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ORIGINAL ARTICLE
Short outpatient pulmonary rehabilitation programme reduces readmission following a hospitalization for an exacerbation of chronic obstructive pulmonary disease OLIVIA REVITT,1 LOUISE SEWELL1, MICHAEL D.L. MORGAN1, MICHAEL STEINER1 AND SALLY SINGH1,2 1
Pulmonary Rehabilitation Research Group, Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester, and 2 Faculty of Health and Life Sciences, Coventry University, Coventry, UK
ABSTRACT Background and objective: The benefits of pulmonary rehabilitation (PR) are now firmly established. However, less is known about the provision and efficacy of PR immediately after an acute exacerbation of chronic obstructive pulmonary disease (COPD). The study aimed to explore the effectiveness of a short outpatient PR programme and the impact upon readmission rates. Methods: One hundred sixty (87 males) patients, mean (SD) age 70.35 (8.59) years, forced expiratory volume in 1 s 0.99 (0.44) litres were assessed for a 7-week PR programme following a hospital admission for an acute exacerbation of COPD. Patients were assessed and commenced PR within 4 weeks of discharge from hospital. Outcome measures included: Incremental Shuttle Walking Test (ISWT), Endurance Shuttle Walk Test (ESWT), Chronic Respiratory Questionnaire Self-Reported (CRQ-SR). Patients were assessed at baseline and at 7 weeks (after the 4-week supervised and 3-week unsupervised components). Readmission data were collected retrospectively for the 12 months pre and post admission (n = 155). Results: Statistically significant improvements were found in the ISWT, ESWT and CRQ-SR at discharge (P < 0.05). The number of admission was significantly less in the 12-month post-pulmonary rehabilitation compared to the previous 12 months. Conclusions: A short course of PR showed improvements in exercise capacity and health status in patients who have had an acute exacerbation of COPD. The number of readmissions was also significantly lower in the year following PR. Key words: chronic obstructive pulmonary disease, disease exacerbation, rehabilitation.
Correspondence: Olivia Revitt, Pulmonary Rehabilitation Research Group, Glenfield Hospital, University Hospitals of Leicester NHS Trust, Groby Road, Leicester LE3 9QP, UK. Email:
[email protected] Received 18 May 2012; invited to revise 20 August 2012, 10 January 2013, 3 March 2013; revised 17 November 2012, 6 February 2013, 12 March 2013; accepted 15 March 2013 (Associate Editor: Neil Eves). © 2013 University Hospital of Leicester NHS Trust Respirology © 2013 Asian Pacific Society of Respirology
SUMMARY AT A GLANCE This is the largest cohort of post-acute exacerbation rehabilitation to date. Statistically significant improvements were found in exercise capacity and health-related quality of life. The number of hospital readmissions reduced significantly in the 12 months following PR.
Abbreviations: COPD, chronic obstructive pulmonary disease; CRQ-SR, Chronic Respiratory Questionnaire Self-Reported; ESWT, Endurance Shuttle Walk Test; ISWT, Incremental Shuttle Walking Test; PR, pulmonary rehabilitation.
INTRODUCTION Chronic obstructive pulmonary disease (COPD) is a major cause of morbidity and a leading cause of death worldwide with an estimated prevalence of 6–7%.1 Patients with COPD experience a range of symptoms including dyspnoea, fatigue, increased disability and frequent hospitalizations.2 Patients who experience acute exacerbations account for 70% of COPD-related costs due to emergency visits and hospitalizations.3 Exacerbations have serious implications for patients, which include a reduction in health-related quality of life and functional independence.4,5 Mortality rates during hospitalization are approximately 10% and during the following year, it is estimated to be up to 40%.6 Readmission rates also present a significant problem. Garcia-Aymerich et al.7 observed a 63% readmission of patients during a mean follow-up of 1.1 years with physical inactivity levels being highlighted as a significant predictor of readmission. It has also been found that patients who have lower levels of physical activity (20 min/day or less) are also at a greater risk of readmission and shorter survival that those with higher activity levels.7 There is a large body of evidence to support the use of pulmonary rehabilitation (PR) in patients with stable disease with an increase in exercise performRespirology (2013) 18, 1063–1068 doi: 10.1111/resp.12141
1064 ance and health status.8 In light of these benefits, there is rationale for implementing PR in patients who have recently been hospitalized with an acute exacerbation of their COPD. The impact of hospitalizations on physical activity and strength levels of patients with COPD has been described by Pitta et al.5 who concluded that physical activity levels were decreased during and after the period of hospitalization, and readmission rates appeared higher in those who were unable to recover physical activity. Pulmonary rehabilitation delivered following an exacerbation may therefore present a timely opportunity to address the consequences of declining physical activity rates in this patient population. Post-exacerbation PR was explored by Man and colleagues in 2004.9 They conducted a randomized controlled trial that investigated the effect of a twice weekly 8-week supervised programme of PR that started within 10 days of discharge compared to usual care. They reported significant improvements in exercise performance and a significantly lower rate of visits to accident and emergency departments in the intervention group compared to usual care at 3 months. However, the study was small with only 16 patients in the early PR group and 18 in the usual care group. A more recent randomized controlled trial by Seymour et al.10 went on to explore whether PR would reduce subsequent hospital admissions over a 3-month period. This study was adequately powered to detect a 50% reduction in hospital admissions and compared 30 patients randomized to PR initiated within a week of hospital discharge and 30 patients to usual care. The authors reported that 33% (n = 10) of patients in the usual care group required a hospital admission and 7% (n = 2) of those in the PR group in the follow-up period. Significant improvements were also found in exercise capacity and health-related quality of life measures in those patients who attended the PR. Importantly, a recent Cochrane review11 of nine trials of post-exacerbation PR has concluded it is a safe and effective treatment that is likely to lead to a reduced risk of future admissions and leads to clinically important benefits in exercise capacity and health-related quality of life. However, they also warn that all the trial studies included relatively small numbers of participants, and also highlight the challenging nature of conducting trials in post-exacerbation PR; and in light of previous documented benefits, it may be deemed unethical to withhold PR in future large randomized trials of postexacerbation PR. Therefore, this study aimed to address two questions. Firstly, is it feasible to deliver post-exacerbation PR in a routine clinical PR service? Secondly, what impact this PR programme would have on exercise performance, health-related quality of life and numbers of hospital admissions in a large cohort?
METHODS Institutional ethical approval was sought but it was determined that formal ethical approval was not required but approval was granted to use patients’ Respirology (2013) 18, 1063–1068
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records for the study. All patients completed an informed written consent form to allow their pulmonary rehabilitation data to be collected and used for audit purposes. Data were collected from patients who attended an outpatient PR assessment at Glenfield Hospital, Leicester, UK from November 2006 to October 2008. All patients had been referred following an admission for an acute exacerbation of COPD (AECOPD).
Participants One hundred and sixty patients with a confirmed diagnosis of COPD were referred following an admission. Patients were excluded if they had significant musculoskeletal problems that prevented them from walking, unstable cardiac disease (such as uncontrolled angina, recent MI, uncontrolled hypertension) or cognitive or neurological deficits that would impede the patient’s ability to take part in the PR class. Procedure Referrals were received from the respiratory specialist nurses, who work in the Respiratory Early Discharge Service, members of the multidisciplinary team such as Physiotherapists, Occupational Therapists and Respiratory Physicians. Patients were individually assessed within 4 weeks of discharge from hospital by a member of the PR team and completed standard outcome measures. Pulmonary rehabilitation Patients attended twice weekly for 4 weeks. Patients continued with a 3-week structured unsupervised home exercise programme.12 Outcome measures were repeated at 7 weeks. Each session lasted for 2 h with 1 h of supervised exercise training and 1 h of education. The supervised exercise component of the programme comprised of aerobic training, including walking and static bike which was completed at each supervised session, and resistance training which was completed at one supervised session per week. The aerobic walking programme was individualized with patients walking at approximately 85% or predicted peak VO2 intensity, which was derived from the Incremental Shuttle Walking Test (ISWT) at their initial assessment. Patients completed an exercise diary and were advised to perform daily walks at home. Progression was achieved through maintaining the walking speed and increasing the duration of walking. Resistance training comprised of three sets of eight repetitions of upper and lower limb exercises (bicep curls, pull ups, sit to stand and step ups), which were completed with dumbbells. Patients were instructed to complete three sessions of resistance training per week, and one of these sessions took place in the supervised session. The load was increased when patient’s scores were 13 or below on the BORG perceived exertion score.13 The education component was delivered in a group setting following the exercise session. Topics included © 2013 University Hospital of Leicester NHS Trust Respirology © 2013 Asian Pacific Society of Respirology
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disease education, managing breathlessness, drugs and medication, relaxation, chest clearance and energy conservation. Following completion of the supervised exercise component, patients were provided with a 3-week structured home exercise programme, which followed on from the supervised component. Patients were instructed to continue their daily walks at the set speed and progress the time for aerobic training and continue the three-times-a-week resistance training programme as taught in the class. Patients attended a discharge appointment where the outcome measures were repeated at 7 weeks.
Outcome measures The ISWT was used to measure maximal exercise capacity.14 All patients completed a practice test. The Endurance Shuttle Walk Test (ESWT),15 which measures sub-maximal exercise capacity, was then completed. Patients walked at a constant speed of 85% intensity of their predicted peak oxygen consumption (VO2), which was derived from their ISWT. The Chronic Respiratory Questionnaire SelfReported (CRQ-SR)16 was used to measure health status (copyright permission sought). Previous studies have shown that the CRQ-SR is sensitive to change following a course of PR.16
Table 1 Baseline characteristics of all patients assessed for pulmonary rehabilitation n = 160
Mean (SD)
Male: female Age (years) FEV1 (litres) ISWT (metres) ESWT (s) MRC (median) BMI
87: 73 70.35 (8.59) 0.99 (0.44) 157.50 (116.51) 149.61 (114.85) 4 25.72 (5.66)
BMI, body mass index; ESWT, Endurance Shuttle Walk Test; ISWT, Incremental Shuttle Walking Test; FEV1, forced expiratory volume in 1 s; MRC, Medical Research Council dyspnoea scale.
Assessed for Pulmonary Rehabilitation (n = 160)
Non-completers RIP prior to programme commencing (n = 1)
Readmission data The data were collected on an intention to treat basis. Computerized admission records to University Hospitals of Leicester NHS Trust were reviewed by Olivia Revitt. The total number of hospital days and number of hospital admissions to respiratory and medical wards were recorded for each subject for the period relating to 12 months immediately before commencement of post-exacerbation PR and 12 months post-completion of post-exacerbation PR. Statistical methods Data were stored and analysed in SPSS version 18.00 (IBM Corp., Armonk, NY, USA). Data were checked for normality prior to analysis. A paired sample t-test was performed on all outcome measures to analyse within group differences. Data relating to hospital admission was not normally distributed. These data are presented as median interquartile range (IQR) and were analysed by negative binomial regression.
Dropout (n = 24) AECOPD (n = 14) Non-COPD-related illness (n = 2) Attended assessment but not starting the programme (n = 1)
Completed programme but unable to attend discharge assessment (n = 18)
Completed programme and attended discharge (n = 100)
Figure 1 Flow of participants from referral to discharge from hospital.
RESULTS One hundred and sixty patients were assessed for PR, and their baseline characteristics are outlined in Table 1. Of these 160 patients, 118 completed the 4-week programme, but 18 were unable to attend the discharge assessment at 7 weeks. Therefore, 100 patients completed the programme, and their results were analysed through a paired sample t-test. The non-completion rate for the programme was 26%. The reasons for non-completers are identified in © 2013 University Hospital of Leicester NHS Trust Respirology © 2013 Asian Pacific Society of Respirology
Figure 1. Patients who completed the programme (n = 100) baseline characteristics are shown in Table 2.
Exercise performance Patients made statistically significant improvements in exercise performance on both the ISWT and ESWT at discharge. Patients walked a mean (standard deviaRespirology (2013) 18, 1063–1068
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Table 2 Baseline characteristics for patients who completed the Pulmonary Rehabilitation programme
Male : female Age (years) FEV1 (litres) ISWT (metres) ESWT (s)* MRC (median) BMI
Mean (SD) Completers (n = 100)
Mean (SD) Non-completers (n = 42)
51:49 70.72 (8.92) 1.01 (0.46) 175.50 (122.39) 168.20 (120.98) 4 25.99 (5.83)
24:18 69.90 (8.71) 0.95 (0.37) 141.82 (100.92) 119.23 (93.94) 4 25.37 (4.57)
BMI, body mass index; ESWT, Endurance Shuttle Walk Test; ISWT, Incremental Shuttle Walking Test; FEV1, forced expiratory volume in 1 s; MRC, Medical Research Council dyspnoea scale. *P = 0.04.
Table 3 Mean changes for patients who completed the pulmonary rehabilitation n = 100 ISWT (metres) ESWT (s) CRQ-SR Dyspnoea CRQ-SR Fatigue CRQ-SR Emotion CRQ-SR Mastery
Mean change (95% CI) 63.40 (51.99 to 75.41)*** 400.42 (330.49 to 470.34)*** 0.65 (0.37 to 0.94)*** 0.94 (0.65 to 1.24)*** 0.83 (0.56 to 1.10)*** 0.94 (0.63 to 1.26)***
CRQ-SR, Chronic Respiratory Questionnaire Self-Reported; ESWT, Endurance Shuttle Walk Test; ISWT, Incremental Shuttle Walking Test. ***P < 0.0001 *P < 0.001.
tion (SD)) of 63.40 metres (58.92) further following their course of PR exceeding the minimal clinically important difference for the ISWT.17 Results for the ESWT also demonstrated statistically significant improvements with a mean change of 400.42 s (350.59) following PR (Table 3) again exceeding the minimal clinically important difference.18
Health status All domains of the CRQ-SR exceeded the minimal clinically important difference of 0.5 with the fatigue and mastery domain showing the greatest improvement with a mean change of 0.94 (1.29) and (1.37), respectively. Results for all domains were statistically significant at discharge (see Table 3). Readmission data Data were collected on 155 patients. There was a median number of hospital admissions 12 months prior to PR of 1.00 (IQR 1) compared to the median number of admissions in the 12 months post PR of 0.00 (IQR 1) (see Fig. 2). The incidence rate ratio = 0.623 (95% CI: 0.462–0.840) (P = 0.002). This means there is a 37.7% reduction in incidence of Respirology (2013) 18, 1063–1068
Figure 2 Number of hospital admissions pre- and postpulmonary rehabilitation.
admissions in year post PR compared to the year prior to PR. Contrastingly, binomial regression analysis did not reveal any significant difference when the total number of hospital days in the year post PR were compared to the total number of hospital days year prior to PR, incidence rate ratio = 0.836 (95% CI: 0.661–1.058) (P = 0.136). It appears that patients encountered a longer duration of stay per admission for the 12 months post PR.
DISCUSSION This study explored whether it was feasible to deliver post-exacerbation PR within a routine PR clinical service and also examined the effects upon exercise performance and health status and hospital admission data. There were no adverse events throughout the supervised short PR programme in a large cohort of patients who have had a recent AECOPD, and the intensity of exercise was well tolerated by patients. In addition, both exercise performance and health status improved following completion of the programme, and we were able to report a reduction in hospital admissions. It would therefore appear that a short course of supervised PR programme is an effective, safe and feasible intervention. Our data were prospectively collected as part of the delivery of our clinical pulmonary rehabilitation service rather than as part of a randomized controlled trial. We are therefore unable to assess the affect of natural recovery after an AECOPD. However, notable previous randomized controlled trials (9 and 10) did not document any natural recovery in their control group. In fact, these patients deteriorated. Puhan19 compared PR within 2 weeks of an exacerbation of COPD to a programme commencing 6 months post exacerbation. No significant differences were found. This suggests that natural recovery may not significantly contribute to the positive effects on exercise tolerance and health status demonstrated in our study, but this possibility cannot not wholly excluded. © 2013 University Hospital of Leicester NHS Trust Respirology © 2013 Asian Pacific Society of Respirology
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Baseline measurements and improvements in exercise performance were similar to those reported by previous studies. In comparison to the study by Seymour et al.10 who conducted their baseline measures within 72 h of hospital discharge, there were some similarities in the baseline ISWT. Our baseline ISWT measured within 4 weeks of hospital discharge was 157.50 metres, and Seymour et al.10 reported 165 and 147 metres for the usual care and PR group, respectively. This suggests that natural recovery of exercise tolerance does not occur within the first month following discharge from hospital. Seymour et al.10 went on to report a mean improvement of 51 metres in the early rehabilitation group, and similarly, we show a mean increase of 63 metres which exceeded the minimal clinically important difference of 48 metres. All domains of the CRQ-SR exceeded the minimal clinically important difference and were statistically significant at discharge. Our baseline scores for all domains of the CRQ-SR are comparable to those reported by Sewell et al.12 The improvements gained over the programme were not as substantial as Sewell et al.12 because although the programme structure was similar, a comparison between results is problematic due to our study reporting on unstable patients. It is accepted that a number of patients who commenced the short PR programme failed to complete it. One hundred eighteen patients attended all of the supervised PR sessions, and this equates to a completion rate of 73.8%. Man et al.9 reported a completion rate of 76.2% for intervention group, and a similar rate of 76.6% was reported by Seymour et al.10 Our completion rate is marginally less than these studies, but this probably reflects the fact that this was based upon all patients attending a clinical service rather than patients who have elected to be part of a research trial. The most commonly cited reason for non-completion in our study was that patients experienced a further exacerbation of their COPD. It is perhaps unsurprising that this will be a more significant problem in this unstable patient group, and strategies should be in place to facilitate completion of the short PR programme once the patients are fit enough to return to PR, and so rolling PR programmes may address this difficulty. Notably, our data also suggest that clinically important improvements can be obtained after a 7-week PR programme consisting of 4 weeks of supervised PR followed by a 3-week, unsupervised exercise programme. Our results were similar to those reported by Sewell et al.12 who reported a mean change of 56.9 metres in the ISWT from baseline to the 4-week time point in a stable population who completed a PR programme of identical format and duration. Furthermore, the ESWT improvements in this present study exceeded those reported by Sewell et al.12 at 7 weeks who recorded a change of 223 s, and we now report a mean improvement of 400 s. Importantly and in addition to improvements in exercise performance and health-related quality of life, we have demonstrated a reduction in the number of hospital admissions in the 12 months post PR by a third. Hospitals utilization data for COPD admissions © 2013 University Hospital of Leicester NHS Trust Respirology © 2013 Asian Pacific Society of Respirology
in relation to our study were collected retrospectively, and we accept certain limitations with this strategy. The computerized hospital admission database was reviewed and admissions to respiratory admissions unit and respiratory wards included. Examination of individual sets of medical notes would have reduced the possibility of misclassification of admissions, but this is not practically possible. It is also accepted that admissions to other hospitals were not recorded. Other causes such as community matrons, general practitioner reviews and the use of stand by antibiotics were not monitored. Therefore, the contribution to the decrease in admission in the 12 months post of these factors is unknown. In summary, this study has shown that exercise performance and health status both improve following a short course of PR offered within 4 weeks of hospital discharge post-acute exacerbation. The improvements demonstrated in this study show that exercise and health status can also be improved in a relatively short time which may be a more cost effective use of resources. Moreover, we have shown that it is possible to implement the findings of these previous RCTs into a clinical PR service, rather than solely in the context of a research trial. The programme was feasible, well tolerated by patients and can be delivered as a pragmatic PR service. This study was also able to demonstrate a reduction in the number of hospital admissions. The implications of these results are that PR should be considered as an important treatment option for patients who have had an AECOPD requiring an admission to hospital.
Acknowledgements The authors would like to thank Dr Neil Greening (University Hospitals of Leicester NHS Trust) for his statistical advice in relation to the analysis of hospital utilization data. The research was supported by the National Institute for Health Research (NIHR) Collaborations for Leadership in Applied Health Research and Care based at the University Hospitals of Leicester NHS Trust. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health. Permission to use the CRQ-SR was granted by the University Hospitals of Leicester NHS Trust, Leicester, UK and McMaster University, Hamilton, Ontario, Canada, which jointly hold the copyright.
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