The effect of pulmonary rehabilitation on healthcare utilization in chronic obstructive pulmonary disease: The Northeast Pulmonary Rehabilitation Consortium

Although pulmonary rehabilitation results in improvement in multiple outcome areas, relatively few studies in the United States have evaluated its effect on healthcare utilization. This study compared aspects of healthcare utilization during the year before to the year after outpatient pulmonary rehabilitation in patients with chronic obstructive pulmonary disease referred to 11 hospital-based centers in Connecticut and New York. Utilization data from 128 of 132 patients who originally gave informed consent were evaluated; their mean age was 69 years and their forced expiratory volume in 1 second was 44% of predicted. Forty-five percent had 1 or more hospitalizations in the year before beginning pulmonary rehabilitation. In the year after pulmonary rehabilitation, there were 0.25 fewer total hospitalizations (P = .017) and 2.18 fewer hospital days (P = .015) per patient and 271 fewer hospital days for the group. Hospitalizations for respiratory reasons also decreased significantly. Most of the reduction in hospital utilization was due to a decrease in intensive care unit days. The number of physician visits decreased by 2.4 in the year after pulmonary rehabilitation (P < .0001); most of this reduction was due to decreased visits to primary care providers. The estimated costs/charges for the aspects of healthcare utilization that we studied decreased by a mean of 4,694 dollars and a median of 390 dollars (P = .0002). This study suggests that pulmonary rehabilitation leads to a reduction in healthcare utilization.     

The trajectory of change over multiple outcome areas during comprehensive outpatient pulmonary rehabilitation

Although pulmonary rehabilitation has proven effectiveness in multiple outcome areas, the optimum duration of this intervention is not clear. We evaluated in an observational study the trajectory of change in upper and lower extremity exercise performance, exertional dyspnea and health status over the course of 12 weeks (24 sessions) of pulmonary rehabilitation in individuals with chronic obstructive pulmonary disease. Demonstrating a plateau in response in these areas might be of practical use for pulmonary rehabilitation programs. We measured outcomes at baseline and at four-session (two week) intervals over the course of our comprehensive outpatient pulmonary rehabilitation program. These included treadmill endurance time at approximately 85% of initial maximal workrate, the number of arm lifts per minute, dyspnea at isotime during treadmill walking and the Chronic Respiratory Disease Questionnaire (CRQ) total score. Thirteen patients with chronic obstructure pulmonary disease (COPD) (five male, eight female) were studied; their age was 66 +/- 8 years and their FEV1 was 34 +/- 11% of predicted. Improvement was noted in all four outcome areas very early in the course of pulmonary rehabilitation. Treadmill endurance time and arm lifts increased significantly over baseline by the fourth and eighth session, respectively, and both increased in a near-linear fashion throughout pulmonary rehabilitation. Exertional dyspnea and CRQ also improved very early, with each showing a significant change from baseline by the fourth session. Their improvement, however, appeared to plateau relatively early during the course of pulmonary rehabilitation. Although the numbers studied are small and the applicability of these results to other programs is undetermined, this study does suggest that 20 or more sessions are needed for optimal acute changes in exercise performance, but improvement in dyspnea and quality of life may occur earlier.     

High versus low intensity exercise training in pulmonary rehabilitation: is more better?

BACKGROUND: Exercise training is considered a necessary component of comprehensive pulmonary rehabilitation. However, to date, there is no consensus on an exercise training strategy for pulmonary rehabilitation, and this has resulted in varied approaches to this intervention in its literature. As in healthy individuals, the effect of exercise training on patients with chronic lung disease is dose dependent, with higher intensities resulting in greater physiological adaptations than lower intensities. RESULTS: It is not clear from our review of the literature that these enhanced physiological effects from higher levels of exercise training translate into a reduced burden of symptoms, hence a better quality of life. Indeed, there is some evidence that pulmonary rehabilitation approaches incorporating lower intensities of exercise training are at least as good in improving questionnaire rated symptoms of health status. This provides food for thought, since the prominent goal of pulmonary rehabilitation should be to reduce bothersome symptoms or enhance health status, not simply increase endurance time on a cycle ergometer.     

Functional status in pulmonary rehabilitation participants

PURPOSE: This study examined functional status abnormalities in pulmonary rehabilitation patients, its responsiveness to pulmonary rehabilitation intervention, and its relationship to patient characteristics and traditional measures of disease severity. METHODS: One hundred sixty-four men and women age 69 years (SD +/- 8), who participated in 1 of 10 pulmonary rehabilitation programs in Connecticut, were studied pre- and postrehabilitation with the following outcome measures: (1) the 6-minute walk distance, (2) the Pulmonary Functional Status Scale (PFSS), and (3) in a subset of 60 subjects, health-related quality of life was measured using the Chronic Respiratory Disease Questionnaire (CRDQ). Patient characteristics were compared to baseline values of these measures using Spearman correlations and Wilcoxon Rank Sum tests, whereas pre- to post-changes in outcome measures were evaluated using Wilcoxon signed-ranks tests. Effect size, representing a standardized measure of change, was calculated for the PFSS. RESULTS: The mean FEV1 was 0.95 +/- 0.50 liters (38 +/- 18% predicted). Rehabilitation resulted in significant increases in the 6-minute walk distance (24%, P < 0.001, the total PFSS scores [13%, P < 0.001, effect size 1.0]) and the total CRDQ (18% P < 0.001). The prerehabilitation function subscore and total PFSS score correlated strongly with the 6-minute walk distance (r = 0.76, 0.73; P < 0.001) and to a lesser degree with the FEV1 (r = 0.31, 0.33; P < 0.001). Males scored higher baseline scores in several PFSS subscales, the total PFSS score, and the 6-minute walk distance; females showed more improvement in some of the PFSS scores. CONCLUSION: The 6-minute walk distance, the PFSS, and CRDQ all improved significantly with rehabilitation. Functional status, as measured by the PFSS is very strongly correlated with the 6-minute walk. Gender differences in the timed walk distance and functional status highlight the need to study this variable more thoroughly.     

Direct clinician-to-patient feedback discussion of inhaled steroid use: its effect on adherence.

STUDY OBJECTIVES: To evaluate whether direct feedback discussion on inhaled steroid use might influence subsequent adherence with this therapy. DESIGN AND SETTING: A 10-week, single-blind, randomized trial in asthma patients. Inclusion criteria included forced expiratory volume in 1 second <80%, one or more markers for low socioeconomic status, and the use of inhaled steroids. Inhaled steroid and beta-agonist use were electronically monitored. All patients received standard asthma care. The treatment group received direct clinician-to-patient feedback discussion on their inhaled steroid and beta-agonist use on all subsequent visits, whereas this information was withheld during the study period in the control group. MEASURES: 1) Mean weekly inhaled steroid adherence [(number of actuations/prescribed number of actuations) x 100]; 2) number of days with overuse of inhaled steroids; 3) 24-hour and nighttime albuterol use; 4) included forced expiratory volume in 1 second; and 5) Asthma Quality of Life Questionnaire total score. RESULTS: Ten treatment and nine control patients completed the study. Mean weekly inhaled steroid adherence over the first week was not significantly different in the treatment and control groups: 61 +/- 9% versus 51 +/- 5%, respectively. However, by the second week, adherence increased to 81 +/- 7% in the treatment group, whereas it decreased to 47 +/- 7% in the control group (P = 0.003). Adherence remained above 70% in the treatment group for the entire trial, but continued to decrease in the control group. Overuse of inhaled steroids was low in both groups. There were no group differences in any of the asthma outcomes. CONCLUSIONS: Direct clinician-to-patient feedback discussion on inhaled steroid use using electronic printouts did improve adherence in the short-term in asthma patients at high-risk for poor adherence.     

An evaluation of severity-modulated compliance with q.i.d. dosing of inhaled beclomethasone.

Although the asthmatic subject's compliance with a regimen of inhaled corticosteroids is often poor, it has been suggested this may improve during periods of increased severity. To test this, we measured daily peak expiratory flow rates (PEFRs), asthma symptoms, and the use of an albuterol inhaler over nine weeks period in ten patients with moderately severe asthma. The effect of changes in these severity indices on compliance with a q.i.d. regimen of inhaled beclomethasone was evaluated. The PEFR was measured in the morning before bronchodilator administration, and symptoms were graded on a scale of 4 to 16, while albuterol and beclomethasone inhalations were electronically recorded. Three measures of compliance with the beclomethasone regimen were used: (1) mean daily compliance ([number of inhalations/number of prescribed inhalations] x 100); (2) underuse, ie, the percentage of days with less than the prescribed number of inhalations; and (3) overuse, ie, the percentage of days with greater than the prescribed number of inhalations. Mean daily compliance was 67 +/- 36 percent, while underuse was observed in 69 percent and overuse in 11 percent of the days. Despite clinical exacerbations in six of the ten patients and considerable variation in the severity indices, no significant relationship was found between the change in asthma severity and compliance with the beclomethasone regimen. These findings do not support the concept of severity-modulated compliance with inhaled corticosteroids.     

An evaluation of nebulized levalbuterol in stable COPD

BACKGROUND: Levalbuterol, the R-isomer of albuterol, has advantages over racemic albuterol in asthma; however, the effectiveness of this beta-agonist in COPD has received little attention. OBJECTIVES: To evaluate the effectiveness of a single dose of nebulized levalbuterol in COPD. DESIGN: A randomized, double-blind, placebo-controlled trial comparing nebulized levalbuterol to racemic albuterol, combined racemic albuterol and ipratropium, and placebo. PATIENTS: Thirty patients with stable COPD (FEV(1) between 45% and 70% of predicted) were studied. METHODS: After withholding usual bronchodilator medications for appropriate washout periods, patients were randomized on separate visits to receive single doses of each the following nebulized bronchodilator medications: (1) levalbuterol, 1.25 mg; (2) racemic albuterol, 2.5 mg; (3) combined racemic albuterol, 2.5 mg, and ipratropium, 0.5 mg; or (4) placebo. FEV(1), FVC, pulse rate, and oxygen saturation were measured at baseline, 0.5 h following nebulization, and hourly for 6 h. Hand tremor, using a 7-point scale, was measured at baseline, 0.5 h, 1 h, and 2 h. Treatment-placebo differences were analyzed using repeated-measures analysis of variance and least-squares means. RESULTS: The mean age (+/- SD) of patients was 69 +/- 15 years. Mean FEV(1) was 1.15 +/- 0.49 L. By 0.5 h following study drug administration, all three nebulized bronchodilator treatments led to similar, significant improvements in FEV(1) compared to placebo. These effects persisted at 1 h and 2 h for all three treatments; however, by 3 h, only the combined albuterol/ipratropium group had a mean change in FEV(1) significantly greater than placebo. There were no significant differences between bronchodilator groups at any time period. A mild increase in pulse rate was observed in all treatment groups. There were no significant treatment-placebo differences in oxygen saturation or hand tremor. CONCLUSION: For single-dose, as-needed use in COPD, there appears to be no advantage in using levalbuterol over conventional nebulized bronchodilators.     

Functional status and survival following pulmonary rehabilitation

BACKGROUND: Functional exercise capacity has been shown to be a strong predictor of survival following pulmonary rehabilitation. This study evaluated whether questionnaire-rated functional status is also predictive of survival. Patients and methods: Following pulmonary rehabilitation, patients with advanced chronic lung disease were evaluated for survival, 6-min walk distance, and questionnaire-rated functional status. The latter was measured using the pulmonary functional status scale, which has subscores of functional activities, psychological status, and dyspnea. Information on survival was available on 149 patients. RESULTS: The mean age was 69 years, and 45% of patients were male. Eighty-nine percent had a diagnosis of COPD, and their FEV(1) was 37+/-18% of predicted. Ninety-one (61%) were married. The 3-year survival for the group was 85%. Age, gender, body mass index, and primary diagnosis were not related to survival. Variables strongly associated with increased survival following pulmonary rehabilitation included a higher postrehabilitation Functional Activities score, a longer postrehabilitation 6-min walk distance, and being married (vs widowed, single, or divorced). Disease severity variables associated with survival included an initial referral to outpatient pulmonary rehabilitation, no supplemental oxygen requirement, and a higher percent-predicted FEV(1). CONCLUSION: Indicators of functional status are strong predictors of survival in patients with advanced lung disease.     

An official American Thoracic Society workshop report: the Integrated Care of The COPD Patient

The optimal care of the patient with chronic obstructive pulmonary disease (COPD) requires an individualized, patient-centered approach that recognizes and treats all aspects of the disease, addresses the systemic effects and comorbidities, and integrates medical care among healthcare professionals and across healthcare sectors. In many ways the integration of medical care for COPD is still in its infancy, and its implementation will undoubtedly represent a paradigm shift in our thinking. This article summarizes the proceedings of a workshop, The Integrated Care of the COPD Patient, which was funded by the American Thoracic Society. This workshop included participants who were chosen because of their expertise in the area as well as their firsthand experience with disease management models. Our summary describes the concepts of integrated care and chronic disease management, details specific components of disease management as they may apply to the patient with COPD, and provides several innovative examples of COPD disease management programs originating from different healthcare systems. It became clear from the discussions and review of the literature that more high-quality research in this area is vital. It is our hope that the information presented here provides a "call to arms" in this regard.