Effects of eHealth-Based Interventions on Adherence to Components of Cardiac Rehabilitation: A Systematic Review.

OBJECTIVE: The aim of this study was to determine the effects of eHealth-based interventions on patient adherence to components of cardiac rehabilitation (CR). METHODS: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement guided this review. Medline, CINAHL, Embase, and Cochrane Library databases were searched for studies published from January 1996 to December 2017. All studies were included in which eHealth-based components of CR and its effects on patient adherence were measured. Because this review included a heterogeneous group of study designs, the authors qualitatively described the effect of eHealth on adherence into a narrative approach. RESULTS: A total of 1520 studies were identified, with 1415 excluded after screening. Of the remaining 105 studies, 90 were excluded after full text assessment, leaving 15 studies for analysis. Most (11) of the 15 studies reported on medication adherence. Other studies focused on adherence to diet, physical activity, vital signs, weight, step counts, smoking, and fluid restriction. The type of eHealth used also varied, ranging from telemonitoring and web-based applications to telephone calls. Of the 15 studies, 7 reported significant improvements with eHealth-based components of CR on adherence. DISCUSSION AND CONCLUSION: This review summarizes the effects of eHealth on components of CR and revealed variations in measurement and evaluation methods. The telemonitoring and web-based applications for self-care behaviors were most effective in promoting adherence. The measurement of adherence should be based on an explicit definition of adherence and should be measured with validated scales tested in the CR population.

An Official American Thoracic Society/European Respiratory Society Policy Statement: Enhancing Implementation, Use, and Delivery of Pulmonary Rehabilitation.

RATIONALE: Pulmonary rehabilitation (PR) has demonstrated physiological, symptom-reducing, psychosocial, and health economic benefits for patients with chronic respiratory diseases, yet it is underutilized worldwide. Insufficient funding, resources, and reimbursement; lack of healthcare professional, payer, and patient awareness and knowledge; and additional patient-related barriers all contribute to the gap between the knowledge of the science and benefits of PR and the actual delivery of PR services to suitable patients. OBJECTIVES: The objectives of this document are to enhance implementation, use, and delivery of pulmonary rehabilitation to suitable individuals worldwide. METHODS: Members of the American Thoracic Society (ATS) Pulmonary Rehabilitation Assembly and the European Respiratory Society (ERS) Rehabilitation and Chronic Care Group established a Task Force and writing committee to develop a policy statement on PR. The document was modified based on feedback from expert peer reviewers. After cycles of review and revisions, the statement was reviewed and formally approved by the Board of Directors of the ATS and the Science Council and Executive Committee of the ERS. MAIN RESULTS: This document articulates policy recommendations for advancing healthcare professional, payer, and patient awareness and knowledge of PR, increasing patient access to PR, and ensuring quality of PR programs. It also recommends areas of future research to establish evidence to support the development of an updated funding and reimbursement policy regarding PR. CONCLUSIONS: The ATS and ERS commit to undertake actions that will improve access to and delivery of PR services for suitable patients. They call on their members and other health professional societies, payers, patients, and patient advocacy groups to join in this commitment.

An official American Thoracic Society/European Respiratory Society statement: key concepts and advances in pulmonary rehabilitation.

BACKGROUND: Pulmonary rehabilitation is recognized as a core component of the management of individuals with chronic respiratory disease. Since the 2006 American Thoracic Society (ATS)/European Respiratory Society (ERS) Statement on Pulmonary Rehabilitation, there has been considerable growth in our knowledge of its efficacy and scope. PURPOSE: The purpose of this Statement is to update the 2006 document, including a new definition of pulmonary rehabilitation and highlighting key concepts and major advances in the field. METHODS: A multidisciplinary committee of experts representing the ATS Pulmonary Rehabilitation Assembly and the ERS Scientific Group 01.02, "Rehabilitation and Chronic Care," determined the overall scope of this update through group consensus. Focused literature reviews in key topic areas were conducted by committee members with relevant clinical and scientific expertise. The final content of this Statement was agreed on by all members. RESULTS: An updated definition of pulmonary rehabilitation is proposed. New data are presented on the science and application of pulmonary rehabilitation, including its effectiveness in acutely ill individuals with chronic obstructive pulmonary disease, and in individuals with other chronic respiratory diseases. The important role of pulmonary rehabilitation in chronic disease management is highlighted. In addition, the role of health behavior change in optimizing and maintaining benefits is discussed. CONCLUSIONS: The considerable growth in the science and application of pulmonary rehabilitation since 2006 adds further support for its efficacy in a wide range of individuals with chronic respiratory disease.

Prevalence and prognostic importance of exercise limitation and physical inactivity in COPD.

Exercise limitation and physical inactivity are separate, but related constructs. Both are commonly present in individuals with COPD, contribute to disease burden over and above the respiratory impairments, and are independently predictive of adverse outcomes. Because of this, clinicians should consider assessing these variables in their patients with COPD. Field tests of exercise performance such as the 6-min walk test and the incremental and endurance shuttle walk tests require limited additional resources, and results correlate with negative outcomes. Laboratory measures of exercise performance using a treadmill or cycle ergometer assess exercise capacity, provide prognostic information and have the advantage of explaining physiological mechanisms (and their interactions) underpinning exercise limitation. Limitations in exercise capacity (i.e. "cannot do") and physical inactivity (i.e. "do not do") are both associated with mortality; exercise limitation appears to be the more important driver of this outcome.

An official American Thoracic Society statement: update on the mechanisms, assessment, and management of dyspnea.

BACKGROUND: Dyspnea is a common, distressing symptom of cardiopulmonary and neuromuscular diseases. Since the ATS published a consensus statement on dyspnea in 1999, there has been enormous growth in knowledge about the neurophysiology of dyspnea and increasing interest in dyspnea as a patient-reported outcome. PURPOSE: The purpose of this document is to update the 1999 ATS Consensus Statement on dyspnea. METHODS: An interdisciplinary committee of experts representing ATS assemblies on Nursing, Clinical Problems, Sleep and Respiratory Neurobiology, Pulmonary Rehabilitation, and Behavioral Science determined the overall scope of this update through group consensus. Focused literature reviews in key topic areas were conducted by committee members with relevant expertise. The final content of this statement was agreed upon by all members. RESULTS: Progress has been made in clarifying mechanisms underlying several qualitatively and mechanistically distinct breathing sensations. Brain imaging studies have consistently shown dyspnea stimuli to be correlated with activation of cortico-limbic areas involved with interoception and nociception. Endogenous and exogenous opioids may modulate perception of dyspnea. Instruments for measuring dyspnea are often poorly characterized; a framework is proposed for more consistent identification of measurement domains. CONCLUSIONS: Progress in treatment of dyspnea has not matched progress in elucidating underlying mechanisms. There is a critical need for interdisciplinary translational research to connect dyspnea mechanisms with clinical treatment and to validate dyspnea measures as patient-reported outcomes for clinical trials.

Defining Modern Pulmonary Rehabilitation. An Official American Thoracic Society Workshop Report.

Pulmonary rehabilitation is a highly effective treatment for people with chronic lung disease but remains underused across the world. Recent years have seen the emergence of new program models that aim to improve access and uptake, including telerehabilitation and low-cost, home-based models. This workshop was convened to achieve consensus on the essential components of pulmonary rehabilitation and to identify requirements for successful implementation of emerging program models. A Delphi process involving experts from across the world identified 13 essential components of pulmonary rehabilitation that must be delivered in any program model, encompassing patient assessment, program content, method of delivery, and quality assurance, as well as 27 desirable components. Only those models of pulmonary rehabilitation that have been tested in clinical trials are currently considered as ready for implementation. The characteristics of patients most likely to succeed in each program model are not yet known, and research is needed in this area. Health professionals should use clinical judgment to determine those patients who are best served by a center-based, multidisciplinary rehabilitation program. A comprehensive patient assessment is critical for personalization of pulmonary rehabilitation and for effectively addressing individual patient goals. Robust quality-assurance processes are important to ensure that any pulmonary rehabilitation service delivers optimal outcomes for patients and health services. Workforce capacity-building and training should consider the skills necessary for emerging models, many of which are delivered remotely. The success of all pulmonary rehabilitation models will be judged on whether the essential components are delivered and on whether the expected patient outcomes, including improved exercise capacity, reduced dyspnea, enhanced health-related quality of life, and reduced hospital admissions, are achieved.

Predictors of Survival in COPD: more than just the FEV1.

Chronic obstructive pulmonary disease (COPD) ranks fourth as a cause of death in the United States, behind heart disease, cancer, and stroke. Additionally, since serious co-morbidities are often present in patients with COPD, many die from other diseases such as cardiac disease or cancer. Not surprisingly, multiple factors, reflective of both respiratory disease process and the substantial co-morbidity, predict survival in the disease. As might be expected, physiologic derangements such as airflow obstruction, hypoxemia, lung hyperinflation, and exercise capacity predict survival in COPD. Anemia, cachexia and reductions in lean body mass also relate to prognosis. Perhaps less recognized is the more recent documentation that more subjective assessments, such as dyspnea and health related quality of life, are also important predictors of survival. The integration of some of the most important of these variables may provide a more comprehensive evaluation of disease severity. For example, a validated multi-dimensional disease rating that includes the body mass index (B), degree of airflow obstruction (O), dyspnea (D), and exercise capacity (E) (BODE Index) is capable of predicting COPD-related hospitalization and mortality more than its individual components.

Validation of Chinese version of the Modified Pulmonary Functional Status and Dyspnea Questionnaire with heart failure patients in Taiwan.

BACKGROUND: Dyspnea is a distressing and functionally limiting symptom that patients with heart failure commonly experience. A valid instrument to quantify dyspnea for comparison of groups and for illness management is important. OBJECTIVE: To validate the Chinese version of the Modified Pulmonary Functional Status and Dyspnea Questionnaire. METHODS: The Chinese version was developed by using translation and back translation and was tested in Taiwan in 88 patients who had heart failure but no pulmonary disease or comorbid conditions limiting physical function. Data on a Taiwanese subsample (n=30) were compared with data on 30 patients in the United States matched by sex, age, and severity of disease to determine the equivalence of the Chinese and English versions. Construct validity was assessed by testing the hypothesis that health-related quality of life measured by using the Minnesota Living With Heart Failure Questionnaire is associated with the score on the dyspnea questionnaire. Reliability was assessed by using the Cronbach alpha and item-total correlations. RESULTS: Equivalence between the US and Taiwanese samples was high, from 0.67 to 0.91 for each item of the questionnaire and for the total score. Satisfactory correlations between the Chinese dyspnea and the Minnesota questionnaires, especially in the physical dimension (r=0.71, P<.001), provided support for the construct validity of the Chinese questionnaire. Reliability of the Chinese questionnaire was adequate (alpha=0.94). CONCLUSIONS: The Chinese Modified Pulmonary Functional Status and Dyspnea Questionnaire is a reliable and valid measure for dyspnea that can be used in Taiwanese patients with heart failure.

Chronic Obstructive Pulmonary Disease Education in Pulmonary Rehabilitation. An Official American Thoracic Society/Thoracic Society of Australia and New Zealand/Canadian Thoracic Society/British Thoracic Society Workshop Report.

According to the 2013 American Thoracic Society/European Respiratory Society statement on pulmonary rehabilitation (PR), education to promote effective self-management is a cornerstone of this intervention. Despite education's stature within PR, there is currently limited evidence supporting its overall efficacy, and minimal evidence guiding its optimal design and delivery. This workshop was convened to focus on the current state of education in PR for patients with chronic obstructive pulmonary disease, who are the most common people referred to PR. The workshop explored the learning needs and limitations of patients participating in PR, promising design features (from work done outside of PR) that may inform our approach to education, and professional development of PR healthcare educators. Areas identified as needing development include: 1) outcome assessment for the educational component; 2) screening patients for conditions that will impede the learning process (anxiety, depression, cognitive deficits and health literacy issues); 3) tailoring content and optimizing delivery of the educational component; and 4) training PR professionals in their roles as educators. By necessity, the workshop conclusions are painted in broad strokes. However, with ongoing interest in improving quality through individualized patient assessment, educational design innovations, and scientific scrutiny comparable to that given to exercise training, the educational component of PR may achieve effective self-management, leading to successful behavior change and enhancement in health.

Incorporating telemedicine into the integrated care of the COPD patient a summary of an interdisciplinary workshop held in Stresa, Italy, 7-8 September 2017.

This report is a summary of a workshop focusing on using telemedicine to facilitate the integrated care of chronic obstructive pulmonary disease (COPD). Twenty-five invited participants from 8 countries met for one and one-half days in Stresa, Italy on 7-8 September 2017, to discuss this topic. Participants included physiotherapists, nurses, a nurse practitioner, and physicians. While evidence-based data are always at the center of sound inference and recommendations, at this point in time the science behind telemedicine in COPD remains under-developed; therefore, this document reflects expert opinion and consensus. While telemedicine has great potential to expand and improve the care of our COPD patients, its application is still in its infancy. While studies have demonstrated its effectiveness in some patient-centered outcomes, the results are by no means consistently positive. Whereas this tool may potentially reduce health care costs by moving some medical interventions from centralized locations in to patient's home, its cost-effectiveness has had mixed results and telemonitoring has yet to prove its worth in the COPD population. These discordant results should not be unexpected in view of patient complexity and the heterogeneity of telemedicine. This is reflected in the very limited support offered by the National Health Services to a wider application of telemedicine in the integrated care of COPD patients. However, this situation should challenge us to develop the necessary science to clarify the role of telemedicine in the medical management of our patients, providing a better and definitive scientific basis to this approach.

Safety of inhaled long-acting anti-muscarinic agents in COPD.

Evidence-based guidelines recommend inhaled long-acting anti-muscarinic agents (LAMAs) as first-line maintenance therapy for symptomatic patients with COPD. Several LAMAs are now available for use either as monotherapy or in combination with other COPD medications, including long-acting ß2-agonists (LABAs) or inhaled corticosteroids (ICS). The efficacy and long-term safety of these medications have been evaluated in multiple clinical trials and real-life studies. This review evaluates the evidence available on the safety of existing LAMAs alone or in combination with LABAs and ICS in patients with COPD.

Why Don't Our Patients with Chronic Obstructive Pulmonary Disease Listen to Us? The Enigma of Nonadherence.

Nonadherence--not taking pharmacologic or nonpharmacologic treatments according to agreed recommendations from a health care provider--is common in patients with chronic obstructive pulmonary disease. Nonadherence in taking maintenance medications, smoking cessation, maintaining regular physical activity and exercise, starting and staying in pulmonary rehabilitation and continuing on with the postrehabilitation exercise/activity prescription, and successfully following self-management directions results in adverse outcomes across multiple areas. These include a faster decline in airway function, higher symptom burden, impaired health status, and increased health care use and mortality risk. Although nonadherence can also occur in health care providers (not following established treatment guidelines), this perspective focuses on patient nonadherence. Factors such as social/economic, health system, therapy-related, patient-related, and condition-related factors all impact this problem. To improve patient adherence, we need to consider these factors in the context of people with chronic obstructive pulmonary disease and implement strategies directly targeting underlying issues. Strategies may include customizing and simplifying learning and intervention regimes, identifying barriers to adherence and addressing them, ensuring patient support structures are in place, and improving self-efficacy. Future directions should focus on research and development in educational design; use of technology to assist education; psychological intervention strategies to support learning, motivation, self-efficacy and behavior change; and ways to improve healthcare providers' engagement with patients.

Meeting the challenge of COPD care delivery in the USA: a multiprovider perspective.

The burden of chronic obstructive pulmonary disease (COPD) in the USA continues to grow. Although progress has been made in the the development of diagnostics, therapeutics, and care guidelines, whether patients' quality of life is improved will ultimately depend on the actual implementation of care and an individual patient's access to that care. In this Commission, we summarise expert opinion from key stakeholders-patients, caregivers, and medical professionals, as well as representatives from health systems, insurance companies, and industry-to understand barriers to care delivery and propose potential solutions. Health care in the USA is delivered through a patchwork of provider networks, with a wide variation in access to care depending on a patient's insurance, geographical location, and socioeconomic status. Furthermore, Medicare's complicated coverage and reimbursement structure pose unique challenges for patients with chronic respiratory disease who might need access to several types of services. Throughout this Commission, recurring themes include poor guideline implementation among health-care providers and poor patient access to key treatments such as affordable maintenance drugs and pulmonary rehabilitation. Although much attention has recently been focused on the reduction of hospital readmissions for COPD exacerbations, health systems in the USA struggle to meet these goals, and methods to reduce readmissions have not been proven. There are no easy solutions, but engaging patients and innovative thinkers in the development of solutions is crucial. Financial incentives might be important in raising engagement of providers and health systems. Lowering co-pays for maintenance drugs could result in improved adherence and, ultimately, decreased overall health-care spending. Given the substantial geographical diversity, health systems will need to find their own solutions to improve care coordination and integration, until better data for interventions that are universally effective become available.

Descriptors of dyspnea by patients with chronic obstructive pulmonary disease versus congestive heart failure.

OBJECTIVES: The purpose of this study was to determine whether differences existed between reports of dyspnea in stable chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF) subjects. METHODS: Sixty stable COPD (n=30) and CHF (n=30) male, outpatient subjects were studied. Subjects were asked to both endorse (from a pre-designed list of descriptors) and volunteer terms that best described their breathing discomfort. Subjects also reported the frequency and the intensity of breathlessness (0-10 scale) using the Pulmonary Functional Status and Dyspnea Questionnaire. RESULTS: From the endorsed list of descriptors, my breath does not go out all the way, was significantly different (COPD=11, CHF=4, P<.05) between groups. The most common terms volunteered by COPD subjects were scary (n=5, P<.02), hard to breathe (n=5), shortness of breath (n=4), and cannot get enough air (n=4), whereas CHF subjects volunteered the terms, shortness of breath (n=9), gasping (n=6), and cannot get enough air (n=4). There was no difference in the frequency with which both groups experienced dyspnea or times per month they reported severe to very severe dyspnea. Subjects with COPD experienced a higher intensity of breathlessness on different occasions P<.05. CONCLUSIONS: Stable COPD and CHF patients use and recognize a variety of terms that describe their breathing distress. There was, however, only 1 unique term among the endorsed and volunteered terms, and that was among the COPD subjects. COPD and CHF subjects shared many common terms and also experienced dyspnea with similar frequency. The uniqueness of terms among the COPD group was less clear. The study highlights the variability of the dyspnea experience among COPD and CHF patients and the potential difficulty identifying unique dyspnea terms in these subjects.

Are self-reports of breathing effort and breathing distress stable and valid measures among persons with asthma, persons with COPD, and healthy persons?

BACKGROUND: Breathing is a subjective experience that includes physical sensations, such as effort to breathe, and an affective element, such as breathing distress. OBJECTIVE: The overall purpose of this investigation was to evaluate whether measurement of the physical sensations (breathing effort) and affective response to these sensations of breathing (breathing distress) are consistent and valid. DESIGN: A longitudinal repeated measures design was used to evaluate a 2-week daily breathing with a sub-sample (n = 43) who also recorded their daily breathing during 4 weeks. SUBJECTS: Age-matched, stable subjects (n = 92) with an average age of 62 were evaluated. The sample consisted of 32 subjects with chronic obstructive pulmonary disease, 27 subjects with asthma, and 33 healthy subjects. MEASURES: Visual Analogue Scales for breathing effort (VAS-E) and breathing distress (VAS-D) were scored daily. RESULTS: The VAS-E and VAS-D mean, highest, and lowest scores were found to be stable over time in the sub-sample and a significant difference (F = 2.56, P <.05) between VAS-E and VAS-D was found. Differences were found in mean and highest VAS-E and VAS-D by group, with the COPD group reporting the highest values. CONCLUSIONS: This investigation provided initial evidence of the stability and validity of daily VAS-E and VAS-D measures and preliminary support for the use of daily VAS logs to evaluate differences in breathing effort and breathing distress.