Motivations for completing pulmonary rehabilitation - A qualitative analysis.

Background: Previous studies have focused on demographic factors that might predict non-completion of pulmonary rehabilitation (PR). We aimed to identify key modifiable factors that promote completion of PR. Methods: A mixed methods survey was offered to participants completing a discharge assessment following PR. Descriptive statistics and inductive thematic analysis were used to analyse the survey responses, with investigator triangulation. Results: 62 of 187 (33%) patients attending a PR discharge assessment between November 2022 and April 2023 returned the anonymised survey. Desire to improve health and wellbeing was the main reason for both initially committing to a course and for continuing with PR past transient thoughts of leaving. The positive impact of staff was the second most common reason. The enjoyment of the PR programme, being held accountable to attend classes, and the importance of other group members were other key themes identified. Conclusions: In conclusion, our findings suggest PR services need to implement strategies which ensure regular promotion and reinforcement of the health benefits of PR as well as implementation of PR modalities which best monopolise on the positive impact skilled staff have on motivating patients to complete PR.

Culturally responsive occupational therapy practice with First Nations Peoples-A scoping review.

INTRODUCTION: First Nations Peoples consistently demonstrate strength and resilience in navigating systemic health care inequities. Acknowledging racism as a health determinant underscores the urgent need for a counterforce-cultural safety. Indigenous Allied Health Australia (IAHA) contends that with cultural responsiveness, the health workforce can take action to create a culturally safe environment. OBJECTIVE: To explore features of culturally responsive occupational therapy (OT) practice when providing a service with First Nations People and examine alignment of those features with the IAHA Cultural Responsiveness in Action Framework. DESIGN: A systematic scoping review was undertaken using CINAHL, Emcare, MEDLINE, PsychInfo and Scopus databases. Examples of culturally responsive OT practice with First Nations Peoples were mapped to the six IAHA Framework capabilities and confirmed by First Nations co-authors. FINDINGS: OT practice with First Nations Peoples aligned with the six capabilities to varying degrees. The importance of OTs establishing relationships with First Nations People, applying self-reflection to uncover cultural biases, and addressing limitations of the profession's Western foundations was evident. DISCUSSION: Recognising the interrelatedness of the six capabilities, the absence of some may result in a culturally unsafe experience for First Nations People. OTs must acknowledge the leadership of First Nations Peoples by privileging their voices and consider how established practices may reinforce oppressive systems. CONCLUSION: To ensure a culturally safe environment for First Nations People, the OT profession must respect the leadership of First Nations Peoples and address the limitations of the profession's Western foundations to uphold the profession's core value of client-centred care.

Feasibility and impact of a physical activity and lifestyle program for Aboriginal families with Machado-Joseph disease in the Top End of Australia.

INTRODUCTION: Physical activity and lifestyle programs are scarce for people with hereditary ataxias and neurodegenerative diseases. Aboriginal families in the Top End of Australia who have lived with Machado-Joseph disease (MJD) for generations co-designed a physical activity and lifestyle program called the Staying Strong Toolbox. The aim of the present study was to explore feasibility and impact of the program on walking and moving around. METHODS: A mixed-methods, multiple case study design was used to pilot the Staying Strong Toolbox. Eight individuals with MJD participated in the program for 4 weeks. Participants tailored their own program using the Toolbox workbook. Families, support workers and researchers facilitated each individual's program. Feasibility was determined through program participation, adherence, coinciding or serious adverse events, participant acceptability and cost. Impact was determined through measures of mobility, ataxia, steps, quality of life, wellbeing and goal attainment, assessed before and after the program. RESULTS: All participants completed the program, averaging five activity sessions per week, 66 minutes per session, of walking (63.5%), strengthening/balance-based activities (16%), cycling (11.4%) and activities of daily living, cultural and lifestyle activities (10.5%). Seven participants were assessed on all measures on three occasions (baseline, pre-program and post-program), while one participant could not complete post-program measures due to ceremonial responsibilities. All had significant improvements in mobility, steps taken and ataxia severity (p<0.05) after the program. Quality of life and wellbeing were maintained. CONCLUSION: The program helped participants remain 'strong on the inside and outside'. Participants recommended implementation in 4-week blocks and for the program to be shared internationally. The Staying Strong Toolbox program was feasible for families with MJD. The program had a positive impact on walking and moving around, with participants feeling stronger on the outside (physically) and inside (emotionally, spiritually, psychosocially). The program could be adapted for use by other families with MJD.

Change in gait speed and adverse outcomes in patients with idiopathic pulmonary fibrosis: A prospective cohort study.

BACKGROUND AND OBJECTIVE: Gait speed is associated with survival in individuals with idiopathic pulmonary fibrosis (IPF). The extent to which four-metre gait speed (4MGS) decline predicts adverse outcome in IPF remains unclear. We aimed to examine longitudinal 4MGS change and identify a cut-point associated with adverse outcome. METHODS: In a prospective cohort study, we recruited 132 individuals newly diagnosed with IPF and measured 4MGS change over 6 months. Death/first hospitalization at 6 months were composite outcome events. Complete data (paired 4MGS plus index event) were available in 85 participants; missing 4MGS data were addressed using multiple imputation. Receiver-Operating Curve plots identified a 4MGS change cut-point. Cox proportional-hazard regression assessed the relationship between 4MGS change and time to event. RESULTS: 4MGS declined over 6 months (mean [95% CI] change: -0.05 [-0.09 to -0.01] m/s; p = 0.02). A decline of 0.07 m/s or more in 4MGS over 6 months had better discrimination for the index event than change in 6-minute walk distance, forced vital capacity, Composite Physiologic Index or Gender Age Physiology index. Kaplan-Meier curves demonstrated a significant difference in time to event between 4MGS groups (substantial decline: >-0.07 m/s versus minor decline/improvers: ≤-0.07 m/s; p = 0.007). Those with substantial decline had an increased risk of hospitalization/death (adjusted hazard ratio [95% CI] 4.61 [1.23-15.83]). Similar results were observed in multiple imputation analysis. CONCLUSION: In newly diagnosed IPF, a substantial 4MGS decline over 6 months is associated with shorter time to hospitalization/death at 6 months. 4MGS change has potential as a surrogate endpoint for interventions aimed at modifying hospitalization/death.

Suicide crises among women and mothers during and around the time of pregnancy: Prevalence and timing of initial contact with first responders and health services.

OBJECTIVES: Suicide is a leading cause of maternal mortality. Suicidality during and around the time of pregnancy can have detrimental impacts on a child's development and outcomes. This paper examines prevalence, demographic characteristics, and timing of initial contact with first responders and health services for a cohort of women who experienced suicidality during and around the time of pregnancy. METHODS: Findings are drawn from the Partners in Prevention (PiP) study, a population-wide linked data set of suicide-related attendances by police or paramedics in Queensland, Australia. A sub-cohort of women was identified, who were between 6 months preconception and 2 years postpartum at the time of a suicide-related contact with police or paramedics (PiP-Maternal). Findings are compared to other girls and women who had a suicide-related contact with police or paramedics (PiP-Female). Prevalence, demographic characteristics, timing of contact with first responders and health services, re-presentations, and mortality are reported. RESULTS: The PiP-Maternal cohort comprised 3020 individuals and 3400 births. Women in the PiP-Maternal cohort were younger, more likely to be of Aboriginal and/or Torres Strait Islander descent and live outside of a major city than the PiP-Female cohort. There were high rates of out-of-hours calls to police and ambulance, and similar perceived seriousness of the call between women in the PiP-Maternal and PiP-Female cohorts. Women in the PiP-Maternal cohort were less likely to be admitted to an emergency department within 24 hours, even after matching on covariates. Prevalence of suicidality for women who were pregnant and up to 2 years postpartum was 1.32% (95% CI = [1.27, 1.37]). CONCLUSION: Vulnerabilities and high rates of contact with police or paramedics, coupled with lower levels of follow-up, highlight the critical need to improve service responses for women with mental health needs during these phases of life.

Commentary: Improving access to cardiac rehabilitation (Heart: Road for health) for Aboriginal and Torres Strait Islander peoples in rural and remote areas of North Queensland.

AIMS: To focus on the needs, challenges and opportunities to improve access to cardiac rehabilitation (CR) (Heart: Road to health [HRH]) for Aboriginal and Torres Strait Islander peoples in rural and remote (R&R) areas of North Queensland. CONTEXT: It is known that there is insufficient access to HRH for Aboriginal and Torres Strait Islander peoples in R&R areas of NQ, who have the highest rates of heart disease and socioeconomic disadvantage mainly due to poor social determinants of health. However, at least in part due to the impact of colonialism and predominantly western medicalised approach to health care, few gains have been made. APPROACH: This commentary draws on recent research and literature and reflects on cultural issues that impact on improving access to an HRH for Aboriginal and Torres Strait Islander peoples in R&R areas. The underutilisation of the skills of Aboriginal and Torres Strait Islander Health Workers (ATSIHW) and a lack of a defined process to ensure access to culturally responsive HRH are discussed. Finally, a way forward is proposed that includes the development of policies, pathways and guidelines to ensure that appropriate support is available in the client's home community. CONCLUSION: It is proposed that culturally responsive, accessible and effective HRH is achievable through the reorientation of current health systems that include a continuous client-centred pathway from hospital to home. In this model, ATSIHW will take a lead or partnership role in which their clinical, cultural brokerage and health promotion skills are fully utilised.

Building the capacity of rural allied health generalists through online postgraduate education: a qualitative evaluation.

INTRODUCTION: Workforce development is a key strategy for building the capacity and capability of a workforce. Accordingly, rural and remote practising allied health professionals require relevant and accessible continuing professional development to enhance their knowledge and skills and improve consumer health outcomes. This study explored the impact of an online postgraduate allied health rural generalist education program, from the perspective of allied health professionals participating in the program and their supervisors and managers. METHODS: A qualitative, exploratory descriptive study design was employed using semistructured interviews. This study formed the qualitative component of a larger convergent mixed-methods evaluation study aimed at evaluating the reach, quality and impact of an online rural generalist education program for allied health professionals in Australia. Allied health professionals from seven professions enrolled in an online postgraduate rural generalist education program, the rural generalist program (RGP). Their designated work-based supervisors and their managers who were responsible for the operational management of the study sites were invited to participate in the study. All participants were employed in rural and remote health services in 10 sites across four Australian states. Study participants' experience and perceptions of the impact of the RGP on themselves, the healthcare service and the broader community were explored using semistructured interviews. Data were thematically analysed site by site, then across sites using Braun and Clarke's (2012) systematic six-phase approach. Provisional codes were generated and iteratively compared, contrasted and collapsed into secondary, more advanced codes until final themes and subthemes were developed. RESULTS: Semistructured interviews were conducted with 23 allied health professionals enrolled in the RGP and their 27 work-based supervisors and managers across the 10 study sites. Three final themes were identified that describe the impact of the RGP: building capability as rural generalist allied health professionals; recruiting and building a rural workforce; enhancing healthcare services and consumer outcomes. CONCLUSION: Allied health professionals working in rural and remote locations valued the RGP because it provided accessible postgraduate education that aligned with their professional and clinical needs. Integrated into a supportive, well-structured development pathway, the experience potentiated learning and facilitated safe clinical practice that met the needs of consumers and organisations. The findings demonstrate that effective work-integrated learning strategies can enhance the development of essential capabilities for rural practice and support early-career allied health professionals' transition to rural and remote practice. These experiences can engage allied health professionals in a way that engenders a desire to remain working in rural and remote contexts.

An unusual case of comedones.

We present the case of a 71-year-old woman with widespread comedones since adolescence. Histological examination revealed branching hyperpigmented rete ridges and cystically dilated follicular infundibulum containing laminated keratinous debris. We explore the differential diagnosis in the context of other reticulate hyperpigmentation disorders.

Digital habits of pulmonary rehabilitation service-users following the COVID-19 pandemic.

OBJECTIVE: We previously demonstrated low levels of digital literacy amongst pulmonary rehabilitation service-users prior to the COVID-19 pandemic. We aimed to identify whether the pandemic accelerated digital literacy in this population, resulting in greater acceptance of remote web-based pulmonary rehabilitation programme models. METHODS: We surveyed digital access and behaviours and pulmonary rehabilitation delivery preferences of service-users referred to pulmonary rehabilitation in 2021 (cohort 2021) and propensity score-matched them to a cohort who completed the survey in 2020 (cohort 2020). RESULTS: There were indicators that digital access and confidence were better amongst the Cohort 2021 but no difference was seen in the proportion of patients choosing remote web-based pulmonary rehabilitation as an acceptable method of receiving pulmonary rehabilitation. CONCLUSION: In an unselected cohort of service-users, remote web-based pulmonary rehabilitation was considered acceptable in only a minority of patients which has implications on healthcare commissioning and delivery of pulmonary rehabilitation.

Importance of cardiac rehabilitation in rural and remote areas of Australia.

OBJECTIVE: To assess implementation of in-patient cardiac rehabilitation (Phase-1-cardiac rehabilitation), impact on people in rural and remote areas of Australia and potential methods for addressing identified weaknesses. DESIGN: Exploratory case study methodology using qualitative and quantitative methods. Qualitative data collection via semi-structured interviews, using thematic analysis, augmented by quantitative data collection via a medical record audit. SETTING: Four regional hospitals (2 Queensland Health and 2 private) providing tertiary health care. PARTICIPANTS: (a) Hospital in-patients with heart disease ≥18 years. (b) Staff responsible for their care. OUTCOME MEASURES: Implementation of Phase-1-cardiac rehabilitation in tertiary hosptials in North Queensland and the impact on in-patients discharge planning and post discharge care. Recommentations and implications for practice are proposed to address deficits. RESULTS: Phase-1-cardiac rehabilitation implementation rates, in-patient understanding and multidisciplinary team involvement were low. The highest rates of Phase-1-cardiac rehabilitation were for in-patients with a length of stay three days or more  in cardiac units with cardiac educators. Rates were lower in cardiac units with no cardiac educators, and lowest for in-patients in all areas of all hospitals with length of stay of two days or less days. Low Phase-1-cardiac rehabilitation implementation rates resulted in poor in-patient understanding about their disease, treatment and post-discharge care. Further, medical discharge summaries rarely mentioned cardiac rehabilitation/secondary prevention or risk factor management resulting in a lack of information for health care providers on cardiac rehabilitation and holistic health care. CONCLUSION: Implementation of Phase-1-cardiac rehabilitation in regional hospitals in this study fell short of recommended best practice, resulting in patients' poor preparation for discharge, and insufficient information on holistic care for health care providers in rural and remote areas. These factors potentially impact on holistic care for people returning home following treatment for heart disease.

Cardiac rehabilitation in rural and remote areas of North Queensland: How well are we doing?

OBJECTIVE: To address access to cardiac rehabilitation (CR) for people in R&R areas, this research aimed to investigate: (1) post discharge systems and support for people returning home from hospital following treatment for heart disease (HD). (2) propose changes to improve access to CR in R&R areas of NQ. SETTING: Four focus communities in R&R areas of NQ. PARTICIPANTS: Focus communities' health staff (resident/visiting) (57), community leaders (10) and community residents (44), discharged from hospital in past 5 years following treatment for heart disease (purposeful sampling). DESIGN: A qualitative descriptive case study, with data collection via semi-structured interviews. Inductive/deductive thematic analysis was used to identify primary and secondary themes. Health service audit of selected communities. RESULTS: Health services in the focus communities included multipurpose health services, and primary health care centres staffed by resident and visiting staff that included nurses, Aboriginal and Torres Strait Islander Health Workers, medical officers, and allied health professionals. Post-discharge health care for people with HD was predominantly clinical. Barriers to CR included low referrals to community-based health professions by discharging hospitals; poorly defined referral pathways; lack of guidelines; inadequate understanding of holistic, multidisciplinary CR by health staff, community participants and leaders; limited centre-based CR services; lack of awareness, or acceptance of telephone support services. CONCLUSION: To address barriers identified for CR in R&R areas, health care systems' revision, including development of referral pathways to local health professionals, CR guidelines and in-service education, is required to developing a model of care that focuses on self-management and education: Heart: Road to Health.

Co-creation of a student-implemented allied health service in a First Nations remote community of East Arnhem Land, Australia.

OBJECTIVES: To co-create a culturally responsive student-implemented allied health service in a First Nations remote community and to determine the feasibility and acceptability of the service. DESIGN: Co-creation involved a pragmatic iterative process, based on participatory action research approaches. Feasibility and acceptability were determined using a mixed-method pre/postdesign. SETTING: The service was in Nhulunbuy, Yirrkala and surrounding remote First Nations communities of East Arnhem Land, Northern Territory, Australia. PARTICIPANTS: Co-creation of the service was facilitated by the Northern Australia Research Network, guided by Indigenous Allied Health Australia leadership, with East Arnhem local community organisations and community members. Co-creation of the day-to-day service model involved local cultural consultants, service users and their families, staff of community organisations, students, supervisors, placement coordinators and a site administrator. FINDINGS: A reciprocal learning service model was co-created in which culturally responsive practice was embedded. The service was feasible and acceptable: it was delivered as intended; resources were adequate; the service management system was workable; and the service was acceptable. Health outcome measures, however, were not appropriate to demonstrate impact, particularly through the lens of the people of East Arnhem. Recommendations for the service included: continuing the reciprocal learning service model in the long term; expanding to include all age groups; and connecting with visiting and community-based services. CONCLUSION: The co-created service was feasible and acceptable. To demonstrate the impact of the service, measures of health service impact that are important to First Nations people living in remote communities of northern Australia are required.

Marŋgithirri guŋga'yunarawu ga guŋga'yunyarawu marŋgithinyarawu Learning to connect and connecting to learn: Preparing the rural and remote allied health workforce through a co-created student-implemented service in East Arnhem, Australia.

OBJECTIVES: To explore the process of learning for allied health students providing a student-implemented service for older Yolŋu in remote East Arnhem, Northern Territory, Australia. DESIGN: An exploratory qualitative study following an 8-week student-implemented service. SETTING: Nhulunbuy and Yirrkala and surrounding remote Aboriginal communities of the East Arnhem Region of the Northern Territory. PARTICIPANTS: Data were collected from: 4 students who implemented the service; 4 professional supervisors, 3 placement coordinators, a Yolŋu cultural consultant and a care manager from a local community organisation, all of whom supported implementation of the service; and 7 older Yolŋu and their families who were recipients of the service. INTERVENTIONS: A student-implemented service for older Yolŋu delivered by allied health students from James Cook University. Clinical, cultural and pastoral supervision and support was provided by Flinders University, James Cook University, Indigenous Allied Health Australia and 2 Yolŋu cultural consultants and 2 local community organisations. MAIN OUTCOME MEASURES: Semi-structured interviews with those who implemented, supported and received the service. Data were analysed thematically using an inductive approach. RESULTS: 'Learning to connect and connecting to learn' described how allied health students were learning to provide a service for older Yolŋu. Four interrelated processes connected their learning: 'preparing and supporting', 'bonding and responding', 'growing and enriching' and 'working and weaving'. CONCLUSION: The co-created student-implemented service provided a unique learning opportunity for allied health students on how to provide a culturally safe service in a remote Aboriginal community in northern Australia.

Augmentative and alternative communication for Aboriginal Australians: Developing core vocabulary for Yolŋu speakers.

Yolŋu, Aboriginal people from Arnhem Land, Australia are at risk of Machado-Joseph disease, with progressive loss of speech. Yolŋu are interested in developing augmentative and alternative communication (AAC) systems in their own languages. This research aimed to develop a culturally responsive process to explore and create a core vocabulary word list for Yolŋu adults living with the disease for inclusion in AAC system prototypes. A list of 243 Yolŋu words and morphemes was created. In this highly collaborative, mixed methods, participatory action research, Balanda (the Yolŋu word for non-Aboriginal people) and Yolŋu researchers conducted cycles of transcription and analysis of a language sample, with oral group discussions to identify which words to include, omit, or add, based on Yolŋu perceptions of the structure and use of their languages. A Yolŋu metaphor, Gulaka-buma ("Harvesting yams"), was identified by Yolŋu researchers to represent and share the research process and findings. Three key themes were identified that summarize the main cultural and linguistic considerations related to changes made to the core vocabulary. Study findings emphasized the role of language as an expression of culture and identity for Indigenous peoples and the importance of considering cultural and linguistic factors in selecting vocabulary for AAC systems.

Designing augmentative and alternative communication systems with Aboriginal Australians: vocabulary representation, layout, and access.

Yolŋu (Aboriginal Australians of northeast Arnhem Land) are interested in developing augmentative and alternative communication (AAC) systems in their own languages to support communication opportunities and participation for their family members living with Machado-Joseph disease. Designing AAC systems in Aboriginal languages requires consideration of unique linguistic and cultural elements. Participatory action research in strength-based communication contexts was carried out by Yolŋu and Balanda (the Yolŋu word for non-Aboriginal people) researchers working together through a collaborative intercultural process. Culturally responsive literacy, language, and AAC activities were used to develop four prototype Yolŋu AAC sytems for Yolŋu with varied literacy skills. Data were coded using gerunds to identify and focus on action in the data. Reflective and analytical collaborative, oral group discussions were used to identify key considerations and, ultimately, a Yolŋu metaphor for the research. Yolŋu language, culture and worldview impacted all aspects of prototype design and decision making. Salient considerations related to representation, organization, layout, and access, are presented. Clinical implications and future research considerations are outlined.

Stroke survivors' perspectives on recovering in rural and remote Australia: A systematic mixed studies review.

INTRODUCTION: Stroke survivors recovering in rural and remote locations often have little or no access to rehabilitation services. The purpose of this study was to review the literature on recovering in rural and remote Australia, from the perspective of stroke survivors. Use of technology to support recovery was also explored. METHODS: A systematic mixed studies review was conducted and reported according to the ENTREQ and PRISMA statements. MEDLINE (Ovid), CINAHL (EBSCOhost), Scopus, PsycINFO (ProQuest), Cochrane Library and Google Scholar were searched from inception to May 2021 for studies investigating stroke survivors' perspectives on recovering in rural or remote Australia. Qualitative, quantitative or mixed methods studies were included. Methodological quality was assessed using the Mixed Methods Appraisal Tool. Studies were not excluded or weighted according to methodological quality. To review the perspectives of stroke survivors on recovering, findings of included studies were mapped to the Living My Life framework and integrated using a convergent qualitative synthesis. The review protocol was registered on PROSPERO (CRD42017064990). RESULTS: Eight studies met the inclusion criteria: six qualitative, one quantitative and one mixed methods. Methodological quality of the small number of studies ranged from low to high, indicating further high-quality research is needed. Included studies involved 152 stroke survivors in total. Review findings indicated that recovering was driven by working towards what mattered to stroke survivors, in ways that matched their beliefs and preferences and that worked for them in their world, including use of technology. CONCLUSION: Stroke survivors recovering in rural and remote locations want to live their life by doing what matters to them, despite the challenges they face. They want support in ways that work for them in their environment. Further research is required to tailor support for stroke survivors that is specific to their life in rural and remote locations.

COPD discharge bundle and pulmonary rehabilitation referral and uptake following hospitalisation for acute exacerbation of COPD.

Pulmonary rehabilitation (PR) following hospitalisations for acute exacerbation of COPD (AECOPD) is associated with improved exercise capacity and quality of life, and reduced readmissions. However, referral for, and uptake of, post-hospitalisation PR are low. In this prospective cohort study of 291 consecutive hospitalisations for AECOPD, COPD discharge bundles delivered by PR practitioners compared with non-PR practitioners were associated with increased PR referral (60% vs 12%, p<0.001; adjusted OR: 14.46, 95% CI: 5.28 to 39.57) and uptake (40% vs 32%, p=0.001; adjusted OR: 8.60, 95% CI: 2.51 to 29.50). Closer integration between hospital and PR services may increase post-hospitalisation PR referral and uptake.

Supervised pulmonary rehabilitation using minimal or specialist exercise equipment in COPD: a propensity-matched analysis.

BACKGROUND: Many trials supporting the benefits of pulmonary rehabilitation (PR) have used specialist exercise equipment, such as treadmills and cycle ergometers. However, access to specialist equipment may not be feasible in some settings. There is growing interest in delivering PR programmes with minimal, low-cost equipment, but uncertainty remains regarding their efficacy compared with programmes using specialist equipment. METHODS: Using propensity score matching, 318 consecutive patients with COPD undergoing supervised PR using minimal equipment (PR-min) were compared 1:1 with a control group of 318 patients with COPD who underwent supervised PR using specialist equipment (PR-gym). A non-inferiority analysis was performed for the primary outcome (incremental shuttle walk (ISW)) and secondary outcomes (Chronic Respiratory Disease Questionnaire (CRQ)-domain and total scores). RESULTS: Similar improvements in ISW and CRQ-domains were observed in PR-min and PR-gym groups (mean difference ISW: 3 m (95% CI -16 to 9); CRQ-total: 0.9 (95% CI -2.7 to 4.5)). The 95% CI between group differences for ISW and CRQ-total did not cross the predefined non-inferiority margins. However, completion rates were lower in PR-min compared with PR-gym (64% vs 73%; p=0.014). CONCLUSIONS: In patients with COPD, PR delivered using minimal equipment produces clinically significant benefits in exercise capacity and health-related quality of life that are non-inferior to rehabilitation delivered using specialist equipment. This study provides support for the provision of PR using minimal exercise equipment, particularly in areas where access to specialist exercise equipment is limited.

Gait speed and adverse outcomes following hospitalised exacerbation of COPD.

BACKGROUND: The 4-m gait speed (4MGS) test is a simple physical performance measure and surrogate marker of frailty that is associated with adverse outcomes in older adults. We aimed to assess the ability of 4MGS to predict prognosis in patients hospitalised with acute exacerbations of chronic obstructive pulmonary disease (AECOPD). METHODS: 213 participants hospitalised with AECOPD (52% male, mean age 72 years and mean forced expiratory volume in 1 s (FEV1) 35% predicted) were enrolled. 4MGS and baseline demographics were recorded at hospital discharge. All-cause readmission and mortality were collected for 1 year after discharge and multivariable Cox proportional hazards regressions were performed. Kaplan-Meier and competing risks analyses were conducted comparing time to all-cause readmission and mortality between 4MGS quartiles. RESULTS: 111 participants (52%) were readmitted and 35 (16%) died during the follow-up period. 4MGS was associated with all-cause readmission, with an adjusted subdistribution hazard ratio of 0.868 (95% CI 0.797-0.945; p=0.001) per 0.1 m·s-1 increase in gait speed, and with all-cause mortality, with an adjusted subdistribution hazard ratio of 0.747 (95% CI 0.622-0.898; p=0.002) per 0.1 m·s-1 increase in gait speed. Readmission and mortality models incorporating 4MGS had higher discrimination than age or FEV1 % pred alone, with areas under the receiver operator characteristic curves of 0.73 and 0.80, respectively. Kaplan-Meier and competing risks curves demonstrated that those in slower gait speed quartiles had reduced time to readmission and mortality (log-rank, both p<0.001). CONCLUSIONS: 4MGS provides a simple means of identifying at-risk patients with COPD at hospital discharge. This provides valuable information to plan post-discharge care and support.

The Effects of a Video Intervention on Posthospitalization Pulmonary Rehabilitation Uptake. A Randomized Controlled Trial.

Rationale: Pulmonary rehabilitation (PR) after hospitalizations for exacerbations of chronic obstructive pulmonary disease (COPD) improves exercise capacity and health-related quality of life and reduces readmissions. However, posthospitalization PR uptake is low. To date, no trials of interventions to increase uptake have been conducted.Objectives: To study the effect of a codesigned education video as an adjunct to usual care on posthospitalization PR uptake.Methods: The present study was an assessor- and statistician-blinded randomized controlled trial with nested, qualitative interviews of participants in the intervention group. Participants hospitalized with COPD exacerbations were assigned 1:1 to receive either usual care (COPD discharge bundle including PR information leaflet) or usual care plus the codesigned education video delivered via a handheld tablet device at discharge. Randomization used minimization to balance age, sex, FEV1 % predicted, frailty, transport availability, and previous PR experience.Measurements and Main Results: The primary outcome was PR uptake within 28 days of hospital discharge. A total of 200 patients were recruited, and 196 were randomized (51% female, median FEV1% predicted, 36 [interquartile range, 27-48]). PR uptake was 41% and 34% in the usual care and intervention groups, respectively (P = 0.37), with no differences in secondary (PR referral and completion) or safety (readmissions and death) endpoints. A total of 6 of the 15 participants interviewed could not recall receiving the video.Conclusions: A codesigned education video delivered at hospital discharge did not improve posthospitalization PR uptake, referral, or completion.