Kylie Johnston

Assessing Sedentary Behavior with the GENEActiv: Introducing the Sedentary Sphere.

BACKGROUND The Sedentary Sphere is a method for the analysis, identification, and visual presentation of sedentary behaviors from a wrist-worn triaxial accelerometer. PURPOSE This study aimed to introduce the concept of the Sedentary Sphere and to determine the accuracy of posture classification from wrist accelerometer data. METHODS Three samples were used: 1) free living (n = 13, ages 20-60 yr); 2) laboratory based (n = 25, ages 30-65 yr); and 3) hospital inpatients (n = 10, ages 60-90 yr). All participants wore a GENEActiv on their wrist and activPAL on their thigh. The free-living sample wore an additional GENEActiv on the thigh and completed the Multimedia Activity Recall for Children and Adults. The laboratory-based sample wore the monitors while seated at a desk for 7 h, punctuated by 2 min of walking every 20 min. The free-living and inpatient samples wore the monitors for 24 h. Posture was classified from wrist-worn accelerometry using the Sedentary Sphere concept. RESULTS Sitting time did not differ between the wrist GENEActiv and the activPAL in the free-living sample and was correlated in the three samples combined (rho = 0.9, P < 0.001), free-living and inpatient samples (r ≃ 0.8, P < 0.01). Mean intraindividual agreement was 85% ± 7%. In the laboratory-based and inpatient samples, sitting time was underestimated by the wrist GENEActiv by 30 min and 2 h relative to the activPAL, respectively (P < 0.05). Posture classification disagreed during reading while standing, cooking while standing, and brief periods during driving. Posture allocation validity was excellent when the GENEActiv was worn on the thigh, evidenced by the near-perfect agreement with the activPAL (96% ± 3%). CONCLUSIONS The Sedentary Sphere enables determination of the most likely posture from the wrist-worn GENEActiv. Visualizing behaviors on the sphere displays the pattern of wrist movement and positions within that behavior.

Barriers to, and facilitators for, referral to pulmonary rehabilitation in COPD patients from the perspective of Australian general practitioners: a qualitative study

Background: Pulmonary rehabilitation (PR) is recommended in the management of people with chronic obstructive pulmonary disease (COPD), but referral to this service is low. Aims: To identify barriers to, and facilitators for, referral to PR programmes from the perspective of Australian general practitioners. Methods: Semi-structured interviews were conducted with general practitioners involved in the care of people with COPD. Interview questions were informed by a validated behavioural framework and asked about participants’ experience of referring people with COPD for PR, and barriers to, or facilitators of, this behaviour. Interviews were audiotaped, transcribed verbatim, and analysed using content analysis. Results: Twelve general practitioners participated in this study, 10 of whom had never referred a patient to a PR programme. Four major categories relating to barriers to referral were identified: low knowledge of PR for COPD; low knowledge of how to refer; actual or anticipated access difficulties for patients; and questioning the need to do more to promote exercise behaviour change. Awareness of benefit was the only current facilitator. Three major categories of potential facilitators were identified: making PR part of standard COPD care through financial incentive; improving information flow with regard to referrals and services; and informing patients and public. Conclusions: Significant barriers to referral exist, but opportunities to change the organisation of practice and information management were identified. Behaviour change strategies which directly target these barriers and incorporate facilitators should make up the key components of interventions to improve referral to PR by general practitioners who care for people with COPD.

Barriers and enablers to physical activity participation in patients with COPD: a systematic review.

PURPOSE: Physical activity (PA) has been shown to improve symptoms in people with chronic obstructive pulmonary disease (COPD). Despite the high health and financial costs, the uptake of management strategies, particularly participation in PA and pulmonary rehabilitation (PR), are low. The review objective here was to identify potential barriers and enablers, which people with COPD report being associated with their participation in PA programs, including PR. METHODS: A systematic search was undertaken to identify studies (published Jan 2000 to Aug 2011) reporting any barriers and enablers experienced by people with COPD regarding participation in PA and PR. Methodological quality of the studies was appraised using McMaster critical appraisal tools. A narrative summary of findings was undertaken reporting on individual study characteristics, country of origin, participants, and potential barriers and enablers. RESULTS: Eleven studies (8 qualitative and 3 quantitative) met the inclusion criteria for this systematic review. Several methodological issues (small sampling, poor description of data collection and analysis, issues with generalizability of the research findings) were common among included studies. Barriers identified included changing health status, personal issues, lack of support, external factors, ongoing smoking, and program-specific barriers. Enablers identified included social support, professional support, personal drivers, personal benefit, control of condition, specific goals, and program-specific enablers. CONCLUSION: The findings from this review may assist health professionals, patients, care givers and the wider community to develop effective strategies to promote participation in PA and PR among people with COPD.

Pulmonary Rehabilitation: Overwhelming Evidence but Lost in Translation?

PURPOSE This report highlights the current international gap between the availability of high-quality evidence for pulmonary rehabilitation (PR) and its low level of implementation. Key barriers are outlined, and potentially effective strategies to improve implementation are presented. SUMMARY OF KEY POINTS Although pulmonary rehabilitation (PR) is recommended by international guidelines as part of the management of patients with chronic obstructive pulmonary disease (COPD), participation in PR remains low. Physician referral to PR ranges from 3% to 16% of suitable patients. Barriers to participation include limited availability of suitable programmes and interrelated issues of referral and access. Individual patient barriers, including factors relating to comorbidities and exacerbations, perceptions of benefit, and ease of access, contribute less overall to low participation rates. Chronic care programmes that incorporate self-management support have some benefit in patients with COPD. However, the demonstrated cost-effectiveness of PR is substantial, and efforts to improve its implementation are urgently indicated. CONCLUSION To improve implementation, a holistic examination of the key issues influencing a patients participation in PR is needed. Such an examination should consider the relative influences of environmental (e.g., health-service-related) factors, organizational factors (e.g., referral and intake procedures), and individual factors (e.g., patient barriers) for all participants. On the basis of these findings, policy, funding, service delivery, and other interventions to improve participation in PR can be developed and evaluated.

Why are some evidence-based care recommendations in chronic obstructive pulmonary disease better implemented than others? Perspectives of medical practitioners.

Background Clinical guidelines for management of patients with chronic obstructive pulmonary disease (COPD) include recommendations based on high levels of evidence, but gaps exist in their implementation. The aim of this study was to examine the perspectives of medical practitioners regarding implementation of six high-evidence recommendations for the management of people with COPD. Methods Semi-structured interviews were conducted with medical practitioners involved with care of COPD patients in hospital and general practice. Interviews sought medical practitioners’ experience regarding implementation of smoking cessation, influenza vaccination, pulmonary rehabilitation, guideline-based medications, long-term oxygen therapy for hypoxemia and plan and advice for future exacerbations. Interviews were audiotaped, transcribed verbatim and analyzed using content analysis. Results Nine hospital-based medical practitioners and seven general practitioners participated. Four major categories were identified which impacted on implementation of the target recommendations in the care of patients with COPD: (1) role clarity of the medical practitioner; (2) persuasive communication with the patient; (3) complexity of behavioral change required; (4) awareness and support available at multiple levels. For some recommendations, strength in all four categories provided significant enablers supporting implementation. However, with regard to pulmonary rehabilitation and plans and advice for future exacerbations, all identified categories that presented barriers to implementation. Conclusion This study of medical practitioner perspectives has indicated areas where significant barriers to the implementation of key evidence-based recommendations in COPD management persist. Developing strategies to target the identified categories provides an opportunity to achieve greater implementation of those high-evidence recommendations in the care of people with COPD.

Barriers to and enablers of physical activity in patients with COPD following a hospital admission: a qualitative study

Background Chronic obstructive pulmonary disease (COPD) is characterized by a persistent blockage of airflow, prompting episodes of shortness of breath, commonly leading to hospitalization. Hospitalization may lead to a decline in physical activity following discharge. Physical activity has been shown to improve symptoms of COPD and reduce readmissions, and to decrease morbidity and mortality. This study aims to explore, from the perspectives of people with COPD, the barriers to and enablers of participation in physical activity following hospitalization for COPD. Methods This study had a qualitative descriptive design and included semistructured interviews with 28 adult COPD patients who had been admitted to hospital with a primary diagnosis of exacerbation of COPD. Results A plethora of barriers to but fewer enablers of participation in physical activity and pulmonary rehabilitation were identified for this cohort of people. The main barriers identified were health-related (comorbidities, COPD symptoms, and physical injury or illness) environment-related (weather, transport, and finance), and self-related. The main enabling factors reported were access to health professionals and equipment, social support, routine and extracurricular activities, personal goals and motivation, and the effect of physical activity and “feeling better”. Conclusion This research provides a snapshot of the barriers to and enablers of physical activity and pulmonary rehabilitation in people with COPD. It is evident that there are significant barriers which hinder the ability of people with COPD to undertake and continue participation in physical activity and pulmonary rehabilitation. While there are some enablers that may counter these barriers, it is clear that health professionals dealing with people suffering from COPD need to actively recognize and address barriers to physical activity and pulmonary rehabilitation. Hospital admission may create an opportunity for implementation of interventions promoting physical activity (such as referral to pulmonary rehabilitation), which may assist in reducing hospital readmission, as well as decreasing morbidity and mortality.

Australian and New Zealand Pulmonary Rehabilitation Guidelines

The aim of the Pulmonary Rehabilitation Guidelines (Guidelines) is to provide evidence‐based recommendations for the practice of pulmonary rehabilitation (PR) specific to Australian and New Zealand healthcare contexts.

Relationship between pre‐discharge occupational therapy home assessment and prevalence of post‐discharge falls

RATIONALE, AIMS AND OBJECTIVE Pre-discharge occupational therapy home assessments are common practice, and considered important for falls prevention in older people. This prospective, observational cohort study describes the association between pre-discharge home assessment and falls in the first month post-discharge from a rehabilitation hospital. METHODS 342 inpatients were recruited and followed up 1 month post-discharge. Patients were classified into diagnostic groups (cardiac, orthopaedic trauma, spinal, peripheral joint surgery, neurological and deconditioned). Age, gender, falls risk [Falls Risk Assessment Scoring System (FRASS)], functional independence scores (FIM™) and receipt (or not) of a home assessment were recorded. Patients completed a diary to document post-discharge falls. Logistic regression analysis tested the effect on falling of receiving a home assessment, age, gender, diagnostic group, FRASS and FIM™. RESULTS Considering all subjects, not receiving a home assessment increased the risk of falling 1 month post-discharge [odds ratio (OR) 2.6, 95% confidence interval (CI) 1.4-4.7, P=0.003]. Neurological and orthopaedic trauma patients had significantly elevated risks of falling [OR (95% CI), respectively, 12.5 (4.7-33.2), 3.4 (1.4-8.4)] relative to the orthopaedic joint group. For all diagnostic groups except neurological, falls risk was mitigated by a home assessment. In non-neurological patients, adjusting for the effect of diagnostic group, FRASS and FIM™ scores indicated a significant association between not receiving a home assessment and falling (OR 4.2, 95% CI 2.1-8.2, P<0.001). CONCLUSIONS Pre-discharge occupational therapy home assessments are sound post-discharge falls-prevention strategies in non-neurological patients. The decision to conduct a home assessment should consider diagnosis, falls risk and functional independence.

Perspectives on use of personal alarms by older fallers

Background: Personal alarms are proposed as a reliable mechanism for older people to obtain assistance after falling. However, little is known about how older people feel about owning and using personal alarms. Aim: This paper reports on experiences of independently living older people, who have recently fallen, regarding alarm use and their independence. Method: Volunteers older than 65 years who had sustained a fall in the previous six months were sought via community invitations. Semistructured telephone interviews were conducted to gain information about their fall and their perspectives on personal alarm use. Interviews were content-analyzed to identify key concepts and themes. Results: Thirty-one interviews were conducted. Twenty callers owned personal alarms. Four subgroups of older fallers were identified; the first group used personal alarms effectively and were advocates for their benefits, the second group owned an alarm but did not use it effectively, the third group did not own alarms mostly because of cost, although were receptive to an alarm should one be provided, and the fourth group did not have an alarm and would not use it even if it was provided. Discussion: Personal alarms produce positive experiences when used effectively by the right people. The cost of personal alarms prohibits some older fallers from being effective alarm users. However, other elderly fallers remain unwilling to consider alarm use even if one was provided. In view of their cost, personal alarms should be targeted to people who will benefit most. Alternative strategies should be considered when alarms are unlikely to be used appropriately.

Which chronic obstructive pulmonary disease care recommendations have low implementation and why? A pilot study

BackgroundClinical care components for people with COPD are recommended in guidelines if high-level evidence exists. However, there are gaps in their implementation, and factors which act as barriers or facilitators to their uptake are not well described. The aim of this pilot study was to explore implementation of key high-evidence COPD guideline recommendations in patients admitted to hospital with a disease exacerbation, to inform the development of a larger observational study.MethodsThis study recruited consecutive COPD patients admitted to a tertiary hospital. Patient demographic, disease and admission characteristics were recorded. Information about implementation of target guideline recommendations (smoking cessation, pulmonary rehabilitation referral, influenza vaccination, medication use and long-term oxygen use if hypoxaemic) was gained from medical records and patient interviews. Interviews with hospital-based doctors examined their perspectives on recommendation implementation.ResultsFifteen patients (aged 76(9) years, FEV1%pred 58(15), mean(SD)) and nine doctors participated. Referral to pulmonary rehabilitation (5/15 patients) was underutilised by comparison with other high-evidence recommendations. Low awareness of pulmonary rehabilitation was a key barrier for patients and doctors. Other barriers for patients were access difficulties, low perceived health benefits, and co-morbidities. Doctors reported they tended to refer patients with severe disease and frequent hospital attendance, a finding supported by the quantitative data.ConclusionsThis study provides justification for a larger observational study to test the hypothesis that pulmonary rehabilitation referral is low in suitable COPD patients, and closer investigation of the reasons for this evidence-practice gap.