CHRONIC OBSTRUCTIVE PULMONARY disease

Transcription

1 347 Benefits of an Inpatient Pulmonary Rehabilitation Program: A Prospective Analysis Deborah G. Stewart, MD, David F. Drake, MD, Charles Robertson, MD, Jennifer H. Marwitz, MA, Jeffrey S. Kreutzer, PhD, David X. Cifu, MD ABSTRACT. Stewart DG, Drake DF, Robertson C, Marwitz JH, Kreutzer JS, Cifu DX. Benefits of an pulmonary rehabilitation program: a prospective analysis. Arch Phys Med Rehabil 2001;82: Objective: To examine the effect of an pulmonary rehabilitation program on functional outcome, supplemental oxygen use, quality of life (QOL), and rehospitalization. Design: A prospective study. Setting: Inpatient pulmonary rehabilitation unit. Patients: One hundred fifty-seven patients with moderate to severe chronic obstructive pulmonary disease (COPD) admitted to an pulmonary rehabilitation program over a 3-year period. Intervention: Comprehensive interdisciplinary pulmonary rehabilitation program with an average length of stay of 21 days. Main Outcome Measures: Improvements in QOL questionnaire scores, COPD knowledge questionnaire scores, 6-minute walking test (with 3 ambulation categories: bed-bound, household ambulators, community ambulators), and supplemental oxygen use. Rehospitalization 1 year after completion of the program was also assessed and compared with hospital days for the year before the program. Results: On discharge from the program, 88% of individuals walked farther (p.0001), and community ambulators doubled their walking distance, whereas bed-bound patients decreased 10-fold; supplemental oxygen use dropped 33% during the day (p.0001) and 57% during the night (p.0001); 82% showed improved QOL (p.0001); 67% showed improved knowledge of COPD (p.0001); and 67% of the sample spent less time in the hospital during the 12 months after program completion compared with the 12 months before admission (p.001). Conclusions: An pulmonary rehabilitation program leads to improved endurance and functional ambulation, decreased supplemental oxygen use, and fewer hospitalizations 1 year after discharge for patients with COPD. Key Words: Lung diseases, obstructive; Oxygen; Quality of life; Rehabilitation by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation From the Brooks Health System, Jacksonville, FL (Stewart); Virginia Commonwealth University, Medical College of Virginia Campus (Drake, Marwitz, Kreutzer, Cifu); and HealthSouth Rehabilitation Hospital of Virginia, Richmond, VA (Robertson). Accepted in revised form June 13, Supported by HealthSouth Rehabilitation Hospital of Virginia. No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the authors or upon any organization with which the author(s) is/are associated. Reprint requests to David F. Drake, MD, PO Box 2527, Richmond, VA 23218, dfdrake42@hotmail.com /01/ $35.00/0 doi: /apmr CHRONIC OBSTRUCTIVE PULMONARY disease (COPD) is a widespread health problem accounting for nearly 15% of all acute hospitalizations 1 and an estimated 85,000 deaths in the United States each year. 2 The disease now ranks as the third leading cause of death among men and the fourth among women aged 55 to COPD primarily affects the elderly, often limiting their ability to perform normal activities of daily life (ADLs), thereby fostering dependence. Dyspnea, often accompanied by anxiety, leaves many patients restricted to bed. Others may find themselves exhausted after a trip to the kitchen or bathroom. Unquestionably, the disease is a major detriment to life quality. A variety of and outpatient pulmonary rehabilitation programs have been offered to address the needs of patients with respiratory disease. Typically, services are provided by an interdisciplinary team of specialists, with the goal of achieving maximum independence and community integration. 3 Progressive exercise to increase tolerance and reduce dyspnea is a primary program element. 4,5 Many programs emphasize education, involvement of family members, and improved life quality. 5,6 Research on pulmonary rehabilitation outcomes has provided evidence of improved exercise capacity, walking distance, and improved health-related quality of life (QOL). Studies have predominantly focused on outpatient services; however, a few studies have been performed. Lengths of treatment typically average 2 to 3 months, with some programs lasting as long as 12 months (table 1). For example, Goldstein et al 7 showed improvements in exercise tolerance and QOL among 78 s with COPD that were sustained for 6 months. With 54 COPD patients, Buchi et al 8 found acute improvements in QOL after pulmonary rehabilitation. However, QOL scores among the 32 patients followed up dropped to prerehabilitation levels 1 year postdischarge. Kirsten et al 9 showed improvement in minute ventilation and oxygen uptake in 29 patients who began pulmonary rehabilitation after an acute COPD exacerbation. Inpatient pulmonary rehabilitation stays as brief as 10 days have been shown to improve exercise tolerance and dyspnea. 10 Ketelaars et al 11 assessed 77 COPD patients at discharge and after 9 months of follow-up. Differential benefits were discovered for patients admitted with moderate and severe QOL impairment, and patients with a moderately impaired QOL showed improvement on discharge. 11 Consistent with Buchi s finding, QOL deteriorated 9 months postdischarge. Patients with severely impaired QOL showed little improvement at discharge, and no deterioration was noted at 9 months after discharge. 11 In a study of 24 COPD patients, Rooyackers et al 12 found improvements in walking distance, QOL, and weightlifting capacity. In summary, several studies have investigated the benefits of comprehensive, interdisciplinary pulmonary rehabilitation. Most have used relatively small samples (eg, 80 subjects) and outcome measurement has been limited. Our

2 348 PULMONARY REHABILITATION BENEFITS, Stewart Table 1: Inpatient Pulmonary Rehabilitation Studies Study Goldstein 7 controlled in-/outpatient Votto 10 Ketelaars 11 Rooyackers 12 controlled Buchi 8 Kirsten 9 controlled n Mean Age (yr) LOS QOL/Dyspnea Supplemental Oxygen wk Sustained for 6mo in training NE d 50% on O 2 at adm did not require supplemental O 2 at * 10 12wk Moderately NE improved at, but not sustained for 9mo 24 59/63? 10wk in training 54 (32 at 1yr) 64 4wk but dropped to initial levels at 1yr 29 62/66? 10d in training Supplemental O 2 did not add to the effects of training on room air. Requirements on not determined Exercise Endurance Sustained for 6mo PFT FEV 1 % 34.8, no change at FEV 1 % 31.4, no change at NE FEV 1 % 38/29, no change at NE NE FEV 1 % 42 on adm, improved to 52% on, dropped to 46% at 1yr NE FEV 1 % 34/37, mild improvement to 38% in training Abbreviations: PFT, pulmonary function tests; NE, not evaluated;, discharge; adm, admission. * Age range.? Mean age of men/women. study used a relatively large sample and a multimethod approach to outcome measurement. It was primarily intended to investigate the benefits of pulmonary rehabilitation with regard to functional ambulation, both day and night supplemental oxygen use, discharge disposition, QOL, and knowledge of disease process. To measure rehabilitation effectiveness further, comparisons were made between hospitalization rates in the year preceding and the year after program participation. METHODS Sample The sample consisted of 157 patients (66% women, 34% men) admitted to a community, free-standing acute care rehabilitation hospital between February 1995 and June Of the 157 admissions, 142 (90%) were admitted from an acute care hospital, 9% came directly from home, and 1% was admitted from an affiliated outpatient day rehabilitation program. The average length of stay (LOS) standard deviation (SD) was days. All patients were referred for a specialized pulmonary rehabilitation program by pulmonologists, and all had a history of moderate to severe COPD (forced expiratory volume in 1sec [FEV 1 ] 40%). As measured by the standard pulmonary function test, FEV 1 averaged 37% 18% of predicted volume. Information regarding other comorbidities is presented in table 2. Information regarding patients age, ethnicity, marital status, and education is presented in table 3. Measures The following are descriptions of the primary dependent measures. Six-minute walk. The maximum distance patients can walk on a level surface within 6 minutes was measured, while uniform encouragement was given. 13,14 Two measures of interest were obtained: (1) total distance walked; and (2) longest distance walked without rest. Based on total distance walked, patients were classified as: (1) community ambulators ( 500ft); (2) household ambulator ( ft); and (3) bedbound ( 150ft). Supplemental oxygen use. A dichotomous variable indicating whether nasal cannula oxygen was required during the day and night.

3 PULMONARY REHABILITATION BENEFITS, Stewart 349 Table 2: Comorbidities Diagnosis % Cancer 15.3 CABG postoperative resp failure 7.0 Other postoperative resp failure 3.2 Pneumonia 18.6 Neuromuscular resp disease 0.6 Pulmonary fibrosis 0.6 Mycobacterium avium 0.6 Abbreviations: CABG, coronary artery bypass graft; resp, respiratory. QOL: QOL scale. The QOL scale 15 is a 7-item scale that relates to life satisfaction, activity level, understanding of disease process, stress, and mood. Items are self-reported and rated on a 7-point scale (1 7) with higher values denoting better QOL. Scores for all 7 items are summed to yield a total score with a maximum of 49. QOL: Pulmonary Rehabilitation Knowledge Test. The Pulmonary Rehabilitation Knowledge Test 16 is a 15-item truefalse and multiple choice test developed to evaluate patient s knowledge regarding COPD. Items address breathing techniques, exercise, respiratory function, and treatment approaches. Examples include: True/False: People with COPD have trouble moving air out of their lungs and When doing pursed lip breathing: (a) breathe out twice as long as it takes you to breathe in; (b) breathe in and out through your nose; (c) only use this method when you are short of breath. A total score is calculated to denote the number of correctly completed items. QOL: discharge disposition. This denotes the setting to which patients were discharged after rehabilitation program completion. Days hospitalized. This denotes the number of days in the year preceding admission and the year after discharge that the patient was hospitalized in an acute care setting for respiratory problems. Procedure A comprehensive program of pulmonary rehabilitation was provided to all participants, based on their needs and abilities. During the course of rehabilitation, the following services were provided: nursing, occupational therapy, pulmonary medicine and related medical services, respiratory therapy, physical therapy, psychologic assessment, therapeutic recreation, and social services. All patient care was directed by a pulmonologist. Participation in therapy was gradually increased until approximately 3 hours per day, 5 days per week were tolerated. During these sessions patients worked on strength and endurance through free walking, treadmill walking, a and upper and lower extremity cycling. b Patients also worked on ADLs under the supervision of an occupational therapist. Oxygen saturation was monitored during exercise, throughout the day, and at night by using portable pulse oxymeters. c Supplemental oxygen was maintained until patients consistently kept saturations greater than 90%. The program s admission and discharge standards were based on Joint Commission on Accreditation of Healthcare Organizations standards. In addition, admission and discharge decisions were based on perceptions of patients needs with input obtained from third-party payment sources (eg, case manager input, formal admission and discharge guidelines, discussion with providers medical directors). With the exception of days hospitalized after discharge, data were collected at the time of program admission and immediately before discharge from the rehabilitation setting. Appropriate members of the interdisciplinary rehabilitation team, by using standard protocols, determined scores for each measure. Scores for the 6-minute walk, supplemental oxygen use, and QOL measure were obtained by the respiratory therapist. Members of the nursing and respiratory therapy staff administered the Pulmonary Rehabilitation Questionnaire. Members of the nursing staff collected information regarding preadmission medical history, demographics, and discharge disposition. Before rehabilitation discharge, each patient gave written consent to collect information regarding preadmission and postdischarge medical care. To obtain data regarding postdischarge medical care, nursing staff maintained regular contact with patients during the year after discharge. Information was collected regarding dates of admission and discharge, and diagnoses. Statistical Analyses Descriptive statistics, including proportions, means, and SDs were compiled for all demographic and outcome measures. To compare admission and discharge status, repeated-measures analyses of variance (ANOVA) were used to examine changes in functional status, QOL, and scores on the pulmonary rehabilitation questionnaire. A repeated-measures ANOVA was performed to compare the number of days hospitalized for pulmonary problems in the 12 months preceding and after rehabilitation. Chi-square analyses were used to compare changes in supplemental oxygen use during the course of rehabilitation. Table 3: Patient Demographics Demographic % Age (range, yr) Mean Ethnicity White 90 African American 10 Marital Status Married 42 Widowed 43 Single/divorced 15 Education Through 8th grade 10.6 High school Some 15.2 Graduate 37.7 College Some 18.0 Graduate 15.2 Postgraduate 3.3

4 350 PULMONARY REHABILITATION BENEFITS, Stewart Table 4: The 6-Minute Walk After Discharge 6-Minute Walk n Mean SD Range Total feet walked on admission Total feet walked on discharge Longest walked without rest on admission Longest walked without rest on discharge RESULTS Endurance and Functional Ambulation The first series of analyses focused on the 6-minute walk test. Means and SDs for total feet walked are displayed in table 4. Seven individuals were unable to complete the task because of perceptions of lack of ability. Eighty-eight percent of the sample walked farther, 2% walked the same distance, and 10% walked less at discharge. On average, the total distance walked at the time of discharge was 67% greater than at admission (table 4). A repeated-measures ANOVA revealed a statistically significant difference between admission and discharge total distance walked over 6 minutes (F , df 147, p.0001). To explore changes in ambulatory status further, the 148 patients with both admission and discharge data were ed into 1 of 3 categories: (1) bed-bound, walked less than 150 feet, (2) household ambulators, walked 150 to 500 feet, and (3) community ambulators, walked greater than 500 feet. As shown in table 5, before participating in the program, 20.3% of patients were bed-bound. However, at program discharge, only 2% were bed-bound. Furthermore, the proportion of community ambulators more than doubled to 59.5% at discharge. The longest distance walked without rest was added as a measure later in the data collection effort; thus, data were available for only 88 cases (table 4). At discharge, 84% of the sample had improved, 2% were unchanged, and 14% walked less compared with performance at admission. Without rest, patients averaged an 81% increase in distance walked. A repeated-measures ANOVA revealed a statistically significant difference between admission and discharge measures of longest distance walked without resting (F 75.13, df 86, p.0001). Supplemental Oxygen Use Supplemental oxygen use data were available for 154 patients at both admission and discharge. On admission, more than 75% of patients required supplemental oxygen, 76% during the day and 79% at night. A substantial decrease was noted at discharge, with supplemental oxygen use ranging from 33% during the day to 57% at night. Changes in oxygen use were Table 5: Percentage of Functional Ambulators Pre- and Postrehabilitation Discharge Total Distance Admission 6-Minute Walk Total Distance 150ft ft 500ft Row Total 150ft 0% 2.0% 0% 2.0% ft 13.5% 22.3% 2.7% 38.5% 500ft 6.8% 29.1% 23.6% 59.5% Column total 20.3% 53.4% 26.3% statistically significant for both day ( 2 1, , p.0001) and night time ( 2 1, , p.0001) use. Quality of Life On admission, scores on the QOL measure ranged from 11 to the maximum score obtainable of 49, with a mean of At the time of discharge, scores ranged from 14 to 49 with a mean of A repeated-measures ANOVA revealed a statistically significant difference between admission and discharge scores (F , df 122, p.0001). A vast majority of patients (82%) scores were higher at the time of discharge, consistent with improved QOL. Eleven percent of the scores were unchanged, and 7% decreased. Two thirds of patients (67%) showed improved knowledge of pulmonary rehabilitation principles relating to breathing techniques, exercise, and treatment protocols. Twenty-four percent showed no change in score and 9% displayed a poorer score on the test. Mean admission and discharge scores were 12.1 and 13.5, respectively. A repeated-measures ANOVA ( , ) revealed a statistically significant difference between admission and discharge scores on the COPD test (F 60.54, df 122, p.0001). As indicated in table 6, 98.8% of patients were discharged to home settings. Two thirds were enrolled in day rehabilitation programs whereas another 7.1% received home health care. Almost 11% received no additional rehabilitation. Fewer than 1% of patients were transferred either to a skilled nursing or to an acute care facility. Rehospitalization Patients averaged days in the hospital for pulmonary problems during the year before admission. In the year after discharge, they averaged acute care hospital days. Furthermore, two thirds of the sample (67%) spent less time in the hospital during the 12 months after program admission compared with the 12-month period before admission. A repeated-measures ANOVA revealed a significant difference in mean days hospitalized before and after pulmonary rehabilitation (F 11.81, df 72, p.001). DISCUSSION Endurance and Functional Ambulation Exercise testing is a standard assessment protocol in most pulmonary rehabilitation programs, and most protocols rely on timed ambulation measures. Improvements in exercise endurance as a function of rehabilitation have been shown in a number of studies. 7,9,11,12 The present investigation was unique because it focused on distance walked before resting as well as total distance walked. In both cases, impressive gains were noted at the time of discharge. On average, participants showed Table 6: Discharge Disposition Discharge Disposition % Home 98.8 Day rehabilitation 64.1 Outpatient rehabilitation 6.4 Other outpatient facility 10.3 No additional rehabilitation/care 10.9 Home health care 7.1 Skilled nursing facility 0.6 Acute care facility 0.6

5 PULMONARY REHABILITATION BENEFITS, Stewart 351 an 81% increase in the distance walked. The findings also extend the existing literature by qualitatively characterizing functional changes in ambulation. Distinctions were made between community ambulators, household ambulators, and bedbound participants. In fact, the number of community ambulators more than doubled, whereas the number of subjects who remained bed-bound dropped 10-fold. Supplemental Oxygen Use The effects of a pulmonary rehabilitation program on supplemental oxygen use has been examined in few studies. Votto et al 10 found that 50% of patients on oxygen at admission to an pulmonary rehabilitation program did not require supplemental oxygen at discharge. In our study, we had similar and even more striking findings, as we delineated between daytime and nighttime use. Daytime supplemental oxygen use dropped from 76% on admission to 33% at discharge, and nighttime use dropped from 79% on admission to 57% at discharge. The relationship between oxygen use, rehabilitation costs, and QOL is worthy of additional investigation. Quality of Life Although there have been numerous studies involving pulmonary rehabilitation, few studies have concentrated on outcome of programs (table 1). Those that have, showed consistent improvement in QOL and exercise endurance. Few, however, showed sustained improvement over time. Goldstein et al 7 found a sustained QOL 6 months postdischarge from an pulmonary rehabilitation program. By contrast, Ketelaars et al 11 and Buchi et al 8 reported a drop in QOL to initial preadmission levels at 9 months and 1 year postdischarge. Our sample had a shorter LOS (average, 3wk vs 4 12wk) than reported in most other studies. Still, a significant increase in QOL was shown in areas relating to activity level, understanding of disease process, stress, and mood. These data suggest that relatively short periods of pulmonary rehabilitation can benefit QOL. Nearly all (98.8%) of the study participants were discharged to home. Further research is needed to identify the association between LOS and QOL outcomes. Rehospitalization Analysis of rehospitalization rates provides important information regarding the relation between pulmonary rehabilitation and long-term health care use. The costs of caring for pulmonary patients is relatively high, and pulmonary rehabilitation can reduce health care costs substantially. For example, researchers have suggested that pulmonary rehabilitation more than pays for itself by substantially reducing the need for emergency department care and hospital admission. 17 Several studies 18,19 have shown a decrease in hospitalization rates after outpatient pulmonary rehabilitation. As indicated by the literature review summarized in table 1, information regarding the relation between pulmonary rehabilitation and rehospitalization rates is sorely lacking. In this investigation, patients were carefully monitored for a year after program discharge. Two thirds of study participants (67%) spent fewer days hospitalized during the year after discharge compared with the 1 year before admission. Specifically, the average number of hospitalized days per year decreased by more than a week, accounting for a potential 1-year savings of approximately $3000 per patient (based on a conservative estimate of $400 per day for an acute care hospital stay). Study Limitations Our investigation involved a relatively large sample, prospective design, and a 1-year postdischarge follow-up. However, a few primary limitations require consideration. First, the study was conducted at a single center. Future research involving participants from multiple centers representing varying geographic regions and ethnic s would be worthwhile. Second, follow-up information was limited to data relating to rehospitalization. Information regarding physician office visits, emergency room visits, costs, and QOL would be helpful to evaluate the true long-term impact of rehabilitation. Finally, our follow-up rate was about 50%. More rigorous follow-up efforts would provide for a more comprehensive assessment of program benefits. The true benefits of rehabilitation are difficult to discern without a control, and some would argue that withholding rehabilitation services is not ethical. Future investigations might benefit by including waitlist controls, as some investigators have done, 20 or comparing patients who receive rehabilitation with those who, for practical reasons, are unable to participate. CONCLUSION Inpatient pulmonary rehabilitation can benefit QOL, improve functional ambulation, and reduce the need for supplemental oxygen. Analysis of pre- and postprogram hospitalization rates indicated a substantial reduction in the need for hospital care. Multicenter research with comprehensive longterm assessment is encouraged. In summary, this study showed that a relatively brief course of pulmonary rehabilitation can lead to significant benefits. Acknowledgments: This project was made possible with help from Sally Gammon, RN, Bill Gibbs, RT, Curt Sessler, MD, Kelli Petersen, JD, HealthSouth Corporation, and all the therapists at HealthSouth Rehabilitation Hospital of Virginia. References 1. Feinleib M, Rosenberg HM, Collins JG, Delozier JE, Pokras R, Chevarley FM. Trends in COPD morbidity and mortality in the United States. Am Rev Respir Dis 1989;140:S Pulmonary Rehabilitation Joint ACCP/AACVPR Evidence-Based Guidelines. Chest 1997;112: Fishman A. Pulmonary rehabilitation research. Am J Respir Crit Care Med 1994;149: Tiep BL. Disease management of COPD with pulmonary rehabilitation. Chest 1997;112: Lacasse Y, Wong E, Guyatt GH, King D, Cook DJ, Goldstein RS. 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6 352 PULMONARY REHABILITATION BENEFITS, Stewart six-, and 12-minute walking tests in respiratory disease. Br Med J 1982;284: Guyatt GH, Pugsley SO, Sullivan MJ, Thompson PJ, Berman L, Jones NL, et al. Effect of encouragement on walking test performance. Thorax 1984;39: Morris K, Hodgkin J. The pulmonary rehabilitation admission and education manual. Rockville (MD): Aspen; Pulmonary Rehabilitation Team Novacare Tri-State Rehabilitation Hospital (US). Pulmonary rehabilitation knowledge test. Evansville (IN): The Hospital; Bickford LS, Hodgkin JE, McInturff SL. National pulmonary rehabilitation survey: update. J Cardiopulm Rehabil 1995;15: Agle DP, Baum GL, Chester EH, Wendt M. Multidiscipline treatment of chronic pulmonary insufficiency: 1. Psychologic aspects of rehabilitation. Psychosom Med 1973;35: Johnson HR, Tanzi F, Balchum OJ, Gunderson MA, De Florio G, Hoyte A. Inpatient comprehensive pulmonary rehabilitation in severe COPD. Respir Ther 1980;May/June: Singh SJ, Smith ME, Hyland ME, Morgan MD. A short outpatient pulmonary rehabilitation programme: immediate and longer term effects on exercise performance and quality of life. Resp Med 1998;92: Suppliers a. Stantrac Treadmill; Unisen Inc, Chambers Rd, Tustin, CA b. Sci-Fit Pro II Cycle; Sinties Scientific Inc, 5616 A S 122nd E Ave, Tulsa, OK c. Nellcor N-20 Pulse-Oximeter; Nellcor Inc, 4280 Hacienda Dr, Pleasanton, CA