Abstract
BackgroundPulmonary rehabilitation is widely advocated for people with chronic obstructive pulmonary disease (COPD) to improve exercise capacity, symptoms and quality of life, however only a minority of individuals with COPD are able to participate. Travel and transport are frequently cited as barriers to uptake of centre-based programs. Other models of pulmonary rehabilitation, including home-based programs, have been proposed in order to improve access to this important treatment. Previous studies of home-based pulmonary rehabilitation in COPD have demonstrated improvement in exercise capacity and quality of life, but not all elements of the program were conducted in the home environment. It is uncertain whether a pulmonary rehabilitation program delivered in its entirety at home is cost effective and equally capable of producing benefits in exercise capacity, symptoms and quality of life as a hospital-based program. The aim of this study is to compare the costs and benefits of home-based and hospital-based pulmonary rehabilitation for people with COPD.Methods/DesignThis randomised, controlled, equivalence trial conducted at two centres will recruit 166 individuals with spirometrically confirmed COPD. Participants will be randomly allocated to hospital-based or home-based pulmonary rehabilitation. Hospital programs will follow the traditional outpatient model consisting of twice weekly supervised exercise training and education for eight weeks. Home-based programs will involve one home visit followed by seven weekly telephone calls, using a motivational interviewing approach to enhance exercise participation and facilitate self management. The primary outcome is change in 6-minute walk distance immediately following intervention. Measurements of exercise capacity, physical activity, symptoms and quality of life will be taken at baseline, immediately following the intervention and at 12 months, by a blinded assessor. Completion rates will be compared between programs. Direct healthcare costs and indirect (patient-related) costs will be measured to compare the cost-effectiveness of each program.DiscussionThis trial will identify whether home-based pulmonary rehabilitation can deliver equivalent benefits to centre-based pulmonary rehabilitation in a cost effective manner. The results of this study will contribute new knowledge regarding alternative models of pulmonary rehabilitation and will inform pulmonary rehabilitation guidelines for COPD.Trial registrationClinicalTrials.gov: NCT01423227.
Highlights
Pulmonary rehabilitation is widely advocated for people with chronic obstructive pulmonary disease (COPD) to improve exercise capacity, symptoms and quality of life, only a minority of individuals with COPD are able to participate
Despite the strong evidence of its benefits, the proportion of people with COPD who receive pulmonary rehabilitation is very small, with estimates from developed countries suggesting that it is delivered to less than 5% of those who would benefit each year [6,7]. Of those people with COPD who are referred to pulmonary rehabilitation, 8% to 50% will never attend [8,9], while non-completion rates range from 10% to 32% [10,11]
Patient-related barriers to attendance have been identified, with travel and transport to centrebased programs being the most common obstacles to attendance in this disabled group [8,10,11,12,13,14,15,16]. In view of these barriers, the current model of a centre-based pulmonary rehabilitation program is not addressing the needs of many people with COPD who would benefit from this intervention
Summary
This research will be the first study comparing both the clinical effects and cost effectiveness of delivering pulmonary rehabilitation in the home and hospital settings. In comparing the two modes of delivery on important clinical features and the economic impact to both the patient and the healthcare system, further information on the feasibility of a home-based model of pulmonary rehabilitation will be obtained. The results of this study will inform guidelines for the provision of pulmonary rehabilitation in COPD and may have a significant impact on the delivery of healthcare to people with COPD. If it is demonstrated that homebased exercise achieves equivalent clinical outcomes and is cost effective compared to a hospital-based program, this increases the options for the provision of this intervention and may assist in overcoming the most frequently identified barriers to pulmonary rehabilitation.
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