Promoting Participation in Pulmonary Rehabilitation after Hospitalization for Chronic Obstructive Pulmonary Disease, Strategies of Top-performing Systems: A Qualitative Study.

Rationale: Pulmonary rehabilitation (PR) after hospitalization for chronic obstructive pulmonary disease (COPD) is recommended by guidelines; however, few patients participate, and rates vary between hospitals. Objectives: To identify contextual factors and strategies that may promote participation in PR after hospitalization for COPD. Methods: Using a positive-deviance approach, we calculated hospital-specific rates of PR after hospitalization for COPD among a cohort of Medicare beneficiaries. At a purposive sample of high-performing and innovative hospitals in the United States, we conducted in-depth interviews with key stakeholders. We defined high-performing hospitals as having a PR rate above the 95th percentile, at least 6.58%. To learn from hospitals that demonstrated a commitment to improving rates of PR, regardless of PR rates after discharge, we identified innovative hospitals on the basis of a review of American Thoracic Society conference research presentations from prior years. Interviews were audio-recorded and transcribed verbatim. Using a directed content analysis approach, transcripts were coded iteratively to identify themes. Results: Interviews were conducted with 38 stakeholders at nine hospitals (seven high-performers and two innovators). Hospitals were diverse regarding size, teaching status, PR program characteristics, and geographic location. Participants included PR medical directors, PR managers, respiratory therapists, inpatient and outpatient providers, and others. We found that high-performing hospitals were broadly focused on improving care for patients with COPD, and several had recently implemented new initiatives to reduce rehospitalizations after admission for COPD in response to the Centers for Medicare and Medicaid Services/Medicare's Hospital Readmission Reduction Program. Innovative and high-performing hospitals had systems in place to identify patients with COPD that enabled them to provide patient education and targeted discharge planning. Strategies took several forms, including the use of a COPD navigator or educator. In addition, we found that high-performing hospitals reported effective interprofessional and patient communication, had clinical champions or external change agents, and received support from hospital leadership. Specific strategies to promote PR included education of referring providers, education of patients to increase awareness of PR and its benefits, and direct assistance in overcoming barriers. Conclusions: Our findings suggest that successful efforts to increase participation in PR may be most effective when part of a larger strategy to improve outcomes for patients with COPD. Further research is necessary to test the generalizability of our findings.

A Geographic Analysis of Racial Disparities in Use of Pulmonary Rehabilitation After Hospitalization for COPD Exacerbation.

BACKGROUND: Guidelines recommend pulmonary rehabilitation (PR) after hospitalization for an exacerbation of COPD, but few patients enroll in PR. We explored whether density of PR programs explained regional variation and racial disparities in receipt of PR. METHODS: We used Centers for Medicare & Medicaid Services data from 223,832 Medicare beneficiaries hospitalized for COPD during 2012 who were eligible for PR postdischarge. We used Hospital-Referral Regions (HRR) as the unit of analysis. For each HRR, we calculated the density of PR programs as a measure of program access and estimated risk-standardized rates of PR within 6 months of discharge overall, and for non-Hispanic, white, and black beneficiaries. We used linear regression to examine the relationship between access to PR and HRR PR rates. We tested for racial disparity in PR rates among non-Hispanic white and black beneficiaries living in the same HRRs. RESULTS: Across 306 HRRs, the median number of PR programs per 1,000 Medicare beneficiaries was 0.06 (interquartile range [IQR], 0.04-0.10). Risk-standardized rates of PR ranged from 0.53% to 6.67% (median, 1.93%). Density of PR programs was positively associated with PR rates overall and among non-Hispanic white beneficiaries (P < .001), but this relationship was not observed among black beneficiaries. Rates were higher among non-Hispanic white beneficiaries (median, 2.08%; IQR, 1.54%-2.87%) compared with black beneficiaries (median, 1.19%; IQR, 1.15%-1.20%). CONCLUSIONS: Greater PR program density was associated with higher rates of PR for non-Hispanic white but not black beneficiaries. Further research is needed to identify reasons for this discrepancy and strategies to increase receipt of PR for black patients.

Participation in Pulmonary Rehabilitation after Hospitalization for Chronic Obstructive Pulmonary Disease among Medicare Beneficiaries.

RATIONALE: Current guidelines recommend pulmonary rehabilitation (PR) after hospitalization for a chronic obstructive pulmonary disease (COPD) exacerbation, but little is known about its adoption or factors associated with participation. OBJECTIVES: To evaluate receipt of PR after a hospitalization for COPD exacerbation among Medicare beneficiaries and identify individual- and hospital-level predictors of PR receipt and adherence. METHODS: We identified individuals hospitalized for COPD during 2012 and recorded receipt, timing, and number of PR visits. We used generalized estimating equation models to identify factors associated with initiation of PR within 6 months of discharge and examined factors associated with number of PR sessions completed. RESULTS: Of 223,832 individuals hospitalized for COPD, 4,225 (1.9%) received PR within 6 months of their index hospitalization, and 6,111 (2.7%) did so within 12 months. Median time from discharge until first PR session was 95 days (interquartile range, 44-190 d), and median number of sessions completed was 16 (interquartile range, 6-25). The strongest factor associated with initiating PR within 6 months was prior home oxygen use (odds ratio [OR], 1.49; 95% confidence interval [CI], 1.39-1.59). Individuals aged 75-84 years and those aged 85 years and older (respectively, OR, 0.70; 95% CI, 0.66-0.75; and OR, 0.25; 95% CI 0.22-0.28), those living over 10 miles from a PR facility (OR, 0.42; 95% CI, 0.39-0.46), and those with lower socioeconomic status (OR, 0.42; 95% CI, 0.38-0.46) were less likely to receive PR. CONCLUSIONS: Two years after Medicare began providing coverage for PR, participation rates after hospitalization were extremely low. This highlights the need for strategies to increase participation.

Integrating the care of the complex COPD patient.

Proceedings of the European Seminars in Respiratory Medicine course, Long-Term Integrated Care of COPD Patients held in Stresa, Italy, on 16-17 June, 2016.

An Official American Thoracic Society/European Respiratory Society Policy Statement: Enhancing Implementation, Use, and Delivery of Pulmonary Rehabilitation.

RATIONALE: Pulmonary rehabilitation (PR) has demonstrated physiological, symptom-reducing, psychosocial, and health economic benefits for patients with chronic respiratory diseases, yet it is underutilized worldwide. Insufficient funding, resources, and reimbursement; lack of healthcare professional, payer, and patient awareness and knowledge; and additional patient-related barriers all contribute to the gap between the knowledge of the science and benefits of PR and the actual delivery of PR services to suitable patients. OBJECTIVES: The objectives of this document are to enhance implementation, use, and delivery of pulmonary rehabilitation to suitable individuals worldwide. METHODS: Members of the American Thoracic Society (ATS) Pulmonary Rehabilitation Assembly and the European Respiratory Society (ERS) Rehabilitation and Chronic Care Group established a Task Force and writing committee to develop a policy statement on PR. The document was modified based on feedback from expert peer reviewers. After cycles of review and revisions, the statement was reviewed and formally approved by the Board of Directors of the ATS and the Science Council and Executive Committee of the ERS. MAIN RESULTS: This document articulates policy recommendations for advancing healthcare professional, payer, and patient awareness and knowledge of PR, increasing patient access to PR, and ensuring quality of PR programs. It also recommends areas of future research to establish evidence to support the development of an updated funding and reimbursement policy regarding PR. CONCLUSIONS: The ATS and ERS commit to undertake actions that will improve access to and delivery of PR services for suitable patients. They call on their members and other health professional societies, payers, patients, and patient advocacy groups to join in this commitment.

Pulmonary Rehabilitation and Physical Activity in Patients with Chronic Obstructive Pulmonary Disease.

Physical inactivity is common in patients with chronic obstructive pulmonary disease (COPD) compared with age-matched healthy individuals or patients with other chronic diseases. Physical inactivity independently predicts poor outcomes across several aspects of this disease, but it is (at least in principle) treatable in patients with COPD. Pulmonary rehabilitation has arguably the greatest positive effect of any current therapy on exercise capacity in COPD; as such, gains in this area should facilitate increases in physical activity. Furthermore, because pulmonary rehabilitation also emphasizes behavior change through collaborative self-management, it may aid in the translation of increased exercise capacity to greater participation in activities involving physical activity. Both increased exercise capacity and adaptive behavior change are necessary to achieve significant and lasting increases in physical activity in patients with COPD. Unfortunately, it is readily assumed that this translation occurs naturally. This concise clinical review will focus on the effects of a comprehensive pulmonary rehabilitation program on physical activity in patients with COPD. Changing physical activity behavior in patients with COPD needs an interdisciplinary approach, bringing together respiratory medicine, rehabilitation sciences, social sciences, and behavioral sciences.

Pulmonary rehabilitation: definition, concept, and history.

Pulmonary rehabilitation is a complex intervention for which it is difficult to craft a succinct yet inclusive definition. Pulmonary rehabilitation should be considered for all patients with chronic obstructive pulmonary disease (COPD) who remain symptomatic or have decreased functional status despite otherwise optimal medical management. The essential components of pulmonary rehabilitation are exercise training and self-management education, tailored to the needs of the individual patient and integrated into the course of the disease trajectory. Emerging data support a role for pulmonary rehabilitation in nontraditional contexts, such as during exacerbation in the non-COPD patient and in the home setting.

Pulmonary rehabilitation: future directions.

Pulmonary rehabilitation is now an established standard of care for patients with chronic obstructive pulmonary disease (COPD). Although pulmonary rehabilitation has no appreciable direct effect on static measurements of lung function, it arguably provides the greatest benefit of any available therapy across multiple outcome areas important to the patient with respiratory disease, including dyspnea, exercise performance, and health-related quality of life. It also appears to be a potent intervention that reduces COPD hospitalizations, especially when given in the periexacerbation period. The role of pulmonary rehabilitation within the larger schema of integrated care represents a fruitful area for further research.

Differences in content and organisational aspects of pulmonary rehabilitation programmes.

The aim was to study the overall content and organisational aspects of pulmonary rehabilitation programmes from a global perspective in order to get an initial appraisal on the degree of heterogeneity worldwide. A 12-question survey on content and organisational aspects was completed by representatives of pulmonary rehabilitation programmes that had previously participated in the European Respiratory Society (ERS) COPD Audit. Moreover, all ERS members affiliated with the ERS Rehabilitation and Chronic Care and/or Physiotherapists Scientific Groups, all members of the American Association of Cardiovascular and Pulmonary Rehabilitation, and all American Thoracic Society Pulmonary Rehabilitation Assembly members were asked to complete the survey via multiple e-mailings. The survey has been completed by representatives of 430 centres from 40 countries. The findings demonstrate large differences among pulmonary rehabilitation programmes across continents for all aspects that were surveyed, including the setting, the case mix of individuals with a chronic respiratory disease, composition of the pulmonary rehabilitation team, completion rates, methods of referral and types of reimbursement. The current findings stress the importance of future development of processes and performance metrics to monitor pulmonary rehabilitation programmes, to be able to start international benchmarking, and to provide recommendations for international standards based on evidence and best practice.

Measuring unsupported arm lifts as an outcome in pulmonary rehabilitation of chronic obstructive pulmonary disease patients.

Pulmonary rehabilitation includes upper and lower extremity exercise training. While validated tests such as the six-minute walk distance (6MWD) and shuttle walk tests are available to evaluate the effectiveness of lower extremity training, the optimal method of evaluating the effectiveness of upper extremity training has not been determined. This study evaluates the potential utility of unsupported arm lifts (UALs) testing as an outcome measurement for pulmonary rehabilitation. Records of chronic obstructive pulmonary disease (COPD) patients who underwent outpatient pulmonary rehabilitation at our institution were reviewed. Outcomes assessed before and immediately after the intervention included 6MWD, the self-administered Chronic Respiratory Questionnaire (CRQ-SA), and UALs. For the latter, the patient repeatedly raises a wooden dowel from thigh to arm level, with the number of repetitions per minute used as the outcome. Changes in variables from pre- to post-pulmonary rehabilitation were analyzed using paired t test. Pearson correlation coefficients were used to evaluate associations. Of the 241 patients, 51% were male. Mean age was 69 ± 9 years, body mass index was 28 ± 7 kg/m(2), and forced expiratory volume in 1 second was 50 ± 20 percent-predicted. All studied variables increased significantly post-pulmonary rehabilitation: the 6MWD by 45 ± 50 m (effect size 0.49), the CRQ-SA total score by 0.84 ± 0.86 units (effect size 0.89), and UAL by 12 ± 13 lifts/minute (effect size 0.75; p < 0.0001 for all). As a measure of upper extremity exercise capacity, UAL appears to be responsive to the comprehensive pulmonary rehabilitation intervention. Using effect sizes, the degree of improvement appears to be between that of 6MWD and CRQ-SA. UAL may be a useful outcome assessment for pulmonary rehabilitation in COPD patients.

Comprehensive pulmonary rehabilitation results in clinically meaningful improvements in anxiety and depression in patients with chronic obstructive pulmonary disease.

PURPOSE: Pulmonary rehabilitation (PR) improves anxiety and depression in patients with chronic obstructive pulmonary disease. However, little is known regarding its ability to produce clinically meaningful improvements in these outcomes. METHODS: We retrospectively analyzed 366 patients who participated in our 8-week outpatient PR program. The Hospital Anxiety and Depression Scale was used to screen for anxiety and depression symptoms (HADA and HADD, respectively); for both, a score of ≥ 10 was considered abnormal, and a change of 1.5 units or greater in magnitude was considered the threshold for a minimal clinically important difference (MCID). Other outcomes included the Chronic Respiratory Disease Questionnaire and the 6-Minute Walk Test. RESULTS: Of the 366 patients, 257 (70%) completed the program and 235 (64%) completed final outcome evaluation. At program entry, 25% had abnormal anxiety scores and 17% had abnormal depression scores; these dropped to 9% and 6%, respectively, in those patients completing outcome analyses (P < .0001). Abnormal HADA and HADD scores predicted noncompletion of the program. Among patients who completed PR, there were significant improvements on all dimensions (increased walk distance, increased quality of life, and reduced symptoms of depression and anxiety). Of the total group, the MCID was exceeded in 41% and 46% for HADA and HADD, respectively. Of those with abnormal anxiety scores at baseline who completed outcome analysis (n = 44), 91% surpassed the MCID, while of those with abnormal depression scores at entry (n = 30), 93% surpassed the MCID. CONCLUSIONS: Pulmonary rehabilitation results in substantial and clinically meaningful changes in both anxiety and depression.

Modifying the course of chronic obstructive pulmonary disease: looking beyond the FEV1.

COPD is defined by airflow limitation that is not fully reversible and is usually progressive. Thus, airflow obstruction (measured as FEV(1)) has traditionally been used as the benchmark defining disease modification with therapy. However, COPD exacerbations and extrapulmonary effects are common and burdensome and generally become more prominent as the disease progresses. Therefore, disease progression should be broader than FEV(1) alone. Interventions that reduce the frequency or severity of exacerbations or ameliorate extrapulmonary effects should also be considered disease modifiers. A narrow focus on FEV(1) will fail to capture all the beneficial effects of therapy on disease modification. Although smoking cessation has been unequivocally demonstrated to slow the rate of FEV(1) decline, inhaled corticosteroid-long-acting bronchodilator therapy may also have modest effects according to post hoc analysis. Maintenance pharmacotherapy with inhaled long-acting anti-muscarinic or ß-adrenergic agents or combined ß-adrenergic--inhaled corticosteroid reduces symptoms, improves lung function, reduces the frequency of exacerbations, and improves exercise capacity and HRQL. Pulmonary rehabilitation reduces symptom burden, increases exercise capacity, improves HRQL, and reduces health care utilization, probably through reducing the severity of exacerbations. Smoking cessation, lung volume reduction surgery, inhaled maintenance pharmacotherapy, and pulmonary rehabilitation administered in the post-exacerbation period may reduce mortality in COPD. These improvements over multiple outcome areas and over relatively long durations suggest that disease modification is indeed possible with existing therapies for COPD. Therefore, therapeutic nihilism in COPD is no longer warranted.

How do we increase activity and participation in our patients?

Patients with chronic respiratory disease such as chronic obstructive pulmonary disease (COPD) are generally very inactive physically, and this physical inactivity is detrimental to their health. Physical inactivity not only impairs quality of life, it probably shortens life expectancy. Therefore, increasing physical activity should be a prominent goal in pulmonary rehabilitation. Physical activity levels correlate better with functional exercise capacity, such as the 6-minute walk distance, than abnormalities on pulmonary function tests. Because functional exercise capacity increases with pulmonary rehabilitation, and other important factors such as motivation and self-efficacy for exercise are also improved, it stands to reason pulmonary rehabilitation should increase activity and participation in extended activities of daily living. Indeed, an emerging medical literature suggests that this is so. We still need to know how effective we are in this area because meaningful changes in some of our outcomes, such as activity counts from motion detectors, have not been established. Pulmonary rehabilitation should incorporate specific interventions to make increased activity and participation specific goals of this comprehensive intervention.

The roles of bronchodilators, supplemental oxygen, and ventilatory assistance in the pulmonary rehabilitation of patients with chronic obstructive pulmonary disease.

In patients with chronic obstructive pulmonary disease, pulmonary rehabilitation significantly improves dyspnea, exercise capacity, quality of life, and health-resource utilization. These benefits result from a combination of education (especially in the promotion of collaborative self-management strategies and physical activity), exercise training, and psychosocial support. Exercise training increases exercise capacity and reduces dyspnea. Positive outcomes from exercise training may be enhanced by 3 interventions that permit the patient to exercise train at a higher intensity: bronchodilators, supplemental oxygen (even for the nonhypoxemic patient), and noninvasive ventilatory support.