Jane Z. Reardon

Variables related to increased mortality following out-patient pulmonary rehabilitation.

Although patients with advanced pulmonary diseases have significant improvement in exercise ability and functional status following comprehensive out-patient pulmonary rehabilitation (OPR), their long-term prognosis once they have reached this stage of their diseases remains poor. To further evaluate predictors of increased mortality in these patients, we related patient characteristics and short-term outcome obtained during OPR assessment of 158 patients to subsequent survival. The time period from OPR to death or collection of survival data was 40.0 +/- 17.1 months. The following variables were tested individually and in stepwise fashion using a proportional hazards model: 1) age; 2) gender; 3) pulmonary diagnosis; 4) prebronchodilator forced expiratory volume in one second (FEV1); 5) arterial oxygen tension (Pa,O2) and arterial carbon dioxide tension (Pa,CO2); 6) body mass index (BMI); 7) pre- and post-OPR 12 min walking distance (12-MW); 8) pre- and post-OPR quality of life, using the Chronic Respiratory Disease Questionnaire (CRDQ); 9) number and type of nonpulmonary diagnoses; and 10) number of medications. Separate survival analyses were performed for all deaths (the total group), respiratory deaths only (nonrespiratory deaths excluded), and nonrespiratory deaths only (respiratory deaths excluded). Forty three patients (27%) died during the study period; and the 3 year survival was 80%. For all three survival analyses, the post-OPR 12-MW was the most significant variable related to prognosis: patients with low timed walking distance had increased mortality both from respiratory and nonrespiratory causes. Other variables related to increased mortality included: elevated Pa,CO2; low pre-OPR 12-MW; reduced Pa,O2; low FEV1; low BMI, increased number of medications, and increased CRDQ dyspnoea. These results indicate that the timed walking distance following out-patient pulmonary rehabilitation is an important predictor of survival in patients with advanced pulmonary disease.

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.

Improvement in Quality of Life Is Unrelated to Improvement in Excercise Endurance After Outpatient Pulmonary Rehabilitation

Improvement in exercise endurance and quality of life have been demonstrated after comprehensive pulmonary rehabilitation. It is unclear, however, whether improvement in these two areas is related. To evaluate this, the authors compared changes in 12-minute walking distance with changes in quality of life in 44 patients completing a 6-week outpatient pulmonary rehabilitation program. Quality of life was measured with the Chronic Respiratory Disease Questionnarie, a self-report tool that assesses dyspnea, fatigue, emotional function, and disease mastery. After completing an outpatient pulmonary rehabilitation program, substatial improvement was found in the 12-minute walking distance and all four dimensions of the quality of life score. Despite these gains, there was no significant relationship found between change in the 12-minute walking distance and change in the quality of life score or any of its dimensions. This suggests that improvement in quality of life does not necessarily depend on improvement in exercise endurance, and both outcome measures should be used to evaluate the effectiveness of outpatient pulmonary rehabilitation programs.

Clinical Competency Guidelines for Pulmonary Rehabilitation Professionals: American Association Of Cardiovascular And Pulmonary Rehabilitation Position Statement

The article provides an outline of clinical competencies recommended for personnel providing comprehensive services in pulmonary rehabilitation (PR), complementing the American Association of Cardiovascular and Pulmonary Rehabilitation Guidelines for Pulmonary Rehabilitation Programs. Individuals wishing to provide PR services should possess a common core of professional and clinical competencies regardless of their academic discipline.

COPD and Exercise: What's Really Important? A Nursing Perspective

Numerous studies demonstrate the importance of exercise training to improve endurance in patients with chronic obstructive pulmonary disease (COPD) and its positive effect on activities of daily living and quality of life. However, successful care of the individual with COPD also relies on recognizing that this person requires individualized care and non-pharmacologic modalities specific to their needs in order to cope with the various aspects of their disease. It is also important to note that improvement in quality of life is not necessarily related to improvement in exercise endurance alone. Comprehensive and effective pulmonary rehabilitation for the COPD patient needs to encompass several components to provide benefit for the spectrum of symptoms of COPD beyond exercise tolerance and dyspnea to ultimately improve quality of life.

Improving COPD Care in a Medically Underserved Primary Care Clinic: A Qualitative Study of Patient Perspectives

Abstract We conducted a focus group study in an urban hospital-based primary care teaching clinic serving an indigent and Hispanic (predominantly Puerto Rican) population in New England in order to learn how patients with Chronic Obstructive Lung Disease (COPD) perceive their disease, how they experience their medical care, and the barriers they face managing their disease and following medical recommendations. The research team included medical doctors, nurses, a medical anthropologist, a clinical pharmacist, a hospital interpreter, and a systems analyst. Four focus groups were conducted in Spanish and English in April and May 2014. The demographic characteristics of the 25 focus group participants closely reflected the demographics of the total COPD clinic patients. The participants were predominantly female (72%) and Hispanic (72%) and had a median age of 63. The major themes expressed in the focus groups included: problems living with COPD; coping with complexities of comorbid illnesses; challenges of quitting smoking and maintaining cessation; dealing with second-hand smoke; beliefs and myths about quitting smoking; difficulty paying for and obtaining medications; positive experiences obtaining and managing medications; difficulties in using sleep machines at home; expressions of disappointment with the departure of their doctors; and overall satisfaction with the clinic health care providers. The study led to the creation of an action plan that addresses the concerns expressed by the focus study participants. The action plan is spearheaded by a designated bilingual and bicultural nurse and is now in operation.