Introduction - Chartered Society of Physiotherapy



Introduction

This document outlines suggestions for the delivery of pulmonary rehabilitation (PR) for people with chronic obstructive pulmonary disease (COPD). This paper was produced by the Steering Group of the Physiotherapy Works project on COPD (see appendix one for Steering Group members), with a specific focus on pulmonary rehabilitation (PR) for COPD.

At the start of the project, Imperial College London (ICL) were commissioned to undertake a systematic review of PR with respect to its effect on exacerbation rates, both community and hospital managed1. The expectation was that we would be able to evidence a cost saving from PR for COPD through reduction of exacerbation rates and healthcare utilisation, which could be used within an economic model. This expected cost saving was shown in the randomised controlled trials (see appendix two for list of RCTs with summary results), but was less evident in the cohort studies, and was not seen in a Clinical Practice Research Data (CPRD) analysis also undertaken (by Dr Jenni Quint, ICL). The recent Healthcare Quality Improvement Partnership commissioned the Royal College of Physicians (RCP)/ British Thoracic Society (BTS) national PR audit2 which demonstrated that participating programmes had wide variation in outcomes.

The COPD economic model that has been developed is based primarily on results from RCT data on COPD patients undertaking PR, to illustrate the potential benefits of a PR service on COPD exacerbation rates and healthcare utilisation. RCTs frequently represent a ‘standardised world’ in which as many sources of variability as possible are accounted for, and they generally use inclusion and exclusion criteria that result in the recruitment of a more homogeneous sample of people, with fewer (or less severe) co-morbidities than occur within the wider population. In trials, patients receive additional attention and may be actively encouraged to participate and complete PR programmes more than in routine clinical settings. This means that RCT outcomes cannot always be replicated outside the trial setting. They do provide useful insights, however, into areas that could be addressed to improve service outcomes. These insights have been used to develop the COPD model and to inform the recommendations within this paper. The COPD model can be downloaded from the Physiotherapy Works pages on the CSP website, at:

Purpose and target audience

These recommendations are aimed at local decision makers and physiotherapy and other staff involved in funding or delivering PR services. The Steering Group has developed them to enable physiotherapists and others to maximise the number of eligible COPD patients undergoing PR and to optimise patient outcomes. The recommendations have been informed primarily by the RCTs upon which the new economic model is based, as well as existing national guidelines3 and quality standards4.

Recommendations

1. Service delivery

1. Services should be delivered in accordance with the BTS Quality Standards for PR4.

2. Provision should be made to ensure there are adequate resources to enable services to provide PR to the BTS Quality Standards and these recommendations3.

3. The PR rehabilitation team should be supported by administration and clerical input, to avoid inefficiencies in staff work schedules.

4. A physiotherapist needs to be integral to the PR rehabilitation team. Physiotherapists are uniquely qualified to individually prescribe and progress the training regimen, and to teach appropriate breathing techniques to enable exercise in those with altered lung pathology and/ or respiratory mechanics. This is particularly important in the complex breathless patient and for those with co-morbidities requiring exercise modification.

5. Physiotherapists should ensure that comprehensive assessments are performed at baseline and upon completion of the PR programme. This should include validated measures of exercise capacity (including measures of strength), health status and dyspnoea, and should include practice walks for field walking tests3, 5, 6.

6. The ‘home exercise’ regimen is an important component of an individual’s PR programme. Adherence to both the ‘face-to-face’ programme and the home programme should be supported.

7. PR programmes should have Standard Operating Procedures for PR. These could be created locally or shared among multiple providers, for example, within a region.

2. Referrals and uptake

Poor referral and uptake greatly affect the efficiency of any PR programme, as highlighted in the recent RCP/BTS Audit2. Referral issues need to be addressed by a) encouraging local referrers to refer all MRC grade 3-5 COPD patients to a PR programme, plus MRC grade 2 patients if they are experiencing functional limitation due to their COPD, and b) ensuring the referral process is as simple as possible for the referrer. Uptake issues can be addressed: by PR services triaging patients for eligibility (referring on, or back, ineligible patients, with constructive suggestions on the appropriate healthcare pathway for that individual); by actively encouraging all those eligible to attend PR; and by identifying barriers to uptake, then seeking local solutions to any barriers identified.

1. Referrers and potential participants all need to be made aware of the value and benefits of PR for COPD1,3.

2. The referral process needs to be as simple as possible.

3. Consideration needs to be given to increasing access to PR and uptake through improved referral pathways and effective triage.

4. There should be a clear and integrated pathway to recruit patients to PR programmes, including those patients post hospitalisation for an acute exacerbation of COPD3,4.

5. Methods for improving referral and uptake should be tested within local populations and evaluated for effectiveness.

3. Drop-outs

Recent BTS/RCP audit data show a variation in drop-out rates across PR programmes2. Drop-outs can occur at various time points: from initial referral to PR baseline assessment, from baseline assessment to first PR attendance, or at any time during the PR programme. Drop-outs at each of these time-points will have different causes and solutions. Understanding and addressing the reasons for drop-out rates within each local service should help towards reducing drop-outs and ultimately improving PR completion rates and outcomes.

3.1 All PR services should conduct internal audit and evaluation to assess drop-out rates at each time-point and consider methods to reduce drop-outs.

4. Measuring and evaluating your service

1. All PR services should contribute to BTS audits.

2. All PR services should carry out local service evaluation to assess clinical and service outcomes 3,4,5.

3. All PR services should ensure continuing quality improvement is built into this process

Links

We recommend that you make use of the following reports, guidance and standards in establishing or developing a PR service.

|Description/ |Hyperlink |

|Organisation | |

|BTS Audit | |

|BTS PR Guidelines and Quality |

|Standards |ne/ |

|Department of Health (DH) | |

|commissioning toolkits | |

|European Respiratory Society (ERS)|Increasing implementation and delivery of pulmonary rehabilitation: key messages from the new |

| |ATS/ERS policy statement |

|ERS/ATS |An official European Respiratory Society/ American Thoracic Society technical standard: field |

|Exercise Tests Technical Standards|walking tests in chronic |

| |respiratory disease |

|Inspire | |

References

1. Moore E et al. Pulmonary rehabilitation as a mechanism to reduce hospitalisations for acute exacerbations of chronic obstructive pulmonary disease: A systematic review and meta-analysis. London; Chest; 2016

2. Steiner M, Holzhauer-Barrie J, Lowe D et al. Pulmonary Rehabilitation: Steps to breathe better. London; RCP & BTS; 2015

3. Steiner M, Holzhauer-Barrie J, Lowe D et al. Pulmonary Rehabilitation: Time to breathe better. London: RCP, November 2015.British Thoracic Society. Guidelines for Pulmonary Rehabilitation in Adults. London; Thorax; September 2013

4. British Thoracic Society. Quality Standards for Pulmonary Rehabilitation in Adults. London; BTS; 2014

5. Holland A, Spruit M, Troosters T, et al. An official European Respiratory Society/American Thoracic Society technical standard: field walking tests in chronic respiratory disease

6. Department of Health (DH) commissioning toolkits

Appendix One Steering Group

Name Representation

Julia Bott Chair

Anne Bruton Educator, Deputy Chair

Noel Baxter Commissioner

Maria Buxton England

Alison Coe England

Judith Colligan Scotland

Ian Culligan ACPRC

Jamie Forrester Deputy England

Rhi Kendrick Deputy Wales

Heather McKee British Lung Foundation

Angela Mooney Northern Ireland

Jane Mullins Wales

Marianne Milligan Co-opted - expertise

Brenda O’Neill Deputy Northern Ireland

Jo Pentland Deputy Scotland

Kat Savage Steward

Sally Singh British Thoracic Society

Michael Soljak Imperial College London (Lead Investigator)

Bowen Su Imperial College London (Research Assistant)

Jenni Quint Imperial College London

Kirsten Bradbury CSP, Assistant Director Physiotherapy Works

Kate Bennett CSP, Project Manager (until August 2016)

Carley King CSP, Professional Advisor (from August 2016)

Appendix Two - Systematic Review

Pulmonary rehabilitation as a mechanism to reduce hospitalizations for acute exacerbations of chronic obstructive pulmonary disease: A systematic review and meta-analysis (for full report see )

Summary: Eighteen studies were included in the systematic review. Results from ten RCTs showed that control groups had a higher overall rate of hospitalisations than pulmonary rehabilitation groups (0.97 hospitalisations/patient-year, 95% Confidence Intervals (CIs) 0.67, 1.40 for control; 0.62 hospitalisations/patient-year, 95% CI 0.33, 1.16 for pulmonary rehabilitation). Five studies compared admission numbers in the 12 months before and after rehabilitation, reporting a significantly higher admission rate before (1.24 hospitalisations/patient-year, 95% CIs 0.66, 2.34) compared to after rehabilitation (0.47 hospitalisations/patient-year, 95% CIs 0.28, 0.79). The pooled result of three cohort studies found the reference group had a lower admission rate compared to the pulmonary rehabilitation group (0.18 hospitalisations/patient-year, 95% CI 0.11, 0.32 for reference group versus 0.28 hospitalisations/patient-year, 95% CI 0.25, 0.32 for pulmonary rehabilitation).

Studies included in the Systematic Review

Behnke M, Jorres RA, Kirsten D, Magnussen H. Clinical benefits of a combined hospital and home-based exercise programme over 18 months in patients with severe COPD. Monaldi Archives for Chest Disease - Pulmonary Series. 2003;59(1):44-51.

Boxall AM, Barclay L, Sayers A, Caplan GA. Managing chronic obstructive pulmonary disease in the community. A randomized controlled trial of home-based pulmonary rehabilitation for elderly housebound patients. Journal of cardiopulmonary rehabilitation. 2005;25(6):378-385.

Cecins N, Geelhoed E, Jenkins SC. Reduction in hospitalisation following pulmonary rehabilitation in patients with COPD. Australian Health Review. 2008;32(3):415-422.

Eaton T, Young P, Fergusson W, et al. Does early pulmonary rehabilitation reduce acute health-care utilization in COPD patients admitted with an exacerbation? A randomized controlled study. Respirology. 2009;14(2):230-238.

Foglio K, Bianchi L, Bruletti G, Battista L, Pagani M, Ambrosino N. Long-term effectiveness of pulmonary rehabilitation in patients with chronic airway obstruction. European Respiratory Journal. 1999;13(1):125-132.

Golmohammadi K, Jacobs P, Sin DD. Economic evaluation of a community-based pulmonary rehabilitation program for chronic obstructive pulmonary disease. Lung. 2004;182(3):187-196.

Guell R, Casan P, Belda J, et al. Long-term effects of outpatient rehabilitation of COPD: A randomized trial. Chest. 2000;117(4):976-983.

Hui KP, Hewitt AB. A simple pulmonary rehabilitation program improves health outcomes and reduces hospital utilization in patients with COPD. Chest. 2003;124(1):94-97.

Ko FW, Dai DL, Ngai J, et al. Effect of early pulmonary rehabilitation on health care utilization and health status in patients hospitalized with acute exacerbations of COPD. Respirology. 2011;16(4):617-624.

Sudo E, Tanuma S, Haraguchi N, et al. A case of chronic obstructive pulmonary disease (COPD) followed by pulmonary rehabilitation. [Japanese]. Nippon Ronen Igakkai zasshi. 2002; Japanese journal of geriatrics. 39(4):439-443.

Liu XD JH, Ng BHP, Gu YH, Wu YC, Lu G. Therapeutic effects of qigong in patients with COPD: a randomized controlled trial. Hong Kong J Occup Ther. 2012;22(1):8.

Major S, Moreno M, Shelton J, Panos RJ. Veterans with chronic obstructive pulmonary disease achieve clinically relevant improvements in respiratory health after pulmonary rehabilitation. Journal of Cardiopulmonary Rehabilitation & Prevention. 2014;34(6):420-429.

Man WD, Polkey MI, Donaldson N, Gray BJ, Moxham J. Community pulmonary rehabilitation after hospitalisation for acute exacerbations of chronic obstructive pulmonary disease: randomised controlled study. BMJ. 2004;329(7476):1209.

Murphy N, Bell C, Costello RW. Extending a home from hospital care programme for COPD exacerbations to include pulmonary rehabilitation. Respiratory Medicine. 2005;99(10):1297-1302.

Nguyen HQ, Harrington A, Liu ILA, Lee JS, Gould MK. Impact of pulmonary rehabilitation on hospitalisations for chronic obstructive pulmonary disease among members of an integrated health care system. Journal of Cardiopulmonary Rehabilitation and Prevention. 2015;35(5):356-366.

Rasekaba TM, Williams E, Hsu-Hage B. Can a chronic disease management pulmonary rehabilitation program for COPD reduce acute rural hospital utilization? Chronic Respiratory Disease. 2009;6(3):157-163.

Revitt O, Sewell L, Morgan MDL, Steiner M, Singh S. Short outpatient pulmonary rehabilitation programme reduces readmission following a hospitalization for an exacerbation of chronic obstructive pulmonary disease. Respirology. 2013;18(7):1063-1068.

Roman M, Larraz C, Gomez A, et al. Efficacy of pulmonary rehabilitation in patients with moderate chronic obstructive pulmonary disease: a randomized controlled trial. BMC family practice. 2013;14:21.

Rubi M, Renom F, Ramis F, et al. Effectiveness of Pulmonary Rehabilitation in Reducing Health Resources Use in Chronic Obstructive Pulmonary Disease. Archives of Physical Medicine and Rehabilitation. 2010;91(3):364-368.

Scherer YK, Schmieder LE. Pulmonary rehabilitation: is it cost effective? The Journal of the New York State Nurses' Association. 1998;29(3-4):16-20.

Seymour JM, Moore L, Jolley CJ, et al. Outpatient pulmonary rehabilitation following acute exacerbations of COPD. Thorax. 2010;65(5):423-428.

Wright RW, Larsen DF, Monie RG, Aldred RA. Benefits of a community-hospital pulmonary rehabilitation program. Respiratory Care. 1983;28(11):1474-1479.

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