Pulmonary rehabilitation for patients with chronic ... - IOS Press

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Physiotherapy Practice and Research 36 (2015) 115–119 DOI 10.3233/PPR-150058 IOS Press

Pulmonary rehabilitation for patients with chronic obstructive pulmonary disease: An audit of referral and uptake C. Condona,∗ , E. Moloneyb , S. Laneb and E. Stokesa a Discipline

of Physiotherapy, Trinity Centre for Health Sciences, Trinity College Dublin, Dublin, Ireland of Respiratory Medicine, Tallaght Hospital, Dublin, Ireland

b Department

Abstract. BACKGROUND: Successful pulmonary rehabilitation (PR) for chronic obstructive pulmonary disease (COPD) is dependent on timely and appropriate referral by health professionals, as well as adequate uptake and completion rates by patients. METHODS: A retrospective medical record audit was conducted on 183 in-patients, 133 day-cases and 532 respiratory outpatients (representing 50% of respiratory OPD clinics) in two academic teaching hospitals in Dublin. The audit period covered from 1st October to 31st December 2012. The audit tool was informed by the British Thoracic Society’s audit tool. The inclusion/ exclusion criteria of the Health Service Executive (HSE) Model of Care for Pulmonary Rehabilitation, was applied, in addition to a record of the patient being referred for PR assessment. The aim was to identify referral, uptake and PR completion rates over the 3-month period. RESULTS: From 183 confirmed COPD cases, 98 (54%) people met the HSE Model of Care criteria for PR, while 39 (21%) were not functionally limited by the disease. 23 (12%) were considered not suitable for PR. Approximately half (n = 50) of the eligible population were referred for PR assessment. However, after six months, only 7 people had completed a programme. CONCLUSIONS: The results of this audit confirm similar work in that referral to PR was adequate but timely uptake by patients remains poor. Low uptake has implications for the effectiveness of PR at reducing mortality rates and hospital readmission rates. Keywords: Pulmonary rehabilitation, referral rate, completion, audit, efficiency

1. Introduction There is considerable evidence that pulmonary rehabilitation (PR) is an effective intervention for people with chronic obstructive pulmonary disease (COPD) suffering from reduced exercise tolerance and dyspnoea [1, 2]. International studies suggest that PR programmes are currently available for less than 2% of the COPD population [3]. However, a combina∗ Corresponding

author: Cillin Condon, Discipline of Physiotherapy, Trinity Centre for Health Sciences, Trinity College Dublin, James Street, Dublin 8, Ireland. Tel.: +353 1 8962123; Fax: +353 1 4531915; E-mail: [email protected].

tion of low referral rates by health professionals and high dropout rates by patients have also been reported [4–6]. The success of rehabilitation can be measured in reduced hospital re-admissions and COPD related mortality rates [1]. Low referral and completion rates contribute to reduced effectiveness of PR programmes. A recent Cochrane review concluded that to reduce COPD related mortality in one person, using PR, six people would need to undergo PR (NNT = 6) and to reduce hospital re-admissions within 3 months of discharge, the number needed to undergo PR is four (NNT = 4) [7]. For any exercise or education programme to have a meaningful impact on the health

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of a population, a sufficient number of people need to be referred and use the services optimally to justify the inputs and gain any health improvements [8]. NICE (UK) has a target of 230 (0.23%) per 100,000 of people with COPD being referred for PR [9]. There are approximately 180,000 people in Ireland with moderate to severe COPD disease [10], indicating 414 people annually should be referred. Over recent years, PR has been developed in Ireland and rolled out as part of the Health Service Executive (HSE) National Clinical Programmes. Approximately 87% of acute hospital and 22% of community services have access to PR [11]. In general there are long waiting lists for programmes, which can be due to pressure from numbers and logistical issues, i.e. staffing, venue, transport etc. Given the demands of the current service, it is worth determining how many people with COPD could benefit from PR. To address this, a retrospective chart audit was conducted to assess the possible population that could be referred for PR. 1.1. Objectives of chart audit 1. To estimate the hospital based population that meet the criteria for PR. 2. To record the percentage of eligible persons who are referred for PR assessment. 3. To record the uptake and completion rates of PR.

2. Method Medical records from two academic teaching hospitals in Dublin from 1st October to 31st December 2012 were examined. Each site has a dedicated respiratory medicine department, with established PR and COPD outreach. Charts were selected based on National Hospital In-Patient codes (HIPE) indicating a diagnosis of COPD, (ICD-10 J440-J449). The total estimated sample frame, after duplicate visits were removed, was 848 (183 in-patients, 133 day-cases and 532 respiratory outpatients representing 50% of respiratory OPD clinics). An audit tool was developed informed by the British Thoracic Society (BTS) Audit [12]. The inclusion/exclusion criteria of the HSE Model of Care for Pulmonary Rehabilitation [1], was applied, in addition to a record of the patient being referred for PR assessment during the audit time frame.

HSE Inclusion Criteria

HSE Exclusion Criteria

• Confirmed diagnosis of respiratory disease

• Uncontrolled cardiovascular conditions limiting participation in an exercise programme • Significant orthopaedic or neurological conditions that reduce mobility or cooperation with physical training

• Functionally limited by dyspnoea despite optimal therapy • Able to travel to venue • Motivated to participate and change lifestyle • Ability to exercise independently without supervision

With confidence level of 95% and 5% margin of error, the proportion of the population assumed to fit the criteria for rehabilitation was set at 65%. This proportion was calculated using data from Sohanpal and others [13–16]. After consultation with a medical statistician, a minimum sample of 262 charts was selected for the audit. Due to the potential for inaccuracies in the HIPE database, a larger sample of 368 was selected. People who were referred to COPD Outreach and/or the respiratory assessment unit (RAU) were recorded as being referred for consideration for PR as this is integrated into the assessment. Descriptive analysis of those referred and attending for PR are presented. 2.1. Ethics Ethical approval and data protection requirements were agreed with the hospital sites, in accordance with local hospital policy. The audit was conducted by CC who was granted access to medical records. No personal identifiable data was collected during the audit and only anonymised data was used for analysis. All audit data was securely stored and as per normal data protection guidelines. 3. Results Prior to conducting the chart audit, a review of 638 electronic patient records (EPR) was conducted on the hospitals electronic patient databases, to determine if the subject was suitable for chart audit. The remaining 210 people were outpatients and no recent relevant details were available on the electronic database. From the EPR, 303 people (47%) had exclusion criteria (138 had another respiratory disease, i.e., asthma TB, infection, 34 current cancer treatment, 14 recent


Table 1 Characteristics of COPD cohort

Age (yrs.) (n = 183) Weight (kg) (n = 89) FEV1 (L/min) (n = 101) FEV1 /FVC (n = 83) COPD Stage (n = 77) Hospital Admissions in past year (n = 174)

Median

Range

68.0 71 59 58 3 2

43–93 44–117

cardiovascular event, 12 orthopaedic/rheumatology condition, 9 cognitive impairment, 6 neurological condition, 19 other reason including social or addiction problems, 5 deceased). In total, 281 charts were reviewed while 87 charts were not available (patients were in-patients or charts were filed elsewhere). Of these, 183 (64%) of people had a written confirmed diagnosis of COPD. There were 12 (4%) unconfirmed COPD diagnoses and 92 (33%) with another respiratory condition (i.e. asthma, sarcoidosis, pulmonary fibrosis etc.) Table 1 presents the characteristics of the COPD cohort. Figure 1 illustrates that 98 (54%) of the confirmed COPD cohort people met the criteria for PR, with a further 39 (21%) people presenting with COPD who were not functionally limited. There were 23 cases (12%) that could not be determined from the medical records while a further 26 (12%) were considered not suitable for PR (current cancer treatment 3, palliative care 5, cognitive impairment 5, orthopedic/rheumatology impairment 2, recent stroke 1, nursing home resident 1, others 9). A total of 20 in-patients or day-cases were referred directly to PR with the remainder from outpatients. Forty patients referred to COPD Outreach or similar units were inpatients/day-case patients and 19 were attending outpatients. People who were referred to COPD outreach or a respiratory assessment unit (RAU) (n = 37) and those who were referred directly for PR (n = 28) were grouped together (n = 50 excluding duplicate referrals). However, the PR completion rate across both sites by June 2013 was low with only 7 people completing a programme (16 sessions) with a further 2 people completing at least 9 sessions (>50% of sessions). 4. Discussion Despite difficulties with patients engaging with rehabilitation, there appears to be reasonable referral

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rates (52%) for PR assessment but there is still scope for improving these rates. It is possible that waiting lists to start PR are one reason for delayed or non-referral but others have suggested low referral rates may due lack of knowledge about the benefit of PR by health professionals and patients [17]. However, after six months, from the audit period, only 7 (7%) people had completed a PR programme after referral while another 7 (7%) people completed part of a programme. This compares poorly with an uptake rate of 20% and a completion rate of 15% in one UK site [6]. It should be noted however, that across both sites, 114 patients started PR within the 12-months (May 12–Jun 13) with 69 completing a programme in this time. This again may reflect the difficulty in getting patients to engage with rehabilitation shortly after referral or after hospitalisation. Nationally (Jan–Dec 2012), 620 people completed a PR programme meeting the NNT to reduce COPD mortality by 50 people per year [18]. However the average time between referral and commencing PR programme is unknown. Early pulmonary rehabilitation following hospitalisation has been suggested to reduce readmission rates [19, 20]. Given the recommendation that PR is offered within 2–4 weeks of an exacerbation, the low number of people starting within even 1-2 months of hospital attendance is of concern. Although this audit is reflective of a 3-month period only, the low uptake rate would have little impact on readmission rates (NNT = 4) or 2-year mortality (NNT = 6). Early and frequent promotion of PR should be done while a patient is in hospital so that is seen as advantageous to patients to be referred to such programmes [21]. One study has highlighted the importance of how pulmonary rehabilitation is introduced and offered to patients as key determinate of starting such programmes [22] while others have noted the role of the nurse specialist in promoting enrolment [23]. Other authors have suggested that patients own expectations and beliefs about PR can predict uptake and completion rates [24]. Another factor that might explain the low uptake is the location of PR within acute tertiary hospitals. Transport and time issues are frequently cited as barriers to PR; locating programmes in the community might have better outcomes. Although both sites in this study have on going rolling programmes, options for patients to try rehabilitation for a ‘one-off’ session without committing to an 8-week programme might be considered to encourage enrolment or trying some of the elements of a programme whilst an in-patient. It is recognised

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Fig. 1. Audit results.

that inpatients are generally sick and not interested in ‘exercise’ at this stage but the aim would be to move patients from pre-contemplation to contemplation and preparation for rehabilitation or foster changes to their physical activity behaviours, which the PR is intended to produce [25]. 4.1. Limitations The new grading system recommended by GOLD (Global Initiative for Chronic Obstructive Lung Disease) [26] was not in general use in the medical notes. It is further recognised that written records do not record non-verbal communication or other conversations, such as issues surrounding transport and family support that would improve access to PR and so while the incidence of non-referral (49%) seems high, it is possible that many valid reasons are not recorded in medical charts. Patient-based barriers such as trans-

port issues, feeling unwell as a consequence of COPD or limited perceived benefit from programme were not been addressed by this audit nor have the reasons for drop out by the 5 persons who completed less that 50% of a programme. Although this audit did not examine whether there was any difference in the baseline characteristics between those who did and those who did not start or consider PR, others could not find a difference in socio-demographic, clinical or psychological variables between those who did or did not complete PR. Drop outs were mostly for medical reasons. It should be noted that the three-month audit period covered the early winter period so could have missed trends occurring throughout the remaining winter and early spring period when exacerbations of COPD are more common. In conclusion, from 183 people who had confirmed COPD, 98 met the inclusion criteria for referral to PR. Of these nearly 50% were referred for PR. Only a small


proportion of eligible people (7%) actually completed a course within 6 months. To improve both referral and uptake rates, pulmonary rehabilitation may need to be ‘reframed’ or packaged in ways that both clinicians and patients become to view it as natural part of the long-term management of the COPD condition Acknowledgments Dr Rory O’Donnell, Consultant in Respiratory Medicine, St James’s Hospital, Dublin. Conﬂict of interest The authors report no conflicts of interest. References [1] HSE. Pulmonary Rehabilitation: Model of Care, National COPD Clinical Programme, 2010. [2] BTS. IMPRESS Guide to the relative value of COPD interventions. 2012. [3] Desveaux L, Janaudis-Ferreira T, Goldstein R, Brooks D. An international comparison of pulmonary rehabilitation: A systematic review. Chronic Obstructive Airways Disease 2014;[Epub ahead of print]. [4] Williams MT, Lewis LK, McKeough Z, Holland AE, Lee A, McNamara R, et al. Reporting of exercise attendance rates for people with chronic obstructive pulmonary disease: A systematic review. Respirology 2014;19:30-7. [5] Butler MW, O’Mahony MJ, Donnelly SC, McDonnell TJ. Managing exacerbations of COPD: Room for improvement. Irish Medical Journal 2004;97:108-10. [6] Jones SE, Green SA, Clark AL, Dickson MJ, Nolan AM, Moloney C, et al. Pulmonary rehabilitation following hospitalisation for acute exacerbation of COPD: Referrals, uptake and adherence. Thorax 2014;69:81-2. [7] Puhan MA, Gimeno-Santos E, Scharplatz M, Troosters T, Walters EH, Steurer J. Pulmonary rehabilitation following exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2011;(10):CD005305. [8] Glasgow RE, McKay HG, Piette JD, Reynolds KD. The REAIM framework for evaluating interventions: What can it tell us about approaches to chronic illness management? Patient Education Counselling 2001;44:119-27. [9] NICE. Pulmonary rehabilitation service for patients with COPD; Commissioning guide. Implementing NICE guidance. 2006. [10] O’Farrell A, De La Harpe D, Johnson H, Bennett K. Trends in COPD mortality and in-patient admissions in men & women: Evidence of convergence. Irish Medical Journal 2011;104: 245-8. [11] Johnson M. An audit of the pulmonary rehabilitation service in Ireland. Conference Presentation, Irish Thoracic Society 2013. Personal communication.

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[12] BTS. European COPD Audit 2010. Available from: http:// www.brit-thoracic.org.uk/Audit/European-COPD-Audit2010.aspx. [Accessed 25 Aug 2013] [13] Sohanpal RHR, Hames R, Priebe S, Taylor S. Reporting participation rates in studies of non-pharmacological interventions for patients with chronic obstructive pulmonary disease: A systematic review. Syst Rev 2012;29(1):66. [14] Scott A, Baltzan M, Fox J, Wolkove N. Success in pulmonary rehabilitation in patients with chronic obstructive pulmonary disease. Canadian Respiratory Journal: Journal of the Canadian Thoracic Society 2010;17:219-23. [15] Crisafulli EPG, Vagaggin B, Pagani M, Rossi G, Costa F, Guarriello V, Paggiaro P, Chetta A, de Blasio F, Olivieri D, Fabbri M, Clini EM. Efficacy of standard rehabilitation in COPD outpatients with comorbidities. European Respiratory Journal Supplement 2010;36:1042-8. [16] Hogg L, Garrod R, Thornton H, McDonnell L, Bellas H, White P. Effectiveness, attendance, and completion of an integrated, system-wide pulmonary rehabilitation service for COPD: Prospective observational study. COPD: Journal of Chronic Obstructive Pulmonary Disease 2012;9:546-54. [17] Johnston K, Young M, Grimmer K, Antic R, Frith P. Barriers to, and facilitators for, referral to pulmonary rehabilitation in COPD patients from the perspective of Australian general practitioners: A qualitative study. Primary Care Respiratory Journal 2013;22:319-24. [18] HSE. HSE National Clinical Programme COPD Ireland [cited 2014 29/9/2014]. link to HSE National Clinical Programme COPD]. Available from: http://www.hse.ie/eng/about/ Who/clinical/natclinprog/copdprogramme/copdprog.html [19] Seymour JM, Moore L, Jolley CJ, Ward K, Creasey J, Steier JS, et al. Outpatient pulmonary rehabilitation following acute exacerbations of COPD. Thorax 2010;65:423-8. [20] COPD Working Group. Pulmonary rehabilitation for patients with chronic pulmonary disease (COPD): An evidence based analysis. Ontario Health Technology Assessment Service [Internet] 2012;12:1-75. [21] Bolton CE, Bevan-Smith EF, Blakey JD, Crowe P, Elkin SL, Garrod R, et al. British Thoracic Society guideline on pulmonary rehabilitation in adults. Thorax 2013;68(Suppl 2):ii1-ii30. [22] Moore L, Hogg L, White P. Acceptability and feasibility of pulmonary rehabilitation for COPD: A community qualitative study. Primary Care Respiratory Journal 2012;21:419-24. [23] Johnston K, Young M, Grimmer K, Antic R, Frith PA. Frequency of referral to and attendance at a pulmonary rehabilitation programme amongst patients admitted to a tertiary hospital with chronic obstructive pulmonary disease. Respirology 2013;18:1089-94. [24] Fischer MJ, Scharloo M, Abbink JJ, van ‘t Hul AJ, van Ranst D, Rudolphus A, et al. Drop-out and attendance in pulmonary rehabilitation: The role of clinical and psychosocial variables. Respiratory Medicine 2009;103:1564-71. [25] Frownfelter D, Dean E. Cardiovascular and pulmonary physical therapy: Evidence to practice. Cardiovascular and Pulmonary Physical Therapy: Evidence to Practice: Elsevier 2012;18. [26] Global Initiative for Chronic Obstructive Lung Disease I. Global Strategy for the Diagnosis, Management and Prevention of COPD, 2013.