ABSTRACT
BackgroundThe uptake of face-to-face supervised outpatient-based pulmonary rehabilitation (PR) following hospitalisation for an acute exacerbation of COPD (AECOPD) is low. One commonly cited barrier is travel. Home-based PR may be an alternative setting. The aim of this study was to determine whether a co-designed home-based exercise training intervention, delivered alongside usual hospital at home (HaH) care post-hospitalisation for an AECOPD, is acceptable and feasible.MethodsA mixed method feasibility study was conducted including a parallel, two-group randomised controlled trial (RCT) (control group: usual HaH care;intervention group: usual care plus home-based exercise training) with convergent qualitative components (interviews: patients, family carers, researchers;focus groups: healthcare professionals [HCPs]).Results16/132 patients screened were recruited to the RCT with 8 allocated to each group and one withdrawn prior to receiving HaH care (56% were male, mean [SD] age: 74 [9] years, median [IQR] FEV1: 29 [21, 40] percent predicted, 87% with an eMRC dyspnoea score of 4, 5a or 5b). Four vs eight and four vs seven attended four week and three-month follow-up assessments in the control and intervention groups respectively. There was no evidence of contamination in the control group. 25% of patients allocated to the intervention group were unable to receive the intervention due to Covid-19. The questionnaire-based outcomes were more complete and appeared more acceptable to patients than physical measures, with very poor uptake for physical activity monitoring via accelerometery. Qualitative findings (interviews: five patients, two family carers, four researchers;focus groups: PR and HaH service HCPs) demonstrated that trial and intervention processes were acceptable, clinically beneficial and safe, but did not explain the disparity between questionnaire-based vs physical outcome measure completion rates.ConclusionThe findings suggest an efficacy trial which investigates home-based exercise training integrated within a HaH service following hospitalisation for an AECOPD would be safe and acceptable to patients, family carers, HCPs and researchers alike, and is qualitatively felt to be of clinical benefit. However, additional piloting is required to optimise intervention fidelity and study processes given the low recruitment rates, high drop out of the control group and poor uptake of some physical assessments.
ABSTRACT
Background: Infection control precautions arising from the COVID-19 pandemic has led to challenges undertaking face-to-face exercise testing required for pulmonary rehabilitation (PR) exercise prescription and evaluation.1 Self-management programmes, incorporating physical activity, have been advocated as an alternative to PR when face-to-face assessment is not possible.1 Daily step count is the most commonly used physical activity outcome and does not require face-to-face assessment. We aimed to estimate the minimal clinically important difference (MCID) for daily pedometer step count in COPD, using response to PR as a model of improvement and longitudinal decline following PR as a model of deterioration. Methods: This was a secondary analysis of a trial that investigated the effectiveness of pedometer-directed step count targets in COPD as an adjunct to PR, with the study arms combined as the intervention did not result in significant between-group differences.2 We measured spirometry, Medical Research Council score, incremental shuttle walk test, Chronic Respiratory Questionnaire and pedometer step count (Yamax Digiwalker CW700) pre-, post- and six months following PR. Post-PR and six months post-PR, participants completed a Global Rating of Change Questionnaire: 'How do you feel your physical activity levels have changed following rehabilitation?' and rated the response on a five-point Likert scale ( '1: I feel much more active' to '5: I feel much less active'). The MCID for improvement was defined as the median for '2: I feel a little more active' at the post-PR assessment. The MCID for deterioration was the median for '4: I feel a little less active' at the six-month assessment (compared to post-PR). Results: 152 participants enrolled in PR;80% and 70% attended the post-PR and six month assessments respectively. Baseline characteristics and change with PR and over time are (Table presented) in table 1. There were significant improvements in daily pedometer step count following PR and reductions at six months. The median (25th, 75th centile) MCID estimate for improvement and deterioration in daily pedometer step count was 427 (-443, 1286) and -456 (-2271, 650) steps respectively. Conclusion: The MCID estimates for improvement with PR and deterioration over time after PR are 427 and -456 steps respectively.