Improving access to community-based pulmonary rehabilitation: 3R protocol for real-world settings with cost-benefit analysis

Abstract

Background Pulmonary rehabilitation (PR) has demonstrated patients’ physiological and psychosocial improvements, symptoms reduction and health-economic benefits whilst enhances the ability of the whole family to adjust to illness. However, PR remains highly inaccessible due to lack of awareness of its benefits, poor referral and availability mostly in hospitals. Novel models of PR delivery are needed to enhance its implementation while maintaining cost-efficiency. We aim to implement an innovative community-based PR programme and assess its cost-benefit. Methods A 12-week community-based PR will be implemented in primary healthcare centres where programmes are not available. Healthcare professionals will be trained. 73 patients with CRD and their caregivers (dyads patient-caregivers) will compose the experimental group. The control group will include dyads age- and disease-matched willing to collaborate in data collection but not in PR. Patients/family-centred outcomes will be dyspnoea (modified Medical Research Council Questionnaire), fatigue (Checklist of individual strength and Functional assessment of chronic illness therapy – fatigue), cough and sputum (Leicester cough questionnaire and Cough and sputum assessment questionnaire), impact of the disease (COPD Assessment Test), emotional state (The Hospital Anxiety and Depression Scale), number of exacerbations, healthcare utilisation, health-related quality of life and family adaptability/cohesion (Family Adaptation and Cohesion Scale). Other clinical outcomes will be peripheral (biceps and quadriceps-hand held dynamometer, 1 or 10 repetition-maximum) and respiratory (maximal inspiratory and expiratory pressures) muscle strength, muscle thickness and cross sectional area (biceps brachialis, rectus femoris and diaphragm-ultrasound imaging), exercise capacity (six-minute walk test and one-minute sit to stand test), balance (brief-balance evaluation systems test) and physical activity (accelerometer). Data will be collected at baseline, at 12 weeks, at 3- and 6-months post-PR. Changes in the outcome measures will be compared between groups, after multivariate adjustment for possible confounders, and effect sizes will be calculated. A cost-benefit analysis will be conducted. Discussion This study will enhance patients access to PR, by training healthcare professionals in the local primary healthcare centres to conduct such programmes and actively involving caregivers. The cost-benefit analysis of this intervention will provide an evidence-based insight into the economic benefit of community-based PR in chronic respiratory diseases. Trial registration The trial was registered in the ClinicalTrials.gov U.S. National Library of Medicine, on 10th January, 2019 (registration number: NCT03799666 ). Electronic supplementary material The online version of this article (10.1186/s12889-019-7045-1) contai...

<p>Minimal Clinically Important Differences for Patient-Reported Outcome Measures of Cough and Sputum in Patients with COPD</p>

“…66 Exacerbations were managed as follows: patients were referred to their clinician, who adjusted their pharmacological therapy, and were instructed to follow the symptoms management strategies taught during educational sessions of PR (energy conservation techniques, postures to relieve dyspnoea and active cycle of breathing techniques). 34 As soon as the contagious risk was controlled and patients felt capable they were encouraged to return to PR (around 7 to 15 days). 67 When patients re-integrated the PR programme the training load was readjusted to their physical condition.…”

“…Since MCIDs are influenced by disease severity, 19,20,47 we recommend interpreting PROMs changes within the MCIDs ranges provided by the different methods and not limiting it to the absolute proposed value. Finally, this study is integrated in a larger trial, 34 therefore, a specific sample size calculation to establish MCIDs was not performed, which might have underpowered this study for its goal. Nevertheless, similar samples sizes have been used to establish MCIDs in other studies, 40,68,69 and the fact that all MCIDs fell within the recommended range of 6 to 10% change in the scale range, which corresponded to a desirable effect size of 0.2 to 0.5, 19,38,48 strengthens the validity of our estimates.…”

Construct validity of the brief physical activity assessment tool for clinical use in COPD

“…This is a secondary analysis of the baseline data of participants with COPD from three research projects on COPD management (SFRH/BD/81328/2011, NCT02122614 ; SAICT‐POL/23926/2016; NCT03799666) 20,21 and PA promotion in COPD (POCI‐01‐0145‐FEDER‐028446) conducted between 2013 and 2019. Ethical approval was obtained from the institutions collaborating in the projects.…”

“…They were instructed to use the accelerometers for at least four consecutive days during their usual activities and asked to report if any activity different from their routine was performed during that period. Participants were included if they had ≥4 days with ≥8 hours of wearing time/day in the accelerometer, 27 as defined in the main projects from where this study was derived 20,21 . An average of the daily time spent in moderate‐intensity PA (1952‐5724 counts‐per‐minute[CPM]), vigorous‐intensity PA (5725‐∞CPM) and a combination of moderate‐to‐vigorous intensity PA (MVPA, 1952‐∞CPM) was calculated using the algorithms incorporated in the software 28 .…”

Pulmonary Rehabilitation: Time for an Upgrade

“…In addition to these policies which largely depend on governments and funding bodies, new research has been recently conducted to increase delivery and uptake of pulmonary rehabilitation. For instance, Marques and colleagues [ 8 ] have designed a real-world non-randomised controlled study, where they plan to engage primary healthcare centres where programmes are not available, by training healthcare professionals in the basics components of PR. This programme has the benefit of bringing PR closer to the community of the patients, thus reducing commuting times to hospital, and therefore improving both access and adherence.…”