Veterans With Chronic Obstructive Pulmonary Disease Achieve Clinically Relevant Improvements in Respiratory Health After Pulmonary Rehabilitation Stephen Major, MD; Marcella Moreno, RN; John Shelton, RRT; Ralph J. Panos, MD

■ PURPOSE: To measure respiratory health and respiratory-related (RR) health care utilization in veterans with chronic obstructive pulmonary disease referred to pulmonary rehabilitation (PR) at the Cincinnati Veterans Administration (VA) Medical Center. ■ METHODS: We reviewed the records of 430 patients referred for PR from 2008 to 2010: 78 met inclusion criteria and completed PR (PR group); 92 qualified for PR but declined participation (referral group). All PR participants completed the St. George’s Respiratory Questionnaire (SGRQ), BODE index, 6-minute walk test (6MWT), UCSD Shortness of Breath Questionnaire (UCSDSOBQ), Pulmonary Disease Knowledge Test, and self-reported use of short-acting bronchodilators before and after PR. All VA health care encounters during the 12 months before and after PR (PR group) or referral (referral group) were reviewed. ■ RESULTS: Respiratory health improved after PR: SGRQ (60.6 ± 15.1, 51.1 ± 16.7), BODE (4.65 ± 1.93, 3.41 ± 1.84), 6MWT (497 ± 367 m, 572 ± 397 m), UCSDSOBQ (68.3 ± 21.1, 61.0 ± 20.9), Pulmonary Disease Knowledge Test (75.9 ± 12.4%, 85.9 ± 11.1%), short-acting bronchodilator (22.5 ± 25.3, 12.8 ± 15.6 inhalations per week) (before, after PR; P < .001 for all comparisons). The RR emergency department (ED) visits (0.71 ± 1.44, 0.44 ± 0.86; P = .04) and RR hospitalizations (0.41 ± 0.73, 0.23 ± 0.51; P = .03) (visits/patient/year; pre-PR, post-PR) decreased following PR. RR ED visits and hospitalizations were the same for the PR and referral groups prior to PR but declined post-PR (0.44 ± 0.86, 0.78 ± 1.36 ED visits/patient/year; P = .05) and (0.23 ± 0.51, 0.59 ± 1.20 hospitalizations/patient/year; P = .01). Ninety-four percent of PR participants achieved the minimal clinically important difference in at least 1 univariate scale (Modified Medical Research Council, UCSDSOBQ, SGRQ, and 6MWT); 82%, 2 scales; 59%, 3 scales; and 24%, all 4 scales. ■ CONCLUSIONS: Pulmonary rehabilitation improves respiratory health in veterans with chronic obstructive pulmonary disease and decreases RR health care utilization.

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chronic obstructive pulmonary disease pulmonary rehabilitation veterans

Author Affiliations: Pulmonary, Critical Care, and Sleep Medicine Division, Cincinnati Veterans Affairs Medical Center (Drs Major and Panos), Pulmonary, Critical Care, and Sleep Medicine Division, University of Cincinnati College of Medicine (Drs Major and Panos), and Pulmonary Rehabilitation Program, Cincinnati Veterans Affairs Medical Center (Ms Moreno, Mr Shelton, and Dr Panos), Cincinnati, Ohio. Conflicts of interest: none declared. Correspondence: Ralph J. Panos, MD, Pulmonary, Critical Care, and Sleep Division, Cincinnati Veterans Affairs Medical Center, Cincinnati, OH 45220 ([email protected]). DOI: 10.1097/HCR.0000000000000079


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Chronic obstructive pulmonary disease (COPD) is a significant cause of morbidity and mortality in the United States and, especially, within the Veterans Health Administration (VHA).1 In 2009, COPD surpassed stroke as the third leading cause of death in the United States2 and 6.3% of American adults have been diagnosed with COPD.3 However, among veterans, the prevalence of COPD is higher and has been measured to be 33% to 43% at the Cincinnati Veterans Affairs Medical Center (VAMC)4 In 2004, the VHA spent approximately $5.5 billion caring for nearly 1 million veterans with COPD.5 At the Cincinnati VAMC in 2008, more than 3200 veterans received care for COPD at a cost of $21 million. These costs and encounters were not uniformly distributed across all patients with COPD; 20% of patients generated nearly 90% of COPD-related expenditures and 60% to 70% of all COPD-related encounters.6 Chronic obstructive pulmonary disease affects a large percentage of veterans, causes excessive morbidity and mortality, and its management generates significant expenses. Pulmonary rehabilitation (PR) is a well-established and effective treatment of COPD.7,8 Pulmonary rehabilitation significantly improves dyspnea, fatigue, exercise tolerance, and health-related quality of life (HRQOL).9,10 Griffiths and colleagues11 showed that a multidisciplinary outpatient PR program was costeffective. While there is extensive evidence that PR improves respiratory health, there are fewer studies demonstrating reductions in health care utilization.11-14 There are only 2 PR programs in VHA facilities that have been accredited by the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR).15 It is likely that veterans would benefit from greater access to and participation in PR but there is little evidence documenting the effectiveness of PR on respiratory health and health care utilization in veterans with COPD. Therefore, we examined the effectiveness of PR in veterans who completed the Cincinnati VAMC Pulmonary Rehabilitation Program and compared their outcomes with veterans who were eligible for but did not participate in PR.

METHODS Records of all patients referred to the Cincinnati VAMC PR program from its inception in 2008 through December 2010 were reviewed (Figure 1). Inclusion criteria were a diagnosis of COPD confirmed by pulmonary function tests (PFT) interpreted using the American Thoracic Society guidelines16 (airflow limitation was defined as a ratio of forced expiratory volume in 1 second [FEV1] to forced vital capacity that was less than the lower limit of normal as determined www.jcrpjournal.com

by the National Health and Nutrition Examination Survey III17), completion of at least 18 of 24 scheduled rehabilitation sessions for the PR group, and no medical conditions precluding safe exercise. Pulmonary rehabilitation patients who did not have COPD were excluded. Patients who were active smokers were allowed to enroll if they agreed to participate in smoking cessation. All PR patients were evaluated by a pulmonologist before starting the program. Patients who met inclusion criteria were categorized into the PR group whereas those who met inclusion criteria but chose not to participate in PR were classified as the referral group (Figure 1). Based on VHA electronic medical records for all patients in both groups, health care utilization for the 12 months before and after completion of PR was recorded for the PR group and for the 12 months before and after the date of referral to PR for the referral group. Every VHA hospitalization and emergency department (ED) visit were reviewed and categorized on the basis of the patient’s chief complaint and the provider’s assessment and diagnosis. Respiratory-related visits included encounters due to cough, wheezing, breathlessness, pneumonia, bronchitis, or COPD exacerbation. Only health care encounters occurring within the VHA system were reviewed. All patients entering the Cincinnati VAMC PR Program undergo a comprehensive evaluation before and after PR that includes calculation of the BODE index (Body mass index, airflow Obstruction, Dyspnea, and Exercise capacity)18; the University of California, San Diego Shortness of Breath Questionnaire (UCSDSOBQ)19; the Modified Medical Research Council (MMRC) Dyspnea Scale20-22; St. George’s Respiratory Questionnaire (SGRQ)23; and a 6-minute walk test (6MWT) conducted according to the American Thoracic Society guidelines.24 Using various methods and thresholds, the 6MWT minimal clinically important difference (MCID) has been estimated to be 25 m,25 26 ± 2 m,26 30 m,27 35 m,28 54 m,29 and 86 m.30 Because Holland and colleagues25 and Puhan and coworkers28 used patients with COPD in PR programs as their study populations for the calculation of a 6MWT MCID, we used 25 and 35 m for the 6MWT MCID. The MCID is 4 units for the SGRQ31 and 5 units for the UCSDSOBQ.32,33 A 1-unit change in the BODE index defines a clinically noticeable change.34 Variations of one unit in the MMRC signify a clinically perceivable difference in breathlessness.35 The Pulmonary Disease Knowledge Test is a 20-question test that assesses knowledge of chronic respiratory illness, treatments, and self-management and was developed by the Cincinnati VAMC PR program (see the Appendix). Other measurements were hand grip strength measured with a dynamometer (Lafayette PR Benefits Veterans With COPD / 421

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430 Veterans referred to the Cincinnati VAMC Pulmonary Rehabilitation Program from 2008-2010.

Excluded • 127 completed PR outside the VHA • 55 did not meet PFT criteria for COPD • 17 did not complete screening after referral • 23 did not complete VHA PR • 25 died before entry into VHA PR or before follow up was completed • 13 were medically excluded 4 psychiatric 4 cardiovascular 3 general debility 1 orthopedic 1 genitourinary

170 charts reviewed for healthcare utilization

78 completed PR at the Cincinnati VAMC (PR Group)

92 chose not to participate in PR (Referral Group)

Figure 1. Flow of study participants. Abbreviations: COPD, chronic obstructive pulmonary disease; PFT, pulmonary function testing; PR, pulmonary rehabilitation; VAMC, Veterans Administration Medical Center; VHA, Veterans Health Administration.

Instrument Co, Lafayette, IN), body mass index, body fat percentage measured by electrical impedance (Omron Fat Loss Monitor Omron Healthcare, Inc, Bannockburn, IL), self-reported short-acting betaagonist (SABA) use, and PFT data within 12 months of entering the program. All measurements except for PFTs were performed at enrollment and at completion of PR. The Cincinnati VAMC PR program consists of 24 sessions scheduled 3 times per week for 8 weeks. The exercise sessions last 1 hour and are individualized according to the patient’s baseline condition and goals. The first 40 minutes consist of supervised aerobic exercise on a treadmill, recumbent stepper, or recumbent bike. For the next 20 minutes, patients use an upper extremity ergometer, weight training, or resistance bands based upon the day of the week. A 30-minute education session is held weekly. Topics

include smoking cessation, inhaler technique, disease management, and breathing techniques. After completing PR, patients are encouraged to enroll in maintenance PR or to continue exercising at home or at a local gym. The Cincinnati VAMC PR Program received AACVPR accreditation on September 12, 2011. This study was approved by the Cincinnati VAMC Research and Development Committee and University of Cincinnati institutional review board.

Statistical Analysis Data for continuous variables are presented as mean ± SD. Categorical variables are reported as frequencies or percentages. Inter- and intragroup comparisons were completed using both paired and unpaired t tests for continuous variables and z test for categorical variables. Two-tailed significance was set at P < .05.

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12 smokers, 5 (41.7%) quit during PR, and 7 (58.3%) continued to smoke.

RESULTS Patients We reviewed 430 unique consults for PR at the Cincinnati VA: 78 patients were classified into the PR group and 92 into the referral group (Figure 1). Excluded patients included 127 patients who completed non-VHA PR programs (generally due to the distance from their homes to the Cincinnati VAMC), 55 who did not have airflow limitation/COPD, 17 who were assessed for PR but either did not complete PR screening or did not enter PR, 23 who began but did not complete PR, and 13 patients who were unable to exercise: 4 with unstable cardiac disease, 4 with severe psychiatric disease, 3 with overwhelming generalized debility, 1 with severe musculoskeletal pain, and one who required genitourinary surgery. Two patients died during PR: 1 from pneumonia and the other from glioblastoma multiforme. Twenty-three patients died before entry into PR or before completion of followup. Baseline demographics are presented in Table 1. Nearly all participants were male and this sexual distribution is representative of the general population served by the Cincinnati VAMC. The majority of the patients (56.4%) had an FEV1< 50% predicted. The difference in percent predicted FEV1 between the PR and referral groups was 5.5% (P = .028) and more PR patients had better lung function than referral patients (Table 1). The PR group patients completed 24 ± 2 exercise sessions. In the PR group, 92.3% of patients completed all 24 prescribed sessions and the remainder completed 22 to 23 sessions. Sixty-six patients (84.6%) were not smoking upon entering PR. Of the T a b l e 1 • Patient Demographics and FEV1 Data by Patient Group PR Group a

Age, y

Male, % FEV1, % predicteda

Referral Group P Value .18

65.4 ± 9.0

70.2 ± 2.2




45.0 ± 17.8

39.5 ± 14.5


FEV1, > 80% predicted, %




FEV1, 50%-79% predicted, %




FEV1, 30%-49% predicted, %




FEV1, < 30% predicted, %




Abbreviation: FEV1, forced expiratory volume in 1 second. a Mean ± SD.


Quality of Life, Disease Knowledge, and Exercise Capacity Measures Respiratory health assessments used before and after PR are listed in Table 2. Comparing the use of SABA before and after PR, it decreased by 43% following PR (P < .001). The MMRC, 6MWT, UCSDSOBQ, and SGRQ all improved after PR (P < .001) and the mean change exceeded the MCID for each scale. The majority of patients (55.7%-81.1%) achieved clinically noticeable improvements in each of these measures and the percentages of patients exceeding the MCID for each measure are presented in Table 2. Clinically important improvement in at least 1 univariate scale (MMRC, UCSD SOBQ, SGRQ, and 6MWT using MCID of 25 m) occurred in 94% of PR participants; 82% improved in 2 scales, 59% in 3, and 24% in all 4 tests. Using a 6MWT MCID of 35 m, 94%, 82%, 55%, and 23% of individuals completing PR noted clinically important improvements in 1, 2, 3, or 4 tests, respectively. Although the body mass index did not change, the percentage of body fat declined. Patients’ strength measured by hand grip improved.

Health Care Utilization The PR group had a similar baseline rate of respiratoryrelated (RR) and non-RR health care encounters in the 12 months prior to PR referral compared with the referral-only group (Table 3). During the 12 months of followup, the referral group had more RR ED visits and hospital admissions than the PR group whereas there was no change in non-RR health care encounters (Table 3). Although the percentages of patients experiencing RR ED visits or hospitalizations declined after PR, they were not less than the percentage of patients having RR health care encounters after referral only (Table 4). The percentage of patients who had 2 ≥ RR ED visits per year decreased after PR (20.5% pre-PR, 7.7% post-PR, P = .021) and the percentage of patients who had ≤ 1 RR ED visit per year increased after PR (79.5% pre-PR, 93.3% post-PR; P = .003) (Figure 2). However, the percentage of patients who had ≥ 2 RR hospitalizations per year did not change after PR (9.0% pre-PR, 3.8% post-PR; P = .19) nor did the percentage of patients who had ≤1 RR hospitalizations per year (91.0% pre-PR, 96.2% postPR; P = .19). The percentages of PR patients experiencing different numbers of non-RR health care encounters did not change after PR. In the referral group, there were no differences in the percentages of patients experiencing different levels of RR or nonRR health care encounters before and after referral (Figure 2). PR Benefits Veterans With COPD / 423

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T a b l e 2 • Pulmonary Rehabilitation Group Outcome Measures Pre-PR


P Value

Percent Improving > MCID


SGRQ, units

60.6 ± 15.1

51.1 ± 16.7

Veterans with chronic obstructive pulmonary disease achieve clinically relevant improvements in respiratory health after pulmonary rehabilitation.

To measure respiratory health and respiratory-related (RR) health care utilization in veterans with chronic obstructive pulmonary disease referred to ...
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