test, t-test, χ²-test, and Mann-Whitney U-test were employed.

RESULTS

Baseline demographics were generally similar between the two groups (P > 0.05). After 10 weeks of intervention, the PR program based on the 5A nursing model group had more significant improvements in self-efficacy (P = 0.001), anxiety (P = 0.005), and depression (P = 0.018) compared to the control group, but there were no significant differences in dyspnea, lung function, or quality of life (P > 0.05). PR compliance was significantly higher in the intervention group than in the control group (P = 0.028). Further within-group comparisons showed significant improvements in DLCO%pred (P = 0.003), dyspnea (P = 0.001), anxiety (P = 0.006), self-efficacy (P < 0.001), and quality of life (P < 0.001) at post-test in patients in the intervention group compared to pre-test.

CONCLUSION

The PR program based on the 5A nursing model is an effective way to reduce anxiety, depression, and improve self-efficacy and PR compliance in patients with ILD.

TRIAL REGISTRATION

Retroactive registration is underway on the Chinese Clinical Trial Registry (ChiCTR).

Understanding the Determinants and Outcomes of Education in Pulmonary Rehabilitation: Moving Toward Person-Centered Care

TOPIC IMPORTANCE

Education and psychosocial support are essential components of pulmonary rehabilitation (PR). However, the delivery of education often follows a one-size-fits-all approach, with individual factors that influence learning rarely considered. Moreover, education-related outcomes are frequently overlooked in PR assessments, and their inconsistent use has limited our understanding of education's impact on people with chronic respiratory diseases. There is a clear need for practical guidance to identify key learning determinants and to define targeted education outcomes, ultimately optmizing PR and establishing quality standards.

REVIEW FINDINGS

Cognitive function, health literacy, psychological status, and social connection can influence an individual's ability to learn. Without proper consideration and assessment, these factors can otherwise become barriers to education and effective self-management. Education in PR should aim to: (1) improve individuals' knowledge to foster informed and active participants; (2) develop their skills to enable autonomy and competence; and (3) enhance their confidence to apply this knowledge and skills in daily life.

SUMMARY

This review emphasizes the importance of person-centered education in PR, provides a framework for understanding which education-related outcomes to target, and highlights the need for future research to enhance this essential component.

A Kano model-based demand analysis and perceived barriers of pulmonary rehabilitation interventions for patients with chronic obstructive pulmonary disease in China

BACKGROUND

Pulmonary rehabilitation (PR) has been recognized to be an effective therapy for chronic obstructive pulmonary disease (COPD). However, in China, the application of PR interventions is still less promoted. Therefore, this cross-sectional study aimed to understand COPD patients' intention to receive PR, capture the potential personal, social and environmental barriers preventing their willingness of receiving PR, and eventually identify demanding PR services with the highest priority from patients' point of view.

METHODS

In total 237 COPD patients were recruited from 8 health care facilities in Zhejiang, China. A self-designed questionnaire was applied to investigate patients' intention to participate in PR and potentially associated factors, including personal dimension such as personal awareness, demographic factors, COPD status and health-related literacy/behaviors, as well as social policies and perceived environmental barriers. The demand questionnaire of PR interventions based on the Kano model was further adopted.

RESULTS

Among the 237 COPD patients, 75.1% of COPD patients were willing to participate in PR interventions, while only 62.9% of the investigated patients had heard of PR interventions. Over 90% of patients believed that the cost of PR services and the ratio of medical insurance reimbursement were potential obstacles hindering them from accepting PR services. The multiple linear regression analysis indicated that the PR skills of medical staff, knowledge promotion and public education levels of PR in the community, patients' transportation concerns and degree of support from family and friends were significantly associated with willingness of participation in PR interventions. By using the Kano model, the top 9 most-requisite PR services (i.e., one-dimensional qualities) were identified from patients' point of view, which are mainly diet guidance, education interventions, psychological interventions and lower limb exercise interventions. Subgroup analysis also revealed that patients' demographics, such as breathlessness level, age, education and income levels, could influence their choice of priorities for PR services, especially services related to exercise interventions, respiratory muscle training, oxygen therapy and expectoration.

CONCLUSIONS

This study suggested that PR-related knowledge education among patients and their family, as well as providing basic package of PR services with the most-requisite PR items to COPD patients, were considerable approaches to promote PR attendance in the future.

Long-term Telerehabilitation or Unsupervised Training at Home for Patients with Chronic Obstructive Pulmonary Disease: A Randomized Controlled Trial

Rationale: Despite the benefits of pulmonary rehabilitation in chronic obstructive pulmonary disease (COPD), many patients do not access or complete pulmonary rehabilitation, and long-term maintenance of exercise is difficult. Objectives: To compare long-term telerehabilitation or unsupervised treadmill training at home with standard care. Methods: In an international randomized controlled trial, patients with COPD were assigned to three groups (telerehabilitation, unsupervised training, or control) and followed up for 2 years. Telerehabilitation consisted of individualized treadmill training at home supervised by a physiotherapist and self-management. The unsupervised training group performed unsupervised treadmill exercise at home. The control group received standard care. The primary outcome was the combined number of hospitalizations and emergency department presentations. Secondary outcomes included time free from the first event; exercise capacity; dyspnea; health status; quality of life; anxiety; depression; self-efficacy; and subjective impression of change. Measurements and Main Results: A total of 120 participants were randomized. The incidence rate of hospitalizations and emergency department presentations was lower in telerehabilitation (1.18 events per person-year; 95% confidence interval [CI], 0.94-1.46) and unsupervised training group (1.14; 95% CI, 0.92-1.41) than in the control group (1.88; 95% CI, 1.58-2.21; P < 0.001 compared with intervention groups). Telerehabilitation and unsupervised training groups experienced better health status for 1 year. Intervention participants reached and maintained clinically significant improvements in exercise capacity. Conclusions: Long-term telerehabilitation and unsupervised training at home in COPD are both successful in reducing hospital readmissions and can broaden the availability of pulmonary rehabilitation and maintenance strategies.

Evaluation of a health and social care programme to improve outcomes following critical illness: a multicentre study

RATIONALE

At present, clinicians aiming to support patients through the challenges after critical care have limited evidence to base interventions.

OBJECTIVES

Evaluate a multicentre integrated health and social care intervention for critical care survivors. A process evaluation assessed factors influencing the programme implementation.

METHODS

This study evaluated the impact of the Intensive Care Syndrome: Promoting Independence and Return to Employment (InS:PIRE) programme. We compared patients who attended this programme with a usual care cohort from the same time period across nine hospital sites in Scotland. The primary outcome was health-related quality of life (HRQoL) measured via the EuroQol 5-dimension 5-level instrument, at 12 months post hospital discharge. Secondary outcome measures included self-efficacy, depression, anxiety and pain.

RESULTS

137 patients who received the InS:PIRE intervention completed outcome measures at 12 months. In the usual care cohort, 115 patients completed the measures. The two cohorts had similar baseline demographics. After adjustment, there was a significant absolute increase in HRQoL in the intervention cohort in relation to the usual care cohort (0.12, 95% CI 0.04 to 0.20, p=0.01). Patients in the InS:PIRE cohort also reported self-efficacy scores that were 7.7% higher (2.32 points higher, 95% CI 0.32 to 4.31, p=0.02), fewer symptoms of depression (OR 0.38, 95% CI 0.19 to 0.76, p=0.01) and similar symptoms of anxiety (OR 0.58, 95% CI 0.30 to 1.13, p=0.11). There was no significant difference in overall pain experience. Key facilitators for implementation were: integration with inpatient care, organisational engagement, flexibility to service inclusion; key barriers were: funding, staff availability and venue availability.

CONCLUSIONS

This multicentre evaluation of a health and social care programme designed for survivors of critical illness appears to show benefit at 12 months following hospital discharge.

From Inception to Implementation: Strategies for Setting Up Pulmonary Telerehabilitation

Background

The emergence of innovative technology-enabled models of care is an opportunity to support more efficient ways of organizing and delivering healthcare services and improve the patient experience. Pulmonary telerehabilitation started as a promising area of research and became a strategic pandemic response to patients' decreased accessibility to rehabilitation care. Still, in the pre-COVID-19 era, we conducted a participatory study aiming to develop strategies for setting up pulmonary telerehabilitation as a person-centered digitally-enabled model of care.

Methods

We performed operational participatory research between June 2019 and March 2020 with the engagement of all stakeholders involved in the implementation of pulmonary telerehabilitation, including 14 people with Chronic Obstructive Pulmonary Disease. Patients were assessed subjectively and objectively pre and post a 3-month pulmonary rehabilitation program including exercise and education, which started in a face-to-face hospital setting during the first month and continued as a home-based, remotely supervised exercise training intervention.

Results

Five major groups of requirements targeted operational strategies for setting up pulmonary telerehabilitation: (1) pulmonary rehabilitation core principles, (2) quality and security standards, (3) technological functionality, (4) home environment appropriateness, and (5) telesetting skills. There was a statistical significance in the median change in the CAT score from 15.5 to 10.5 (p = 0.004) and in the PRAISE score from 49.5 to 53.0 (p = 0.006). Patients' mean levels of satisfaction regarding rehabilitation goals achievements were 88.1 ± 8.6% and the mean levels of satisfaction regarding the telerehabilitation experienced as a model of care were 95.4% ± 6.3%.

Conclusions

The success of telerehabilitation implementation was grounded on stakeholder engagement and targeted strategies for specific setup requirements, achieving patients' high satisfaction levels. Such operational experiences should be integrated into the redesigning of upgraded telerehabilitation programs as part of the solution to improve the effectiveness, accessibility, and resilience of health systems worldwide.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

The Impact of a Baseline Exercise Test on Confidence to Perform Subsequent Incremental Shuttle Walk Tests, Walk at Home, and Manage Breathlessness

PURPOSE

Incremental shuttle walk tests (ISWTs) are routinely conducted as outcome measures in pulmonary rehabilitation (PR) assessments and in clinical trials; however, there is a paucity of data describing the impact of simply conducting an exercise test and the change produced in the perceived ability of the individual to perform exercise subsequently, which may in turn influence therapy and study outcomes.

METHODS

We conducted a prospective observational cohort study at Glenfield Hospital, Leicester, UK (University Hospitals of Leicester NHS Trust). At initial PR assessment, we asked patients pre- and post-practice ISWT to report confidence in three areas (walking at home [Q1], managing breathlessness [Q2], and performing an ISWT [Q3]) based on a visual analog scale (0-10).

RESULTS

A total of 100 patients with chronic respiratory disease (age 68.0 ± 10.3 yr, male 49%, chronic obstructive pulmonary disease 63%, Medical Research Council 2-5) completed visual analog scale confidence questions pre- and post-practice ISWT. Confidence in all questions improved after a practice ISWT (all P < .01 Wilcoxon signed rank). A statistically significant improvement in ISWT distance was noted (practice ISWT 207.3 ± 132.7 m to second ISWT 227.4 ± 142.0 m, mean difference = 20.1 m). No association was found between changes in confidence and changes between walk 1 and walk 2 (r2 = [Q1] -0.04, [Q2] -0.09, [Q3] 0.04, P >.05).

CONCLUSIONS

Confidence increased in all areas post-practice ISWT, but this was not related to changes in performance. However, this change may be an important consideration when designing research trials as exercise behaviors (eg, walking at home) may be affected by conducting baseline exercise tests.

Self-Efficacy Intervention Programs in Patients with Chronic Obstructive Pulmonary Disease: Narrative Review

Chronic obstructive pulmonary disease (COPD) is a common chronic disease whose development is irreversible, which leads to more than six million deaths each year. There is no treatment confirmed effective for the improvement of impaired lung function, but the combination of drug therapy with non-drug therapy such as pulmonary rehabilitation training has demonstrated a great potential in reducing the occurrence of complications and delaying the progression of COPD. Self-efficacy is the core of cognitive theory, which is crucial for chronic disease management. It has been proposed as an important component of disease management to help people develop skills to manage diseases more effectively. This study reviewed the development of self-efficacy and its application in patients with COPD, with the purpose of providing a better clinical reference for the treatments of COPD.

Home-based pulmonary rehabilitation early after hospitalisation in COPD (early HomeBase): protocol for a randomised controlled trial

INTRODUCTION

Chronic obstructive pulmonary disease (COPD) is characterised by exacerbations of respiratory disease, frequently requiring hospital admission. Pulmonary rehabilitation can reduce the likelihood of future hospitalisation, but programme uptake is poor. This study aims to compare hospital readmission rates, clinical outcomes and costs between people with COPD who undertake a home-based programme of pulmonary rehabilitation commenced early (within 2 weeks) of hospital discharge with usual care.

METHODS

A multisite randomised controlled trial, powered for superiority, will be conducted in Australia. Eligible patients admitted to one of the participating sites for an exacerbation of COPD will be invited to participate. Participants will be randomised 1:1. Intervention group participants will undertake an 8-week programme of home-based pulmonary rehabilitation commencing within 2 weeks of hospital discharge. Control group participants will receive usual care and a weekly phone call for attention control. Outcomes will be measured by a blinded assessor at baseline, after the intervention (week 9-10 posthospital discharge), and at 12 months follow-up. The primary outcome is hospital readmission at 12 months follow-up.

ETHICS AND DISSEMINATION

Human Research Ethics approval for all sites provided by Alfred Health (Project 51216). Findings will be published in peer-reviewed journals, conferences and lay publications.

TRIAL REGISTRATION NUMBER

ACTRN12619001122145.

Community Participation by People with Chronic Obstructive Pulmonary Disease

Little is known regarding community participation in individuals with chronic obstructive pulmonary disease (COPD). The aim of this study was to explore community participation in individuals with COPD and to determine whether there is an association between community participation and activity-related outcome variables commonly collected during pulmonary rehabilitation assessment. We also sought to investigate which of these variables might influence community participation in people with COPD. Ninety-nine individuals with COPD were enrolled (67 ± 9 years, FEV₁: 55 ± 22% predicted). We assessed community participation (Community Participation Indicator (CPI) and European Social Survey (ESS) for formal and informal community participation), daily physical activity levels (activity monitor), exercise capacity (6-minute walk test), breathlessness (Modified Medical Research Council, MMRC scale), self-efficacy (Pulmonary Rehabilitation Adapted Index of Self-Efficacy) and anxiety and depression (Hospital Anxiety and Depression Scale). Higher levels of community participation on the CPI were associated with older age and greater levels of physical activity (total, light and moderate-to-vigorous) (all r_s = 0.30, p < 0.05). Older age and more moderate-to-vigorous physical activity independently predicted greater community participation measured by CPI. Higher levels of depression symptoms were associated with less formal and informal community participation on ESS (r_s = -0.25). More formal community participation on ESS was weakly (r_s = 0.2-0.3) associated with older age, better lung function, exercise capacity and self-efficacy, and less breathlessness. Self-efficacy, exercise capacity, and age independently predicted formal community participation in individuals with COPD. Strategies to optimize self-efficacy and improve exercise capacity may be useful to enhance community participation in people with COPD.

Pulmonary rehabilitation outcomes in individuals with chronic obstructive pulmonary disease: a systematic review

BACKGROUND

The magnitude of response to pulmonary rehabilitation (PR) is influenced by the selection of outcomes and measures.

OBJECTIVES

This systematic review aimed to review all outcomes and measures used in clinical trials of PR for individuals with chronic obstructive pulmonary disease (COPD).

METHODS

The review involved a search of Scopus, Web of Knowledge, Cochrane Library, EBSCO, Science Direct and PubMed databases for studies of stable individuals with COPD undergoing PR. Frequency of reporting for each domain, outcome and measure was synthesized by using Microsoft Excel.

RESULTS

We included 267 studies (43153 individuals with COPD). A broad range of domains (n=22), outcomes (n=163) and measures (n=217) were reported. Several measures were used for the same outcome. The most reported outcomes were exercise capacity (n=218) assessed with the 6-min walk test (n=140), health-related quality of life (n=204) assessed with the Saint George's respiratory questionnaire (n=99), and symptoms (n=158) assessed with the modified Medical Research Council dyspnea scale (n=56). The least reported outcomes were comorbidities, adverse events and knowledge.

CONCLUSIONS

This systematic review reinforces the need for a core outcome set for PR in individuals with COPD because of high heterogeneity in reported outcomes and measures. Future studies should assess the importance of each outcome for PR involving different stakeholders.

PROSPERO ID

CRD42017079935.

How is the education component of pulmonary rehabilitation delivered in practice--Is it patient-centred?

OBJECTIVES

Pulmonary rehabilitation (PR) involves a significant component of education, but little has been published on what educational content is covered or how it is delivered. This survey study set out to investigate how PR education is delivered in practice.

METHODS

A survey was designed to investigate the current educational delivery and which topics respondents reported should be included in a PR programme. The survey was sent to 11 Scottish PR Action group regional leads.

RESULTS

Nine completed the questionnaire (81.8%). Education was reported to be predominately group-based and face-to-face (n = 9, 100%) consisting of between 6 and 12 sessions. Most educational topics lasted 15 min or less, some topic areas were not consistently covered. The educational content was variable and not personalised to individual needs. Three health areas undertook informal literacy assessment at baseline assessment and when tailoring COPD plans. Often attendance at educational sessions was not needed to 'complete' PR.

CONCLUSIONS

Content and delivery of educational topics were varied, and no consistent outcome measure to assess the effectiveness of education was used.

PRACTICE IMPLICATIONS

Education needs to be delivered in a patient-centred way tailoring for literacy skills using a range of different teaching approaches and aids.

Digital interventions for the management of chronic obstructive pulmonary disease

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is associated with dyspnoea, cough or sputum production (or both) and affects quality of life and functional status. More efficient approaches to alternative management that may include patients themselves managing their condition need further exploration in order to reduce the impact on both patients and healthcare services. Digital interventions may potentially impact on health behaviours and encourage patient engagement.

OBJECTIVES

To assess benefits and harms of digital interventions for managing COPD and apply Behaviour Change Technique (BCT) taxonomy to describe and explore intervention content.

SEARCH METHODS

We identified randomised controlled trials (RCTs) from the Cochrane Airways Trials Register (date of last search 28 April 2020). We found other trials at web-based clinical trials registers.

SELECTION CRITERIA

We included RCTs comparing digital technology interventions with or without routine supported self-management to usual care, or control treatment for self-management. Multi-component interventions (of which one component was digital self-management) compared with usual care, standard care or control treatment were included.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Two review authors independently selected trials for inclusion, extracted data, and assessed risk of bias. Discrepancies were resolved with a third review author. We assessed certainty of the evidence using the GRADE approach. Primary outcomes were impact on health behaviours, self-efficacy, exacerbations and quality of life, including the St George's Respiratory Questionnaire (SGRQ). The minimally important difference (MID) for the SGRQ is 4 points. Two review authors independently applied BCT taxonomy to identify mechanisms in the digital interventions that influence behaviours.

MAIN RESULTS

Fourteen studies were included in the meta-analyses (1518 participants) ranging from 13 to 52 weeks duration. Participants had mild to very severe COPD. Risk of bias was high due to lack of blinding. GRADE ratings were low to very low certainty due to lack of blinding and imprecision. Common BCT clusters identified as behaviour change mechanisms in interventions were goals and planning, feedback and monitoring, social support, shaping knowledge and antecedents. Digital technology intervention with or without routine supported self-management Interventions included mobile phone (three studies), smartphone applications (one study), and web or Internet-based (five studies). Evidence is very uncertain about effects on impact on health behaviours as measured by six-minute walk distance (6MWD) at 13 weeks (mean difference (MD) 26.20, 95% confidence interval (CI) -21.70 to 74.10; participants = 122; studies = 2) or 23 to 26 weeks (MD 14.31, 95% CI -19.41 to 48.03; participants = 164; studies = 3). There may be improvement in 6MWD at 52 weeks (MD 54.33 95% CI -35.47 to 144.12; participants = 204; studies = 2) but studies were varied (very low certainty). There may be no difference in self-efficacy on managing Chronic Disease Scale (SEMCD) or pulmonary rehabilitation adapted index of self-efficacy tool (PRAISE). Evidence is very uncertain. Quality of life may be slightly improved on the chronic respiratory disease questionnaire (CRQ) at 13 weeks (MD 0.45, 95% CI 0.01 to 0.90; participants = 123; studies = 2; low certainty), but is not clinically important (MID 0.5). There may be little or no difference at 23 or 52 weeks (low to very low certainty). There may be a clinical improvement on SGRQ total at 52 weeks (MD -26.57, 95% CI -34.09 to -19.05; participants = 120; studies = 1; low certainty). Evidence for COPD assessment test (CAT) and Clinical COPD Questionnaire (CCQ) is very uncertain. There may be little or no difference in dyspnoea symptoms (CRQ dyspnoea) at 13, 23 weeks or 52 weeks (low to very low certainty evidence) or mean number of exacerbations at 26 weeks (low-certainty evidence). There was no evidence for the number of people experiencing adverse events. Multi-component interventions Digital components included mobile phone (one study), and web or internet-based (four studies). Evidence is very uncertain about effects on impact on health behaviour (6MWD) at 13 weeks (MD 99.60, 95% CI -15.23 to 214.43; participants = 20; studies = 1). No evidence was found for self-efficacy. Four studies reported effects on quality of life (SGRQ and CCQ scales). The evidence is very uncertain. There may be no difference in the number of people experiencing exacerbations or mean days to first exacerbation at 52 weeks with a multi-component intervention compared to standard care. Evidence is very uncertain about effects on the number of people experiencing adverse events at 52 weeks.

AUTHORS' CONCLUSIONS

There is insufficient evidence to demonstrate a clear benefit or harm of digital technology interventions with or without supported self-management, or multi-component interventions compared to usual care in improving the 6MWD or self-efficacy. We found there may be some short-term improvement in quality of life with digital interventions, but there is no evidence about whether the effect is sustained long term. Dyspnoea symptoms may improve over a longer duration of digital intervention use. The evidence for multi-component interventions is very uncertain and as there is little or no evidence for adverse events, we cannot determine the benefit or harm of these interventions. The evidence base is predominantly of very low certainty with concerns around high risk of bias due to lack of blinding. Given that variation of interventions and blinding is likely to be a concern, future, larger studies are needed taking these limitations in consideration. Future studies are needed to determine whether the small improvements observed in this review can be applied to the general COPD population. A clear understanding of behaviour change through the BCT classification is important to gauge uptake of digital interventions and health outcomes in people with varying severity of COPD. Currently there is no guidance for interpreting BCT components of a digital intervention for changes to health outcomes. We could not interpret the BCT findings to the health outcomes we were investigating due to limited evidence that was of very low certainty. In future research, standardised approaches need to be considered when designing protocols to investigate effectiveness of digital interventions by including a standardised approach to BCT classification in addition to validated behavioural outcome measures that may reflect changes in behaviour.

Evolution and impact of self-efficacy during French COVID-19 confinement: a longitudinal study

Based on social cognitive theory, we propose that self-efficacy is a personal resource that protects people from the impact of confinement in the context of the COVID-19 pandemic. In a longitudinal study where 197 French citizens were surveyed over 8 weeks of confinement (though only 25 participants responded each of these 8 weeks), we examined the relationships between general self-efficacy and positive affect, negative affect and adaptive performance at work. Consistent with theoretical expectations, self-efficacy was relatively stable during confinement and was positively related to positive affect and negatively related to negative affect. Self-efficacy was also positively correlated with all dimensions of adaptive performance at work during confinement. The role of self-efficacy as a protective factor against depressive risks induced by the stressful COVID-19 pandemic is discussed.

Psychometric Properties of Patient-Reported Outcome Measures Assessing Self-Efficacy in Patients with Chronic Obstructive Pulmonary Disease (COPD): A Systematic Review

This systematic review aimed to synthesize the evidence of the psychometric properties of self-efficacy patient-reported outcome measures (PROMs) in patients with chronic obstructive pulmonary disease (COPD). We conducted a systematic search of MEDLINE and other common databases from inception until September 2020. Studies that reported psychometric properties of self-efficacy outcome measures in COPD patients were included. We used the Consensus-Based Standards for the Selection of Health Measurement Instruments (COSMIN) 2018 guidelines for data extraction and evidence synthesis. Eighteen studies that assessed nine self-efficacy PROMs were eligible for inclusion. The assessment of structural validity indicated sufficient results rating for the Exercise Self-Regulatory Efficacy Scale and the Self-Care-Self-Efficacy Scale, and insufficient rating for the COPD Self-Efficacy Scale and the Pulmonary Rehabilitation Adaptation Index for Self-Efficacy (PRAISE). Construct validity measures displayed sufficient results rating with correlations ranging from -0.48 to - 0.71 between self-efficacy PROMs and other PROMs such as St. George's Respiratory Questionnaire, Hospital Anxiety and Depression Scale and Chronic Respiratory Questionnaire. Internal consistency measures indicated sufficient rating for all self-efficacy PROMs with a Cronbach's alpha range of 0.71 - 0.98. Responsiveness was assessed for the PRAISE with an overall sufficient rating (effect sizes of 0.21 - 0.37). The evidence regarding the psychometric properties of self-efficacy PROMs in COPD is variable. The PRAISE is responsive to changes in self-efficacy in COPD patients attending a pulmonary rehabilitation program. When using self-efficacy PROMs in clinical practice or research, clinicians and researchers should consider the psychometric properties and choose the appropriate outcome measure based on the purpose.

Early home-based pulmonary rehabilitation following acute exacerbation of COPD: A feasibility study using an action research approach

Objective:

Pulmonary rehabilitation (PR) improves function, reduces symptoms and decreases healthcare usage in people with chronic obstructive pulmonary disease (COPD) following an acute exacerbation (AECOPD). However, rehabilitation uptake rates are low. This study aimed to address barriers to uptake and completion of PR following AECOPD.

Methods:

An action research approach was used to reflect on study feasibility, and to plan and implement an improved protocol. Phase I tested the feasibility of home-based PR started early after AECOPD. Phase II used qualitative interviews to identified potential barriers to program uptake. Phase III re-tested the program with changes to recruitment and assessment strategies.

Results:

Phase I: From 97 screened patients, 26 were eligible and 10 (38%) started home-based PR. Eight participants undertook ≥70% of PR sessions, achieving clinically meaningful improvement in 6-minute walk distance (mean (SD) change 76 (60) m) and chronic respiratory disease questionnaire total score (15 (21) units). Phase II: Potential barriers to uptake of home-based PR included access issues, confidence to exercise, and lack of information about PR benefits. Phase III: From 77 screened patients, 23 were eligible and 5 (22%) started the program.

Discussion:

Home-based PR improved clinical outcomes, but program eligibility and uptake remain challenging. Efforts should be made to ensure PR program eligibility criteria are broad enough to accommodate patient needs, and new ways of engaging patients are needed to improve PR uptake after AECOPD.

Pulmonary rehabilitation adapted index of self-efficacy (PRAISE) validated to Portuguese respiratory patients

INTRODUCTION AND OBJECTIVES

Recent updates on Pulmonary Rehabilitation highlight the importance of patients' self-efficacy on long-term adherence to health-enhancing behaviors. The Pulmonary Rehabilitation Adapted Index of Self-Efficacy (PRAISE) is an adaptation of the General Self-Efficacy Scale. This study aimed to translate, culturally adapt and evaluate reliability and validity of PRAISE in Portuguese respiratory patients.

PATIENTS OR MATERIALS AND METHODS

Forward-backward translation and pilot testing were performed. Content validity was assessed by a multidisciplinary panel of expert judges. To evaluate reliability and validity, 150 respiratory outpatients on Pulmonary Rehabilitation participated in a cross-sectional study. Descriptive and reliability analyses, and exploratory factorial analysis using principal axis factoring, followed by oblique oblimin factor rotation were conducted to identify construct validity. IBM® SPSS® version 22 was used to perform statistical analysis.

RESULTS

150 patients with a mean age of 67 years, 54% male and 83% currently on Pulmonary Rehabilitation participated in the study. These included mainly Chronic Obstructive Pulmonary Disease patients (46.7%) but also Bronchiectasis (20%), Interstitial Lung Disease (20%) and other respiratory diseases. PRAISE mean score was 49. Exploratory factor analysis extraction provided a 4-factor solution that cumulatively explained 52.3% of total variance (F1: 26.6%; F2: 9.7%; F3: 8.7%; F4: 7.3%). Portuguese PRAISE showed a reliability of 0.78 (Chronbach alpha).

CONCLUSIONS

The Portuguese version of PRAISE showed adequate psychometric properties for it to be used as an instrument to measure self-efficacy as a patient-centered outcome on Pulmonary Rehabilitation.

The efficacy of a flipping education program on improving self-management in patients with chronic obstructive pulmonary disease: a randomized controlled trial

Purpose: Self-management is widely used among patients with a chronic disease to control their condition. However, the self-management programs are less distinctive for patients with chronic obstructive pulmonary disease (COPD) than those with other chronic diseases. This study examines the efficacy of a flipping education program on improving self-management in patients with COPD.

Patients and methods: A single-blinded, randomized controlled trial was conducted at a medical center in northern Taiwan from January 2015 to May 2016. Sixty participants were randomized to an experimental group and a control group. The self-management program with flipped teaching, customized action plans, and scheduled telephone interviews was implemented in the experimental group for three months. Conventional patient education was implemented in the control group. Disease knowledge, self-efficacy, the patient’s activation level, and the impact of COPD were assessed at baseline, 1 month, and 3 months after the intervention. SPSS 22.0 was used for data analysis.

Results: The results showed that the patients who received the flipping education program of self-management had statistically significant improvements in their disease knowledge (p<0.05), self-efficacy (p<0.01), and activation levels (p<0.01) from baseline to the 1 month and 3 months follow-up compared to the control group.

Conclusion: The findings supported that flipped teaching could be applied to patient education in adults and that a nurse case manager can feasibly use this flipping education program of self-management to motivate and support patients with COPD to acquire self-management skills, carry out their action plans, and help them achieve beneficial behaviors in their daily lives.

Pulmonary rehabilitation for obstructive lung disease

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

Effect of Health Coaching Delivered by a Respiratory Therapist or Nurse on Self-Management Abilities in Severe COPD: Analysis of a Large Randomized Study

BACKGROUND

Self-management of patients with COPD has received increasing attention in recent years given its association with improved outcomes. There is a scarcity of feasible interventions that can improve self-management abilities. We recently reported the positive effect of health coaching, started at the time of hospital discharge, on re-hospitalizations and emergency department visits for patients with COPD admitted for an exacerbation. In this substudy, we aimed to investigate the effects of health coaching delivered by a respiratory therapist or a nurse compared with guideline-based usual care on self-management abilities in COPD.

METHODS

Self-management was measured by using the Chronic Respiratory Disease Questionnaire mastery domain and was assessed at baseline, at 6 months, and at 12 months after hospitalization.

RESULTS

Two hundred and fifteen subjects hospitalized for a COPD exacerbation were randomized to the intervention or the control. The mean change in the Chronic Respiratory Disease Questionnaire mastery score from baseline to month 6 was Δ0.58 32 ± 1.29 on the intervention arm and Δ0.17 32 ± 1.14 on the control arm (P = .02). Of the intervention subjects, 55% had at least a 0.5-point increase in Chronic Respiratory Disease Questionnaire mastery (minimum clinically important difference) compared with 38% in the control group. Health coaching was an independent predictor of the minimum clinically important difference or greater change in the Chronic Respiratory Disease Questionnaire mastery score at 6 months after initiation of the intervention (odds ratio 1.95, 95% CI 1.01-3.79). The changes in the Chronic Respiratory Disease Questionnaire mastery score at 12 months showed a trend but did not attain statistical significance.

CONCLUSIONS

Health coaching delivered by a respiratory therapist or a nurse improved self-management abilities when applied to subjects with COPD after hospital discharge for an exacerbation. (ClinicalTrials.gov Identifier: NCT01058486, Mayo IRB 09-004341).

Improvement of physical activity in chronic obstructive pulmonary disease by pulmonary rehabilitation and pharmacological treatment

Physical activity (PA) is defined as bodily movement produced by skeletal muscles with energy expenditure beyond resting levels. PA is closely related to reduced morbidity and mortality in chronic obstructive pulmonary disease (COPD). Self-report questionnaires are often subject to recall bias, correlating poorly with objectively qualified PA, and do not provide an accurate estimate of free-living energy expenditure. PA may be objectively evaluated by newly developed tri-axial accelerometers by quantifying steps or body movements over a period of time. Low-intensity, home-based pulmonary rehabilitation (PR) using pedometer feedback improves PA. Improvement in physiological factors correlates with increased walking time in stable elderly COPD patients. This review focuses on the effects of PR and pharmacological treatment on PA in COPD patients. We selected 32 studies from our literature search evaluating the effects of PR and 11 studies examining the effects of pharmacological treatment on PA. Findings in both categories were inconsistent. Nineteen studies showed a positive effect with PR whereas 13 showed no effect. Eight studies showed a positive effect, while three revealed no effect from pharmacological intervention. As both interventions increase exercise capacity without a consistent effect on PA, counseling with behavioral changes may be necessary to achieve a significant and lasting increase in PA. Changing PA behavior in COPD patients requires an interdisciplinary approach involving specialists in respiratory medicine, rehabilitation, social, and behavioral sciences. Future research in this area is warranted to advance our knowledge in this area, specifically with regard to the interaction of pharmacological and non-pharmacological interventions.

Knowledge, Skill, and Confidence in People Attending Pulmonary Rehabilitation: A Cross-Sectional Analysis of the Effects and Determinants of Patient Activation

Background

Patient activation is a significant predictor of health behaviors; however, the level of activation in people attending a pulmonary rehabilitation program and the effect of pulmonary rehabilitation on patient activation have not been measured. Furthermore, the potential determinants and relationship between patient activation and characteristics of people attending pulmonary rehabilitation have not previously been reported.

Methods

The Patient Activation Measure (PAM) was measured in people with a chronic respiratory disease or congestive cardiac failure at a baseline pulmonary rehabilitation assessment and again at the completion of the 8-week outpatient program.

Results

This study included 194 people with chronic respiratory disease or congestive cardiac failure (41% male; mean [standard deviation, SD] age: 73 [11] years; mean [SD] forced expiratory volume in 1 second % predicted: 60% [20%]). The pulmonary rehabilitation program was completed by 61% (n = 118) of participants. The mean (SD) PAM score at baseline was 60.5 (15.7), which improved to 65.4 (15.5) after completion of the pulmonary rehabilitation program (P = .001). In a stepwise forward multiple regression analysis, anxiety, lung information needs, and health-related quality of life impact were found to be significant determinants of baseline PAM. This model explained 12% (P < .001) of the variance.

Conclusion

People with a chronic respiratory disease or congestive cardiac failure commencing a pulmonary rehabilitation program demonstrated a moderate level of activation, which improved following an 8-week hospital outpatient pulmonary rehabilitation program. Anxiety, a higher level of lung information needs, and greater health-related quality of life impact were significantly associated with poor patient activation.

Promoting Physical Activity Using the Internet: Is It Feasible and Acceptable for Patients With Chronic Obstructive Pulmonary Disease and Bronchiectasis?

Older people with chronic lung diseases and with low physical activity participation rates are at higher risk of morbidity and mortality. This study assessed the feasibility and acceptability of a purpose-designed Internet-based program (ActivOnline) to monitor and encourage exercise and physical activity. Twelve participants with chronic obstructive pulmonary disease or bronchiectasis were recruited (54-84 years). Primary outcome measures were feasibility measured by frequency of program access, and acceptability measured by semistructured interview, system usability scores, and participant perception of benefit. The results suggest regular participation in physical activity and exercise during the 8-week study period and high usability scores (mean = 90% ± 9%). Major themes were the importance of regular exercise and how sustained lifestyle changes were essential to be physically active, regular contact with clinicians assisted with motivation, and aspects of ActivOnline facilitated individual behavior change and confidence to continue exercising. Most participants (82%) reported a benefit from using ActivOnline, and 55% wished to remain on the program indefinitely.

Telerehabilitation versus traditional centre-based pulmonary rehabilitation for people with chronic respiratory disease: protocol for a randomised controlled trial

BACKGROUND

Pulmonary rehabilitation is an effective therapeutic intervention for people with chronic respiratory disease. However, fewer than 5% of eligible individuals receive pulmonary rehabilitation on an annual basis, largely due to limited availability of services and difficulties associated with travel and transport. The Rehabilitation Exercise At Home (REAcH) study is an assessor-blinded, multi-centre, randomised controlled equivalence trial designed to compare the efficacy of home-based telerehabilitation and traditional centre-based pulmonary rehabilitation in people with chronic respiratory disease.

METHODS

Participants will undertake an 8-week group-based pulmonary rehabilitation program of twice-weekly supervised exercise training, either in-person at a centre-based pulmonary rehabilitation program or remotely from their home via the Internet. Supervised exercise training sessions will include 30 min of aerobic exercise (cycle and/or walking training). Individualised education and self-management training will be delivered. All participants will be prescribed a home exercise program of walking and strengthening activities. Outcomes will be assessed by a blinded assessor at baseline, after completion of the intervention, and 12-months post intervention. The primary outcome is change in dyspnea score as measured by the Chronic Respiratory Questionnaire - dyspnea domain (CRQ-D). Secondary outcomes will evaluate the efficacy of telerehabilitation on 6-min walk distance, endurance cycle time during a constant work rate test, physical activity and quality of life. Adherence to pulmonary rehabilitation between the two models will be compared. A full economic analysis from a societal perspective will be undertaken to determine the cost-effectiveness of telerehabilitation compared to centre-based pulmonary rehabilitation.

DISCUSSION

Alternative models of pulmonary rehabilitation are required to improve both equity of access and patient-related outcomes. This trial will establish whether telerehabilitation can achieve equivalent improvement in outcomes compared to traditional centre-based pulmonary rehabilitation. If efficacious and cost-effective, the proposed telerehabilitation model is designed to be rapidly deployed into clinical practice.

TRIAL REGISTRATION

Clinical trial registered with the Australian and New Zealand Clinical Trials Register at ( ACTRN12616000360415 ). Registered 21 March 2016.

Intensive Care Syndrome: Promoting Independence and Return to Employment (InS:PIRE). Early evaluation of a complex intervention

BACKGROUND

Many patients suffer significant physical, social and psychological problems in the months and years following critical care discharge. At present, there is minimal evidence of any effective interventions to support this patient group following hospital discharge. The aim of this project was to understand the impact of a complex intervention for ICU survivors.

METHODS

Quality improvement project conducted between September 2014 and June 2016, enrolling 49 selected patients from one ICU in Scotland. To evaluate the impact of this programme outcomes were compared to an existing cohort of patients from the same ICU from 2008-2009. Patients attended a five week peer supported rehabilitation programme. This multidisciplinary programme included pharmacy, physiotherapy, nursing, medical, and psychology input. The primary outcome in this evaluation was the EQ-5D, a validated measure of health-related quality of life. The minimally clinically important difference (MCID) in the EQ-5D is 0.08. We also measured change in self-efficacy over the programme duration. Based on previous research, this study utilised a 2.4 (6%) point change in self-efficacy scores as a MCID.

RESULTS

40 patients (82%) completed follow-up surveys at 12 months. After regression adjustment for those factors known to impact recovery from critical care, there was a 0.07-0.16 point improvement in quality of life for those patients who took part in the intervention compared to historical controls from the same institution, depending on specific regression strategy used. Self-efficacy scores increased by 2.5 points (6.25%) over the duration of the five week programme (p = 0.003), and was sustained at one year post intervention. In the year following ICU, 15 InS:PIRE patients returned to employment or volunteering roles (88%) compared with 11 (46%) in the historical control group (p = 0.15).

CONCLUSIONS AND RELEVANCE

This historical control study suggests that a complex intervention may improve quality of life and self-efficacy in survivors of ICU. A larger, multi-centre study is needed to investigate this intervention further.

Psychometric properties of the Korean version of the Pulmonary Rehabilitation Adapted Index of Self-Efficacy (PRAISE) for individuals with COPD

PURPOSE

Self-efficacy is related to the emotional functioning and coping skills of an individual and is thought to be a predictor of health behaviors, which are particularly important for pulmonary rehabilitation (PR). To our knowledge, no measure of self-efficacy has been validated to explore behavior changes in the context of PR for patients with COPD in Korea. This study aimed to evaluate the psychometric properties of the Korean version of the Pulmonary Rehabilitation Adapted Index of Self-Efficacy (PRAISE).

PATIENTS AND METHODS

The original scale, developed and validated by Vincent et al was translated into Korean through a process involving forward and back translation of the original scale, and transcultural adaptation was performed following the structured procedure. Content validity was assessed by a panel of 6 expert judges. In a convenience sample of 118 patients with COPD, exploratory factor analysis using principal axis factoring, followed by oblique rotation was conducted to identify construct validity, and the concurrent validity was evaluated by testing correlations between the PRAISE and 6-minute walking distance test and the PRAISE and Saint George Respiratory Questionnaire results. Internal consistency was examined by calculating Cronbach's alpha coefficients.

RESULTS

Exploratory factor analysis confirmed the 2-dimensional structure of the scale constructed from the original 15-item scale. The final scale was composed of 14 items that cumulatively explained 60.3% of the total variance. The 2 factors in the scale were named "general self-efficacy" and "exercise self-efficacy." Significant correlations between the PRAISE, and 6-minute walking distance test and Saint George Respiratory Questionnaire showed the concurrent validity of the PRAISE. The Cronbach's alpha coefficient of the PRAISE was 0.93.

CONCLUSION

The Korean version of the PRAISE showed adequate construct validity and reliability. These results suggest that the PRAISE is suitable for use in clinical settings as a predictor of PR behavior in Korean patients with COPD.

Comparison of a structured home-based rehabilitation programme with conventional supervised pulmonary rehabilitation: a randomised non-inferiority trial

BACKGROUND

Standardised home-based pulmonary rehabilitation (PR) programmes offer an alternative model to centre-based supervised PR for which uptake is currently poor. We determined if a structured home-based unsupervised PR programme was non-inferior to supervised centre-based PR for participants with COPD.

METHODS

A total of 287 participants with COPD who were referred to PR (187 male, mean (SD) age 68 (8.86) years, FEV₁% predicted 48.34 (17.92)) were recruited. They were randomised to either centre-based PR or a structured unsupervised home-based PR programme including a hospital visit with a healthcare professional trained in motivational interviewing, a self-management manual and two telephone calls. Fifty-eight (20%) withdrew from the centre-based group and 51 (18%) from the home group. The primary outcome was dyspnoea domain in the chronic respiratory disease questionnaire (Chronic Respiratory Questionnaire Self-Report; CRQ-SR) at 7 weeks. Measures were taken blinded. We undertook a modified intention-to-treat (mITT) complete case analysis, comparing groups according to original random allocation and with complete data at follow-up. The non-inferiority margin was 0.5 units.

RESULTS

There was evidence of significant gains in CRQ-dyspnoea at 7 weeks in both home and centre-based groups. There was inconclusive evidence that home-based PR was non-inferior to PR in dyspnoea (mean group difference, mITT: -0.24, 95% CI -0.61 to 0.12, p=0.18), favouring the centre group at 7 weeks.

CONCLUSIONS

The standardised home-based programme provides benefits in dyspnoea. Further evidence is needed to definitively determine if the health benefits of the standardised home-based programme are non-inferior or equivalent to supervised centre-based rehabilitation.

TRIAL REGISTRATION NUMBER

ISRCTN81189044.

High Level of Integration in Integrated Disease Management Leads to Higher Usage in the e-Vita Study: Self-Management of Chronic Obstructive Pulmonary Disease With Web-Based Platforms in a Parallel Cohort Design

Background

Worldwide, nearly 3 million people die of chronic obstructive pulmonary disease (COPD) every year. Integrated disease management (IDM) improves disease-specific quality of life and exercise capacity for people with COPD, but can also reduce hospital admissions and hospital days. Self-management of COPD through eHealth interventions has shown to be an effective method to improve the quality and efficiency of IDM in several settings, but it remains unknown which factors influence usage of eHealth and change in behavior of patients.

Objective

Our study, e-Vita COPD, compares different levels of integration of Web-based self-management platforms in IDM in three primary care settings. The main aim of this study is to analyze the factors that successfully promote the use of a self-management platform for COPD patients.

Methods

The e-Vita COPD study compares three different approaches to incorporating eHealth via Web-based self-management platforms into IDM of COPD using a parallel cohort design. Three groups integrated the platforms to different levels. In groups 1 (high integration) and 2 (medium integration), randomization was performed to two levels of personal assistance for patients (high and low assistance); in group 3 there was no integration into disease management (none integration). Every visit to the e-Vita and Zorgdraad COPD Web platforms was tracked objectively by collecting log data (sessions and services). At the first log-in, patients completed a baseline questionnaire. Baseline characteristics were automatically extracted from the log files including age, gender, education level, scores on the Clinical COPD Questionnaire (CCQ), dyspnea scale (MRC), and quality of life questionnaire (EQ5D). To predict the use of the platforms, multiple linear regression analyses for the different independent variables were performed: integration in IDM (high, medium, none), personal assistance for the participants (high vs low), educational level, and self-efficacy level (General Self-Efficacy Scale [GSES]). All analyses were adjusted for age and gender.

Results

Of the 702 invited COPD patients, 215 (30.6%) registered to a platform. Of the 82 patients in group 1 (high integration IDM), 36 were in group 1A (personal assistance) and 46 in group 1B (low assistance). Of the 96 patients in group 2 (medium integration IDM), 44 were in group 2A (telephone assistance) and 52 in group 2B (low assistance). A total of 37 patients participated in group 3 (no integration IDM). In all, 107 users (49.8%) visited the platform at least once in the 15-month period. The mean number of sessions differed between the three groups (group 1: mean 10.5, SD 1.3; group 2: mean 8.8, SD 1.4; group 3: mean 3.7, SD 1.8; P=.01). The mean number of sessions differed between the high-assistance and low-assistance groups in groups 1 and 2 (high: mean 11.8, SD 1.3; low: mean 6.7, SD 1.4; F1,80=6.55, P=.01). High-assistance participants used more services (mean 45.4, SD 6.2) than low-assistance participants (mean 21.2, SD 6.8; F1,80=6.82, P=.01). No association was found between educational level and usage and between GSES and usage.

Conclusions

Use of a self-management platform is higher when participants receive adequate personal assistance about how to use the platform. Blended care, where digital health and usual care are integrated, will likely lead to increased use of the online program. Future research should provide additional insights into the preferences of different patient groups.

Trial Registration

Nederlands Trial Register NTR4098; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=4098 (Archived by WebCite at http://www.webcitation.org/6qO1hqiJ1)

Interactive web-based pulmonary rehabilitation programme: a randomised controlled feasibility trial

OBJECTIVES

The aim of this study was to determine if an interactive web-based pulmonary rehabilitation (PR) programme is a feasible alternative to conventional PR.

DESIGN

Randomised controlled feasibility trial.

SETTING

Participants with a diagnosis of chronic obstructive pulmonary disease were recruited from PR assessments, primary care and community rehabilitation programmes. Patients randomised to conventional rehabilitation started the programme according to the standard care at their referred site on the next available date.

PARTICIPANTS

103 patients were recruited to the study and randomised: 52 to conventional rehabilitation (mean (±SD) age 66 (±8) years, Medical Research Council (MRC) 3 (IQR2-4)); 51 to the web arm (mean (±SD) age 66 (±10) years, MRC 3 (IQR2-4)). Participants had to be willing to participate in either arm of the trial, have internet access and be web literate.

INTERVENTIONS

Patients randomised to the web-based programme worked through the website, exercising and recording their progress as well as reading educational material. Conventional PR consisted of twice weekly, 2 hourly sessions (an hour for exercise training and an hour for education).

OUTCOME MEASURES

Recruitment rates, eligibility, patient preference and dropout and completion rates for both programmes were collected. Standard outcomes for a PR assessment including measures of exercise capacity and quality of life questionnaires were also evaluated.

RESULTS

A statistically significant improvement (p≤0.01) was observed within each group in the endurance shuttle walk test (WEB: mean change 189±211.1; PR classes: mean change 184.5±247.4 s) and Chronic Respiratory disease Questionnaire-Dyspnoea (CRQ-D; WEB: mean change 0.7±1.2; PR classes: mean change 0.8±1.0). However, there were no significant differences between the groups in any outcome. Dropout rates were higher in the web-based programme (57% vs 23%).

CONCLUSIONS

An interactive web-based PR programme is feasible and acceptable when compared with conventional PR. Future trials maybe around choice-based PR programmes for select patients enabling stratification of patient care.

TRIAL REGISTRATION NUMBER

ISRCTN03142263; Results.

Changes in physical activity and sedentary behaviour following pulmonary rehabilitation in patients with COPD

A more profound investigation about the responses in activity levels following pulmonary rehabilitation (PR) in patients with COPD is needed. We aimed to describe groups of patients with COPD according to patterns of change in physical activity and sedentary behaviour following PR. 90 patients with COPD (60% male; mean age 67 ± 8; median FEV₁ 47 (32-62) %pred) completed a comprehensive PR programme. A triaxial accelerometer was used to assess the time in sedentary behaviour, light activities and moderate-to-vigorous physical activity (MVPA). Additionally, exercise capacity, quality of life, and symptoms of anxiety and depression were assessed before and after PR. Six groups with different patterns of change in physical activity and sedentary behaviour were identified. The two most prevalent patterns were represented by good responders (increase in physical activity and reduction in sedentary behaviour, 34%) and poor responders (decrease in physical activity and increase in sedentary behaviour, 30%). Good responders had greater improvements in six-minute walk distance (6MWD) and symptoms of depression than poor responders (P < 0.05 for all). Strong correlation was found between changes in sedentary behaviour and changes in light activities (r_s = -0.89; P < 0.0001). Changes in 6MWD correlated fairly with changes in sedentary behaviour (r_s = -0.26), light activities (r_s = 0.25), and MVPA (r_s = 0.24); P < 0.05 for all. Different patterns of change in activity levels following PR can be found in patients with COPD. Focusing on light physical activities might be a potential strategy to make patients less sedentary, but for this to be achieved prior (or at least parallel) improvements in functional capacity seem to be necessary.

Home-based telerehabilitation via real-time videoconferencing improves endurance exercise capacity in patients with COPD: The randomized controlled TeleR Study

BACKGROUND AND OBJECTIVE

Telerehabilitation has the potential to increase access to pulmonary rehabilitation (PR) for patients with COPD who have difficulty accessing centre-based PR due to poor mobility, lack of transport and cost of travel. We aimed to determine the effect of supervised, home-based, real-time videoconferencing telerehabilitation on exercise capacity, self-efficacy, health-related quality of life (HRQoL) and physical activity in patients with COPD compared with usual care without exercise training.

METHODS

Patients with COPD were randomized to either a supervised home-based telerehabilitation group (TG) that received exercise training three times a week for 8 weeks or a control group (CG) that received usual care without exercise training. Outcomes were measured at baseline and following the intervention.

RESULTS

Thirty-six out of 37 participants (mean ± SD age = 74 ± 8 years, forced expiratory volume in 1 s (FEV₁ ) = 64 ± 21% predicted) completed the study. Compared with the CG, the TG showed a statistically significant increase in endurance shuttle walk test time (mean difference = 340 s (95% CI: 153-526, P < 0.001)), an increase in self-efficacy (mean difference = 8 points (95% CI: 2-14, P < 0.007)), a trend towards a statistically significant increase in the Chronic Respiratory Disease Questionnaire total score (mean difference = 8 points (95% CI: -1 to 16, P = 0.07)) and no difference in physical activity (mean difference = 475 steps per day (95% CI: -200 to 1151, P = 0.16)).

CONCLUSION

This study showed that telerehabilitation improved endurance exercise capacity and self-efficacy in patients with COPD when compared with usual care.

Home-based rehabilitation for COPD using minimal resources: a randomised, controlled equivalence trial

BACKGROUND

Pulmonary rehabilitation is a cornerstone of care for COPD but uptake of traditional centre-based programmes is poor. We assessed whether home-based pulmonary rehabilitation, delivered using minimal resources, had equivalent outcomes to centre-based pulmonary rehabilitation.

METHODS

A randomised controlled equivalence trial with 12 months follow-up. Participants with stable COPD were randomly assigned to receive 8 weeks of pulmonary rehabilitation by either the standard outpatient centre-based model, or a new home-based model including one home visit and seven once-weekly telephone calls from a physiotherapist. The primary outcome was change in 6 min walk distance (6MWD).

RESULTS

We enrolled 166 participants to receive centre-based rehabilitation (n=86) or home-based rehabilitation (n=80). Intention-to-treat analysis confirmed non-inferiority of home-based rehabilitation for 6MWD at end-rehabilitation and the confidence interval (CI) did not rule out superiority (mean difference favouring home group 18.6 m, 95% CI -3.3 to 40.7). At 12 months the CI did not exclude inferiority (-5.1 m, -29.2 to 18.9). Between-group differences for dyspnoea-related quality of life did not rule out superiority of home-based rehabilitation at programme completion (1.6 points, -0.3 to 3.5) and groups were equivalent at 12 months (0.05 points, -2.0 to 2.1). The per-protocol analysis showed the same pattern of findings. Neither group maintained postrehabilitation gains at 12 months.

CONCLUSIONS

This home-based pulmonary rehabilitation model, delivered with minimal resources, produced short-term clinical outcomes that were equivalent to centre-based pulmonary rehabilitation. Neither model was effective in maintaining gains at 12 months. Home-based pulmonary rehabilitation could be considered for people with COPD who cannot access centre-based pulmonary rehabilitation.

TRIAL REGISTRATION NUMBER

NCT01423227, clinicaltrials.gov.

Evaluation of a tablet-based instruction of breathing technique in patients with COPD

PURPOSE

Tablet computers are a convenient audio-visual aid for patient education. Teaching patients with chronic obstructive pulmonary disorder (COPD) appropriate therapeutic breathing techniques and encouraging them to practice regularly has been recognized as an effective care strategy. The purpose of this study was to evaluate the effectiveness of using a tablet computer with the Breathing Easier Support Toolkit (BEST), a supplemental software application we developed that instructs and assists COPD patients during the process of respiratory retraining.

PATIENTS AND METHODS

From May 2013 to September 2014, participants were randomly assigned to an experimental group (n=36) or a control group (n=35). Correct breathing technique, practice frequency, application of breathing technique, self-efficacy, quality of life, and patient feedback on the tablet-computer education were evaluated with blinded assessments at baseline and immediate, 1-month, and 3-month follow-up assessments after training completion. Data analysis consisted of basic characteristics and outcome indicators presented in terms of descriptive statistics; inferential statistics were estimated by generalized estimating equations.

RESULTS

The participants were mostly male (83.1%) with an average age of 71.5 (SD=11.4). Both the experimental and control groups showed statistically significant improvement in correct breathing technique and application of breathing technique from baseline for each follow-up (p<0.001). A significantly increase in self-efficacy for the experimental group was found immediately after completing the breathing retraining program compared to the control group (p=0.045).

CONCLUSION

Our tablet computer-assisted educational aid did not provide an improvement over the traditional method for teaching breathing techniques to elderly patients with COPD. The results only showed an immediate effect on the self-efficacy of the breathing technique. The elderly did not use the tablet computer actively and the research was conducted without intervention after discharge, which may be a reason why the effect did not last. Further research to evaluate the effectiveness of such a strategy for the elderly is needed in the future.

Effect of a hospital outreach intervention programme on decreasing hospitalisations and medical costs in patients with chronic obstructive pulmonary disease in China: protocol of a randomised controlled trial

INTRODUCTION

Patients with chronic obstructive pulmonary disease (COPD) often have multiple hospitalisations because of exacerbation. Evidence shows disease management programmes are one of the most cost-effective measures to prevent re-hospitalisation for COPD exacerbation, but lack implementation and economic appraisal in China. The aims of the proposed study are to determine whether a hospital outreach invention programme for disease management can decrease hospitalisations and medical costs in patients with COPD in China. Economic appraisal of the programme will also be carried out.

METHODS AND ANALYSIS

A randomised single-blinded controlled trial will be conducted. 220 COPD patients with exacerbations will be recruited from the Third Xiangya Hospital, Central South University, China. After hospital discharge they will be randomly allocated into an intervention or a control group. Participants in the intervention group will attend a 3-month hospital-based pulmonary rehabilitation intervention and then receive a home-based programme. Both groups will receive identical usual discharge care before discharge from hospital. The primary outcomes will include rate of hospitalisation and medical cost, while secondary outcomes will include mortality, self-efficacy, self-management, health status, quality of life, exercise tolerance and pulmonary function, which will be evaluated at baseline and at 3, 12 and 24 months after the intervention. Cost-effectiveness analysis will be employed for economic appraisal.

ETHICS AND DISSEMINATION

The study has been approved by the institutional review board (IRB) of the Third Xiangya Hospital, Central South University (IRB2014-S159). Findings will be shared widely through conference presentations and peer-reviewed publications. Furthermore, the results of the programme will be submitted to health authorities and policy reform will be recommended.

TRIAL REGISTRATION NUMBER

Chi CTR-TRC-14005108; Pre-results.

Can a supported self-management program for COPD upon hospital discharge reduce readmissions? A randomized controlled trial

INTRODUCTION

Patients with COPD experience exacerbations that may require hospitalization. Patients do not always feel supported upon discharge and frequently get readmitted. A Self-management Program of Activity, Coping, and Education for COPD (SPACE for COPD), a brief self-management program, may help address this issue.

OBJECTIVE

To investigate if SPACE for COPD employed upon hospital discharge would reduce readmission rates at 3 months, compared with usual care.

METHODS

This is a prospective, single-blinded, two-center trial (ISRCTN84599369) with participants admitted for an exacerbation, randomized to usual care or SPACE for COPD. Measures, including health-related quality of life and exercise capacity, were taken at baseline (hospital discharge) and at 3 months. The primary outcome measure was respiratory readmission at 3 months.

RESULTS

Seventy-eight patients were recruited (n=39 to both groups). No differences were found in readmission rates or mortality at 3 months between the groups. Ten control patients were readmitted within 30 days compared to five patients in the intervention group (P>0.05). Both groups significantly improved their exercise tolerance and Chronic Respiratory Questionnaire (CRQ-SR) results, with between-group differences approaching statistical significance for CRQ-dyspnea and CRQ-emotion, in favor of the intervention. The "Ready for Home" survey revealed that patients receiving the intervention reported feeling better able to arrange their life to cope with COPD, knew when to seek help about feeling unwell, and more often took their medications as prescribed, compared to usual care (P<0.05).

CONCLUSION

SPACE for COPD did not reduce readmission rates at 3 months above that of usual care. However, encouraging results were seen in secondary outcomes for those receiving the intervention. Importantly, SPACE for COPD appears to be safe and may help prevent readmission with 30 days.

Exploring self-conscious emotions in individuals with chronic obstructive pulmonary disease

This study aimed to explore the extent to which self-conscious emotions are expressed, to explore any associations with adverse health outcomes, and to compare self-conscious emotions in individuals with chronic obstructive pulmonary disease (COPD) to healthy controls. A two-stage mixed-methods study design was employed. Interviews with 15 individuals with COPD informed the choice of questionnaires to assess self-conscious emotions which were completed by individuals with COPD and healthy controls. Five overarching themes were abstracted: grief, spectrum of blame, concern about the view of others, concealment, and worry about the future. The questionnaires were completed by 70 patients (mean( SD) age 70.8(9.4) years, forced expiratory volume in one second predicted 40.5(18.8), 44% male) and 61 healthy controls (mean( SD) age 62.2(12.9) years, 34% male]. Self-conscious emotions were associated with reduced mastery, heightened emotions, and elevated anxiety and depression (all p < 0.001). Individuals with COPD reported lower self-compassion, higher shame, and less pride than healthy controls (all p ≤ 0.01). There is a need to increase awareness of self-conscious emotions in individuals with COPD. Therapies to target such emotions may improve mastery, emotions, and psychological symptoms.

The evaluation of an interactive web-based Pulmonary Rehabilitation programme: protocol for the WEB SPACE for COPD feasibility study

INTRODUCTION

Pulmonary Rehabilitation (PR) is an evidence-based intervention that has been recommended in guidelines to be available to those who may benefit. However, not all patients with chronic obstructive pulmonary disease (COPD) have access to this service. Healthcare services have shown the need for the provision of PR in other forms to enable patient choice and service capacity. There is an increase in evidence for the use of the internet in the management of long-term conditions to provide education and promote self-management. The aim of this study is to see if an interactive web-based PR programme is a feasible alternative compared with conventional PR.

METHODS AND ANALYSIS

This is a feasibility study designed to evaluate the efficacy of providing a web-based PR programme to improve patients exercise capacity, quality of life and promote self-management in patients with moderate to severe COPD compared with conventional PR programmes. Eligible patients will be randomly allocated to receive either the web-based programme or conventional rehabilitation programme for 7 weeks using an internet-based randomisation system. Participants will be recruited from PR assessments, primary care and community rehabilitation programmes. Those randomised to the web-based programme work through the website which contains all the information that the patients receive in the PR classes. They receive weekly phone calls by a professional to help progress through the course on line. The outcome measures will be recruitment rates and eligibility as well as that standard for a PR assessment including measures of exercise capacity, quality of life questionnaires and physical activity.

ETHICS AND DISSEMINATION

The research ethics committee for Northampton has provided ethical approval for the conduct of the study. The results of the study will be disseminated through appropriate conference presentations and peer reviewed journals.

TRIAL REGISTRATION NUMBER

ISRCTN03142263.

Domain-specific self-efficacy is associated with measures of functional capacity and quality of life among patients with moderate to severe chronic obstructive pulmonary disease

RATIONALE

The relationship between self-efficacy and health behaviors is well established. However, little is known about the relationship between self-efficacy and health-related indicators among patients with chronic obstructive pulmonary disease (COPD).

OBJECTIVES

The purpose of this cross-sectional cohort study was to test the hypothesis that the total score and specific subdomain scores of the COPD Self-Efficacy Scale (CSES) are associated with functional capacity and quality of life in a group of patients with moderate to severe COPD.

METHODS

Relationships were examined in a cross-sectional study of baseline data collected as part of a randomized trial. Self-efficacy was measured using the five domains of the CSES: negative affect, emotional arousal, physical exertion, weather/environment, and behavioral. Measures of quality of life and functional capacity included SF-12: physical and mental composite scores, Chronic Respiratory Questionnaire dyspnea domain, and the 6-minute-walk test. Statistical analyses included Spearman correlation and categorical analyses of self-efficacy ("confident" vs. "not confident") using general linear models adjusting for potential confounders.

MEASUREMENTS AND MAIN RESULTS

There were 325 patients enrolled with a mean age (standard deviation) of 68.5 (9.48) years, 49.5% male, and 91.69% non-Hispanic white. The negative affect, emotional arousal, and physical exertion domains were moderately correlated (range, 0.3-0.7) with the SF-12 mental composite score and Chronic Respiratory Questionnaire dyspnea domain. In models exploring each CSES domain as "confident" versus "not confident" and adjusting for age, sex, race, pack-years, and airflow obstruction severity, there were multiple clinically and statistically significant associations between the negative affect, emotional arousal, and physical exertion domains with functional capacity and quality of life.

CONCLUSIONS

The aggregated total CSES score was associated with better quality of life and functional capacity. Our analysis of subdomains revealed that the physical exertion, negative affect, and emotional arousal subdomains had the largest associations with functional capacity and quality of life indicators. These findings suggest that interventions to enhance self-efficacy may improve the functional capacity and quality of life of patients with moderate to severe COPD.

Time to adapt exercise training regimens in pulmonary rehabilitation--a review of the literature

Exercise intolerance, exertional dyspnea, reduced health-related quality of life, and acute exacerbations are features characteristic of chronic obstructive pulmonary disease (COPD). Patients with a primary diagnosis of COPD often report comorbidities and other secondary manifestations, which diversifies the clinical presentation. Pulmonary rehabilitation that includes whole body exercise training is a critical part of management, and core programs involve endurance and resistance training for the upper and lower limbs. Improvement in maximal and submaximal exercise capacity, dyspnea, fatigue, health-related quality of life, and psychological symptoms are outcomes associated with exercise training in pulmonary rehabilitation, irrespective of the clinical state in which it is commenced. There may be benefits for the health care system as well as the individual patient, with fewer exacerbations and subsequent hospitalization reported with exercise training. The varying clinical profile of COPD may direct the need for modification to traditional training strategies for some patients. Interval training, one-legged cycling (partitioning) and non-linear periodized training appear to be equally or more effective than continuous training. Inspiratory muscle training may have a role as an adjunct to whole body training in selected patients. The benefits of balance training are also emerging. Strategies to ensure that health enhancing behaviors are adopted and maintained are essential. These may include training for an extended duration, alternative environments to undertake the initial program, maintenance programs following initial exercise training, program repetition, and incorporation of approaches to address behavioral change. This may be complemented by methods designed to maximize uptake and completion of a pulmonary rehabilitation program.

A self-management programme for COPD: a randomised controlled trial

Studies of programmes of self-management support for chronic obstructive pulmonary disease (COPD) have been inconclusive. The Self-Management Programme of Activity, Coping and Education (SPACE) FOR COPD is a 6-week self-management intervention for COPD, and this study aimed to evaluate the effectiveness of this intervention in primary care.

A single-blind randomised controlled trial recruited people with COPD from primary care and randomised participants to receive usual care or SPACE FOR COPD. Outcome measures were performed at baseline, 6 weeks and 6 months. The primary outcome was symptom burden, measured by the self-reported Chronic Respiratory Questionnaire (CRQ-SR) dyspnoea domain. Secondary outcomes included other domains of the CRQ-SR, shuttle walking tests, disease knowledge, anxiety, depression, self-efficacy, smoking status and healthcare utilisation.

184 people with COPD were recruited and randomised. At 6 weeks, there were significant differences between groups in CRQ-SR dyspnoea, fatigue and emotion scores, exercise performance, anxiety, and disease knowledge. At 6 months, there was no between-group difference in change in CRQ-SR dyspnoea. Exercise performance, anxiety and smoking status were significantly different between groups at 6 months, in favour of the intervention.

This brief self-management intervention did not improve dyspnoea over and above usual care at 6 months; however, there were gains in anxiety, exercise performance, and disease knowledge.

Self-management in patients with COPD: theoretical context, content, outcomes, and integration into clinical care

In this narrative review, we put self-management in the context of a 50-year history of research about how patients with COPD respond to their illness. We review a definition of self-management, and emphasize that self-management should be combined with disease management and the chronic care model in order to be effective. Reviewing the empirical status of self-management in COPD, we conclude that self-management is part and parcel of modern, patient-oriented biopsychosocial care. In pulmonary rehabilitation programs, self-management is instrumental in improving patients' functional status and quality of life. We conclude by emphasizing how studying the way persons with COPD make sense of their illness helps in refining self-management, and thereby patient-reported outcomes in COPD.

Approaches to outcome assessment in pulmonary rehabilitation

A comprehensive assessment is the foundation of a successful pulmonary rehabilitation programme. There is a broad selection of outcome measures that tend to be categorized into measures of exercise performance (including measures of strength) quality of life (health status), psychological well-being, nutritional status and more recently knowledge and self-efficacy. There is a growing interest in the measurement of physical activity too, although this is a current line of research activity. A sophisticated suite of outcomes allows the rehabilitation program to be personalised to the individual and deliver effective rehabilitation.