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Introduction

The IPCRG is working on a project, in response to our members' expressed interest, on describing how to refer to and set up pulmonary rehabilitation and making the case for change to policy makers.

 

Position paper: Pulmonary Rehabilitation for breathlessness

September 2017: at review stage.

Positioning PR as an effective treatment for COPD

COPD Value Pyramid from the London Respiratory Network (downloaded from http://thorax.bmj.com/content/early/2014/07/01/thoraxjnl-2014-205667. and also available from http://www.respiratoryfutures.org.uk/knowledge-portal/london-respiratory-network/copd-value-pyramid-thorax-publication/

Desktop helper

The first product is the Desktop Helper No. 7 (click here to view and download).  This desktop helper aims to be practical: it is based on the IPCRG network’s own experience of trying to implement best practice with limited resources in low, middle and high income countries.  It was generated from the evidence, guidelines and experience shared at an experience-led care meeting in May 2017 attended by GPs, researchers, physiotherapists, a psychologist, health planners and managers.  Further comments and contributions were received from GPs, nurses and physiotherapists in other countries.

Authors: Siân Williams and Val Amies on behalf of the international expert group listed below.

Reviewer: Prof Sally Singh.  

Boehringer Ingelheim funded the experience-led care meeting, writing and production. They took no part in the meeting or drafting.

This desktop helper is advisory; it is intended for general use and should not be regarded as applicable to a specific case.

See www.ipcrg.org/disclaimer

Creative Commons Licence Attribution-NonCommercial-ShareAlike

 

Attendees at the experience-led care meeting (principal role and experience listed only - most are involved in research)

DrRadostAssenovaBulgariaGP
ProfPeymaneAdabEnglandProfessor of Chronic Disease Epidemiology and Public Health
MsMariaBuxtonEnglandConsultant Respiratory Physiotherapist
Dr RupertJonesUK and UgandaGP researcher
DrRachelJordanEnglandSenior Lecturer
DrAlanKaplanCanadaGP
Dr Annemarije KruisNetherlandsGP researcher
MsSarahLunnEnglandRespiratory psychologist
DrMargretheSmidthDenmarkPlanner
DrIoannaTsiligianniCreteAssistant Professor, Primary care
DrChristophUlrich WernerGermanyGP
MrAlexWoodwardEnglandRespiratory Physiotherapist


Those who contributed their experience in writing


Dr  Rowshan    Alam              Bangladesh       GP
MsMonicaFerrerSpainPrimary care nurse
Dr MonsurHabibBangladeshGP
DrAndersOstremNorwayGP 
MsAnnaPantouvakiCretePhysiotherapist
MsLilianaSilvaPortugalRehabilitation nurse
MsMarianna TrouliCretePhysiotherapist

GP colleagues Dr Monsur Habib

and Dr Rowshan Alam learning

how to implement PR, courtesy of

Prof Sally Singh, Leicester. September

2017





Strategic frameworks for physical activity and rehabilitation

Development of a draft global action plan to promote physical activity by World Health Organization

In 2013, a global voluntary target was set by the World Health Assembly to reduce physical inactivity by 10% by 2025, but progress towards achieving this target has been slow. Although 86% of countries have developed national NCD action plans, which – in 71% of countries -- include operational plans for reducing physical inactivity, progress on implementation has been challenging.  Now there will be a draft global action plan to promote physical activity for consideration by Member States at the 71st World Health Assembly in May 2018, through the 142nd Executive Board in January 2018.

Rehabilitation 2030

The World Health Organization launched a call to action in Februrary 2017.  Pulmonary rehabilitation is included in this.
 

Guidelines for Pulmonary Rehabilitation

Resources for patients about breathlessness and COPD

Written - general

Written - specific

Video

This is a hard-hitting video that talks about issues including end-of-life and the daily challenges of living with COPD

 Resources for patients about Pulmonary Rehabilitation

Peer to peer videos

Resources for providers

There are some general toolkits:

 

Assessment tools (general)

Assessing breathlessness

Assessing quality of life and disease control

  • CAT COPD Assessment Test
  • CCQ Clinical COPD Questionnaire
  • ACT Asthma Control Test
  • ACQ Asthma Control Questionnaire
  • Activation levels (Judith Hibbard): NHS site, Kings Fund, Insignia,  HIbbard J et al Development of the Patient Activation Measure (PAM): Conceptualizing and Measuring Activation in Patients and Consumers.Health Serv Res. 2004 Aug; 39(4 Pt 1): 1005–1026. doi:  10.1111/j.1475-6773.2004.00269.x

     

Exercise guidelines and exercise prescription

Perceived exertion

The simplest is a visual analogue scale from 0-10 that you can make. Other tools are available but subject to copyright.  These include

Written (general)


Self management plans

Videos

Treating tobacco dependence

Written

Video 

Referral criteria

Referral letters

Mosleh SM, Bond CM, Lee AJ, Kiger A, Campbell NC. Effectiveness of theory-based invitations to improve attendance at cardiac rehabilitation: A randomized controlled trial. Eur J Cardiovasc Nurs [Internet]. 2014;13(3):201–10. Available from: https://doi.org/10.1177/1474515113491348

References from our desktop helper and position paper

Effectiveness

  • Cochrane Review McCarthy B et al 2015 Issue 2This review highlights that pulmonary rehabilitation improves the health-related quality of life of people with COPD. Results strongly support inclusion of pulmonary rehabilitation as part of the management and treatment of patients with COPD.  Future studies should concentrate on identifying the most important components of pulmonary rehabilitation, the ideal length of a programme, the intensity of training required and how long the benefits of the programme last.

Pulmonary rehabilitation reduced hospital admissions and mortality compared with usual community care (no rehabilitation). Quality of life was also improved and the effect was substantially larger than the minimal important difference. Pulmonary rehabilitation appears to be a highly effective and safe intervention in COPD patients after suffering an exacerbation.

Overall, evidence of high quality shows moderate to large effects of rehabilitation on health-related quality of life and exercise capacity in patients with COPD after an exacerbation. Some recent studies showed no benefit of rehabilitation on hospital readmissions and mortality and introduced heterogeneity as compared with the last update of this review. Such heterogeneity of effects on hospital readmissions and mortality may be explained to some extent by the extensiveness of rehabilitation programmes and by the methodological quality of the included studies. Future researchers must investigate how the extent of rehabilitation programmes in terms of exercise sessions, self-management education and other components affects the outcomes, and how the organisation of such programmes within specific healthcare systems determines their effects after COPD exacerbations on hospital readmissions and mortality.

Although results from RCTs suggested that PR reduces subsequent exacerbations, pooled results from the cohort studies did not favour PR, likely reflecting the heterogeneous nature of individuals included in observational research and the varying standards of PR programmes.


Cost-effectiveness and affordability - the business case

  • Glasziou P et al. Evidence for underuse of effective medical services around the world. Lancet. Elsevier Ltd; 2017;390(10090):169–77.  Particularly wasteful is the global failure to capitalise on effective non-pharmalogical therapies, which, although less intensively marketed, are in many cases equally or more effective than their pharmacological counterparts. For example, pulmonary rehabilitation, which involves progressive exercise and education, has been shown to reduce hospital re-admissions and deaths for patients with chronic obstructive pulmonary disease by 70%; daily application of sunscreen can cut invasive melanoma rates by 50%; and insecticide impregnated bednets can prevent 50% of malaria cases.[McGlynn, EA, Asch, SM, Adams, J et al. The quality of health care delivered to adults in the United States. N Engl J Med. 2003; 348: 2635–2645]. Unlike their pharmaceutical counterparts, non-drug treatments are less intensively studied, more poorly described in research, weakly regulated, and inadequately marketed, particularly when the treatment or prevention is cheap or free."  

  • Griffiths et al 2001 This outpatient pulmonary rehabilitation programme produces cost per QALY ratios within bounds considered to be cost effective and is likely to result in financial benefits to the health service.

This home-based pulmonary rehabilitation model, delivered with minimal resources, produced short-term clinical outcomes that were equivalent to centre-based pulmonary rehabilitation.

Barriers to adherence 

In a large national dataset, we have shown that patients living in more deprived areas are less likely to complete PR. However, deprivation was not associated with clinical outcomes in patients who complete therapy. Interventions targeted at enhancing referral, uptake and completion of PR among patients living in deprived areas could reduce morbidity and healthcare costs in such hard-to-reach populations."

Note: there is now a published Cochrane protocol Young J et al 2017  Interventions to promote referral, uptake and adherence to pulmonary rehabilitation for people with chronic obstructive pulmonary disease (COPD)

Role of psychology and psychologists

The diverse and evolving role of a psychologist within a respiratory multidisciplinary team (MDT) is described, providing a working model for service provision. The rationale for appointing a psychologist within a respiratory MDT is presented first, citing relevant policy and research and outlining the wider psychosocial impact of respiratory disease. This is followed by an insight into the psychologist’s role by highlighting important areas, including key therapy themes and the challenge of patient engagement. The way in which the psychologist supports the collective aims and aspirations of respiratory colleagues to provide a more holistic package of care is illustrated throughout.

 

 

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