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ORIGINAL ARTICLE
Repeating pulmonary rehabilitation: Prevalence, predictors and outcomes HAZEL HENG,1 ANNEMARIE L. LEE2,3 AND ANNE E. HOLLAND1,2,3 1
Department of Physiotherapy, La Trobe University and 2Department of Physiotherapy, Alfred Health and 3Institute for Breathing and Sleep, Melbourne, Victoria, Australia
ABSTRACT Background and objective: Pulmonary rehabilitation (PR) is a cornerstone of care in chronic respiratory diseases; yet its benefits diminish over time. Repeating PR may be beneficial; however, little is known about the characteristics and outcomes of repeaters. This study aimed to establish the proportion of repeaters, identify characteristics that predict repetition and compare the magnitude of benefits achieved between initial and subsequent programmes. Methods: Patients with stable chronic respiratory diseases who attended PR over a 9-year period were included. Outcome measures included the 6-min walk distance (6MWD) and the Chronic Respiratory Disease Questionnaire-Self-Reported (CRDQ-SR). Independent predictors of repeating were identified. Results: Of 296 patients, 59 (20%) repeated PR, most within 1–3 years. Following the initial programme, repeaters had significant decline in 6MWD (−96.1 ± 84.6 m; P < 0.001) and CRDQ-SR scores (mean decline −3.6 points, range −0.1 to −7.9 points; P < 0.005). The improvement in 6MWD was less in the repeat programme compared with the first (38.4 ± 50.7 m vs 67 ± 40.4 m; P = 0.005), while the change in CRDQ-SR was similar in all domains. A chronic obstructive pulmonary disease diagnosis increased the odds of repeating PR (odds ratio (OR) 4.8; P = 0.005) while improved mastery in the initial programme reduced the odds (OR 0.9; P = 0.033). Conclusions: One in five patients repeated PR, achieving clinically significant improvements in exercise tolerance and quality of life. Patients with small improvements in disease mastery after initial PR were more likely to repeat the programme and may benefit from earlier intervention or longer duration PR. Key words: 6-min walk test, chronic obstructive pulmonary disease, exercise, quality of life, rehabilitation. Abbreviations: 6MWD, 6-min walk distance; 6MWT, 6-min walk test; COPD, chronic obstructive pulmonary disease; CRDQSR, Chronic Respiratory Disease Questionnaire-Self-Reported; Correspondence: Anne E. Holland, La Trobe University Clinical School, Level 4, The Alfred Centre, 99 Commercial Road, Melbourne, Vic. 3004, Australia. Email: [email protected] Received 27 February 2014; invited to revise 2 April and 2 May 2014; revised 16 April and 6 May 2014; accepted 16 May 2014 (Associate Editor: Melissa Benton). © 2014 Asian Pacific Society of Respirology
SUMMARY AT A GLANCE Patients who have smaller changes in disease mastery following pulmonary rehabilitation (PR) are more likely to repeat the programme. Repeating PR is associated with clinically significant benefits for exercise tolerance and health-related quality of life.
FER, forced expiratory ratio; FEV1, force expiratory volume in 1 s; FVC, forced vital capacity; HRQOL, Health-related quality of life; OR, odds ratio; ppi, points per item; PR, pulmonary rehabilitation.
INTRODUCTION Pulmonary rehabilitation (PR) is well established as an integral component of chronic obstructive pulmonary disease (COPD) management,1 with improvements in health-related quality of life (HRQOL) and exercise capacity, as well as reductions in acute exacerbations and hospitalizations.2–4 Its benefits in other respiratory diseases have also been demonstrated.1 However, a decline in PR-related benefits has been found over 12 to 24 months following programme completion.1,5,6 Although reasons for this decline are not fully understood, a clinical consequence is that a proportion of people with respiratory disease are often referred to repeat a course of PR. A previous study in 76 participants reported that 22% of patients (n = 17) repeated an inpatient PR programme;7 however it is unknown whether these results reflect practice in outpatient PR programmes. Significant gains in exercise tolerance and HRQOL following a repeat course of PR in COPD have been demonstrated; however, the magnitude of improvement did not consistently reach a clinically important threshold.8–10 Previous studies have only included people with COPD9,10 which may not reflect current clinical practice where people with other respiratory diseases are also included in PR.1 Existing studies also have limited subject numbers (n = 29–76);7–10 as a result, it is unknown which factors predict the need for repetition. Given the small proportion of patients Respirology (2014) doi: 10.1111/resp.12365
2 who need PR that are able to access this recommended treatment on even one occasion,11–13 programme repetition has significant implications for health-care resources and programme planning. The primary aim of this study was to establish the proportion of patients who repeat PR. Secondary aims were to identify the characteristics of those repeating PR, and to compare the magnitude of benefits achieved in repeat programmes to the initial programme.
METHODS Research design and approval This was a retrospective cohort study of people who completed PR at the Alfred Hospital between 2001 and the end of 2009. This study was approved by The Alfred Human Research Ethics Committee and the Faculty of Human Ethics Committee of La Trobe University (Ethics number—FHEC13/048). Participants Participants were diagnosed with a chronic respiratory disease and had symptoms of exertional dyspnoea, with this inclusion criteria remaining consistent for the study duration. Participants were referred to the programme when they were in a stable disease state or recovering from an acute exacerbation of their condition.1 Patients were excluded if they had severe cognitive impairment, or any musculoskeletal or neurological disorders that prevented the safe completion of exercise. Patients were considered to have completed the first rehabilitation programme if data were available for both initial and final assessment. Census date was the end of 2010, to allow a minimum of 1-year follow up for all participants. PR programme The PR programme ran for a duration of 6–11 weeks in an outpatient setting.1 Patients attended twice weekly for a 90-min supervised exercise session and a 60-min education session, and were encouraged to undertake at least one additional unsupervised exercise session at home each week.1 The content of the educational programme was consistent with current recommendations1 and was delivered by a multidisciplinary team, with topics including exercise, symptoms management, self-management training, psychological support and nutritional advice. The exercise programme consisted of an individualized cardiovascular exercise and upper and lower limb strength training for each participant, with initial exercise prescription and progression conducted according to standard recommendations.1 The principles of exercise prescription and progression and the content of the education programme remained consistent over the study duration. The demographics collected were age, spirometry, body mass index and primary diagnostic condition.14 Outcome measures Exercise capacity and HRQOL were measured at baseline and programme completion. Exercise Respirology (2014)
H Heng et al.
capacity was assessed using the 6-min walk test (6MWT), which was completed on an indoor track of 25–30 m in length using standardized instructions and encouragement, with two tests performed on each occasion.15 The minimal important difference for the 6-min walk distance (6MWD) in individuals with COPD was defined as 25 m.16 HRQOL was measured using the self-reported version of the Chronic Respiratory Disease Questionnaire-SelfReported (CRDQ-SR).17 The minimal important difference is 0.5 points per question within each domain.18–20 The primary outcome of this study was the proportion of patients who repeated PR. The secondary outcomes were: (i) characteristics and predictors of patients who repeat PR; (ii) the change in exercise capacity following initial and repeated programme(s) using the 6MWD; and (iii) the change in HRQOL following initial and repeated programme(s) using the CRDQ-SR.
Statistical analysis The proportion of patients who repeated PR was reported descriptively. Differences in baseline characteristics and response to initial PR programme between repeaters and non-repeaters were analysed using t-tests or Mann–Whitney U-test, depending on data distribution. Pearson’s chi-square test was used to compare categorical variables. Logistic regression was used to determine the baseline characteristics which predicted the likelihood of PR repetition. Demographic variables or initial PR response variables which had a univariate relationship with repetition (P < 0.1) were included in the model. The magnitude of change of outcome measures (6MWD and all four domains of the CRDQ-SR) between initial and subsequent programmes were compared using repeated measures analysis of variance. A two-tailed α was set at less than 0.05.
RESULTS From 2001 to the end of 2009, 296 patients completed PR at the Alfred hospital, 158 (53%) of whom were male. The mean age was 67 years old with a range of 22–91 years and the mean force expiratory volume in 1 s (FEV1)% predicted was 52% (range: 13–125). The characteristics of patients are summarized in Table 1. In total, 215 (73%) patients were diagnosed with COPD. Fifty-nine patients (20%) repeated PR during the study period. Eleven patients repeated twice and one patient repeated three times. Figure 1 illustrates the time course over which patients repeated PR, with programme repetition predominantly occurring between 1 and 3 years following the initial programme. The median time between the initial programme and the first repeated programme was 1.96 years and the median time from the first repeat programme to the second was 2.32 years. A higher proportion of patients with COPD repeated the programme in comparison to patients from other disease groups (Table 1). Repeaters also had a © 2014 Asian Pacific Society of Respirology
3
Benefits and predictors of repeating PR Table 1 Anthropometric, demographic and functional characteristics of patients at baseline
Gender (male : female, n) Age (year) No. of sessions attended Body mass index (kg/m2) Diagnosis (Number/%) COPD Asthma Chronic bronchitis ILD Other GOLD stage COPD (%) Stage I Stage II Stage III Stage IV FEV1 (% pred) FVC (% pred) FEV1/FVC (FER) Resting SpO2 (%) Nadir SpO2 (%) 6MWD (m) CRDQ-SR (ppi) Dyspnoea Fatigue Mastery Emotional function
Repeaters (n = 59) Mean (SD)
Non-repeaters (n = 237) Mean (SD)
33:26 67 (8) 12 (3) 26.5 (6.1)
125:112 68 (11) 12 (3) 26.8 (7.2)
53 (25) 3 (13) 2 (8) 1 (5) 0 (0)
162 (75) 21 (87) 22 (92) 19 (95) 10 (100)
3.9 33.3 39.2 23.5 45.5 (21.1) 78.8 (23.6) 0.45 (0.16) 94.4 (2.2) 87 (7.1) 371.2 (103.5)
17.9 28.4 41.6 12.1 56.7 (23.6) 81.1 (22.7) 0.53 (0.19) 94.5 (2.2) 89.6 (5.6) 368.5 (117.2)
0.384 0.543
ORIGINAL ARTICLE
Repeating pulmonary rehabilitation: Prevalence, predictors and outcomes HAZEL HENG,1 ANNEMARIE L. LEE2,3 AND ANNE E. HOLLAND1,2,3 1
Department of Physiotherapy, La Trobe University and 2Department of Physiotherapy, Alfred Health and 3Institute for Breathing and Sleep, Melbourne, Victoria, Australia
ABSTRACT Background and objective: Pulmonary rehabilitation (PR) is a cornerstone of care in chronic respiratory diseases; yet its benefits diminish over time. Repeating PR may be beneficial; however, little is known about the characteristics and outcomes of repeaters. This study aimed to establish the proportion of repeaters, identify characteristics that predict repetition and compare the magnitude of benefits achieved between initial and subsequent programmes. Methods: Patients with stable chronic respiratory diseases who attended PR over a 9-year period were included. Outcome measures included the 6-min walk distance (6MWD) and the Chronic Respiratory Disease Questionnaire-Self-Reported (CRDQ-SR). Independent predictors of repeating were identified. Results: Of 296 patients, 59 (20%) repeated PR, most within 1–3 years. Following the initial programme, repeaters had significant decline in 6MWD (−96.1 ± 84.6 m; P < 0.001) and CRDQ-SR scores (mean decline −3.6 points, range −0.1 to −7.9 points; P < 0.005). The improvement in 6MWD was less in the repeat programme compared with the first (38.4 ± 50.7 m vs 67 ± 40.4 m; P = 0.005), while the change in CRDQ-SR was similar in all domains. A chronic obstructive pulmonary disease diagnosis increased the odds of repeating PR (odds ratio (OR) 4.8; P = 0.005) while improved mastery in the initial programme reduced the odds (OR 0.9; P = 0.033). Conclusions: One in five patients repeated PR, achieving clinically significant improvements in exercise tolerance and quality of life. Patients with small improvements in disease mastery after initial PR were more likely to repeat the programme and may benefit from earlier intervention or longer duration PR. Key words: 6-min walk test, chronic obstructive pulmonary disease, exercise, quality of life, rehabilitation. Abbreviations: 6MWD, 6-min walk distance; 6MWT, 6-min walk test; COPD, chronic obstructive pulmonary disease; CRDQSR, Chronic Respiratory Disease Questionnaire-Self-Reported; Correspondence: Anne E. Holland, La Trobe University Clinical School, Level 4, The Alfred Centre, 99 Commercial Road, Melbourne, Vic. 3004, Australia. Email: [email protected] Received 27 February 2014; invited to revise 2 April and 2 May 2014; revised 16 April and 6 May 2014; accepted 16 May 2014 (Associate Editor: Melissa Benton). © 2014 Asian Pacific Society of Respirology
SUMMARY AT A GLANCE Patients who have smaller changes in disease mastery following pulmonary rehabilitation (PR) are more likely to repeat the programme. Repeating PR is associated with clinically significant benefits for exercise tolerance and health-related quality of life.
FER, forced expiratory ratio; FEV1, force expiratory volume in 1 s; FVC, forced vital capacity; HRQOL, Health-related quality of life; OR, odds ratio; ppi, points per item; PR, pulmonary rehabilitation.
INTRODUCTION Pulmonary rehabilitation (PR) is well established as an integral component of chronic obstructive pulmonary disease (COPD) management,1 with improvements in health-related quality of life (HRQOL) and exercise capacity, as well as reductions in acute exacerbations and hospitalizations.2–4 Its benefits in other respiratory diseases have also been demonstrated.1 However, a decline in PR-related benefits has been found over 12 to 24 months following programme completion.1,5,6 Although reasons for this decline are not fully understood, a clinical consequence is that a proportion of people with respiratory disease are often referred to repeat a course of PR. A previous study in 76 participants reported that 22% of patients (n = 17) repeated an inpatient PR programme;7 however it is unknown whether these results reflect practice in outpatient PR programmes. Significant gains in exercise tolerance and HRQOL following a repeat course of PR in COPD have been demonstrated; however, the magnitude of improvement did not consistently reach a clinically important threshold.8–10 Previous studies have only included people with COPD9,10 which may not reflect current clinical practice where people with other respiratory diseases are also included in PR.1 Existing studies also have limited subject numbers (n = 29–76);7–10 as a result, it is unknown which factors predict the need for repetition. Given the small proportion of patients Respirology (2014) doi: 10.1111/resp.12365
2 who need PR that are able to access this recommended treatment on even one occasion,11–13 programme repetition has significant implications for health-care resources and programme planning. The primary aim of this study was to establish the proportion of patients who repeat PR. Secondary aims were to identify the characteristics of those repeating PR, and to compare the magnitude of benefits achieved in repeat programmes to the initial programme.
METHODS Research design and approval This was a retrospective cohort study of people who completed PR at the Alfred Hospital between 2001 and the end of 2009. This study was approved by The Alfred Human Research Ethics Committee and the Faculty of Human Ethics Committee of La Trobe University (Ethics number—FHEC13/048). Participants Participants were diagnosed with a chronic respiratory disease and had symptoms of exertional dyspnoea, with this inclusion criteria remaining consistent for the study duration. Participants were referred to the programme when they were in a stable disease state or recovering from an acute exacerbation of their condition.1 Patients were excluded if they had severe cognitive impairment, or any musculoskeletal or neurological disorders that prevented the safe completion of exercise. Patients were considered to have completed the first rehabilitation programme if data were available for both initial and final assessment. Census date was the end of 2010, to allow a minimum of 1-year follow up for all participants. PR programme The PR programme ran for a duration of 6–11 weeks in an outpatient setting.1 Patients attended twice weekly for a 90-min supervised exercise session and a 60-min education session, and were encouraged to undertake at least one additional unsupervised exercise session at home each week.1 The content of the educational programme was consistent with current recommendations1 and was delivered by a multidisciplinary team, with topics including exercise, symptoms management, self-management training, psychological support and nutritional advice. The exercise programme consisted of an individualized cardiovascular exercise and upper and lower limb strength training for each participant, with initial exercise prescription and progression conducted according to standard recommendations.1 The principles of exercise prescription and progression and the content of the education programme remained consistent over the study duration. The demographics collected were age, spirometry, body mass index and primary diagnostic condition.14 Outcome measures Exercise capacity and HRQOL were measured at baseline and programme completion. Exercise Respirology (2014)
H Heng et al.
capacity was assessed using the 6-min walk test (6MWT), which was completed on an indoor track of 25–30 m in length using standardized instructions and encouragement, with two tests performed on each occasion.15 The minimal important difference for the 6-min walk distance (6MWD) in individuals with COPD was defined as 25 m.16 HRQOL was measured using the self-reported version of the Chronic Respiratory Disease Questionnaire-SelfReported (CRDQ-SR).17 The minimal important difference is 0.5 points per question within each domain.18–20 The primary outcome of this study was the proportion of patients who repeated PR. The secondary outcomes were: (i) characteristics and predictors of patients who repeat PR; (ii) the change in exercise capacity following initial and repeated programme(s) using the 6MWD; and (iii) the change in HRQOL following initial and repeated programme(s) using the CRDQ-SR.
Statistical analysis The proportion of patients who repeated PR was reported descriptively. Differences in baseline characteristics and response to initial PR programme between repeaters and non-repeaters were analysed using t-tests or Mann–Whitney U-test, depending on data distribution. Pearson’s chi-square test was used to compare categorical variables. Logistic regression was used to determine the baseline characteristics which predicted the likelihood of PR repetition. Demographic variables or initial PR response variables which had a univariate relationship with repetition (P < 0.1) were included in the model. The magnitude of change of outcome measures (6MWD and all four domains of the CRDQ-SR) between initial and subsequent programmes were compared using repeated measures analysis of variance. A two-tailed α was set at less than 0.05.
RESULTS From 2001 to the end of 2009, 296 patients completed PR at the Alfred hospital, 158 (53%) of whom were male. The mean age was 67 years old with a range of 22–91 years and the mean force expiratory volume in 1 s (FEV1)% predicted was 52% (range: 13–125). The characteristics of patients are summarized in Table 1. In total, 215 (73%) patients were diagnosed with COPD. Fifty-nine patients (20%) repeated PR during the study period. Eleven patients repeated twice and one patient repeated three times. Figure 1 illustrates the time course over which patients repeated PR, with programme repetition predominantly occurring between 1 and 3 years following the initial programme. The median time between the initial programme and the first repeated programme was 1.96 years and the median time from the first repeat programme to the second was 2.32 years. A higher proportion of patients with COPD repeated the programme in comparison to patients from other disease groups (Table 1). Repeaters also had a © 2014 Asian Pacific Society of Respirology
3
Benefits and predictors of repeating PR Table 1 Anthropometric, demographic and functional characteristics of patients at baseline
Gender (male : female, n) Age (year) No. of sessions attended Body mass index (kg/m2) Diagnosis (Number/%) COPD Asthma Chronic bronchitis ILD Other GOLD stage COPD (%) Stage I Stage II Stage III Stage IV FEV1 (% pred) FVC (% pred) FEV1/FVC (FER) Resting SpO2 (%) Nadir SpO2 (%) 6MWD (m) CRDQ-SR (ppi) Dyspnoea Fatigue Mastery Emotional function
Repeaters (n = 59) Mean (SD)
Non-repeaters (n = 237) Mean (SD)
33:26 67 (8) 12 (3) 26.5 (6.1)
125:112 68 (11) 12 (3) 26.8 (7.2)
53 (25) 3 (13) 2 (8) 1 (5) 0 (0)
162 (75) 21 (87) 22 (92) 19 (95) 10 (100)
3.9 33.3 39.2 23.5 45.5 (21.1) 78.8 (23.6) 0.45 (0.16) 94.4 (2.2) 87 (7.1) 371.2 (103.5)
17.9 28.4 41.6 12.1 56.7 (23.6) 81.1 (22.7) 0.53 (0.19) 94.5 (2.2) 89.6 (5.6) 368.5 (117.2)
0.384 0.543
