Home-based maintenance tele-rehabilitation reduces the risk for acute exacerbations of COPD, hospitalisations and emergency department visits

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    Publication Date

    16-02-2017

    Source Authors

    Antiopi Genimata, S., Chynkiamis, N., Kaltsakas, G., Kortianou, E., Kostikas, K., Koulouris, N. G., Louvaris, Z., Palamidas, A., Papaioannou, A. I, Spetsioti, S., Vasilopoulou, M., Vogiatzis, I.

    Source Title

    Home-based maintenance tele-rehabilitation reduces the risk for acute exacerbations of COPD, hospitalisations and emergency department visits

    Source Issue

    European Respiratory Journal

    49

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    La riabilitazione respiratoria è tutt’oggi poco praticata tra i pazienti idonei ad effettuarla, poiché l’accesso a lungo termine alla stessa è basso a causa di fondi e risorse insufficienti ed altre barriere paziente-dipendenti. La sua efficacia per il miglioramento della capacità funzionale, della dispnea cronica e dal punto di vista psicologico è comprovata; questi benefici vengono però solitamente perduti a distanza di 12 mesi se non viene implementata una strategia di mantenimento. Per questo motivo sono stati raccomandati approcci alternativi dalla ATS (American Thoracic Society) come la tele-riabilitazione per estendere i benefici iniziali della riabilitazione respiratoria sul lungo termine. Per tele-riabilitazione si intende l’utilizzo di tecnologie della comunicazione per rendere accessibile la riabilitazione respiratoria direttamente a casa, con l’obiettivo di far sì che in un ambiente familiare i pazienti integrino più facilmente gli esercizi proposti nella loro routine quotidiana.

    Il presente trial randomizzato controllato e prospettico (effettuato tra Dicembre 2013 e Luglio 2015) mira a stabilire se la tele-riabilitazione effettuata a casa sia efficace quanto la riabilitazione praticata in ospedale, e migliore rispetto all’assistenza di base nel ridurre il rischio di riacutizzazioni nella BPCO, le ospedalizzazioni e le visite al pronto soccorso dei pazienti con tale patologia. Per questo un totale di 150 pazienti di età superiore a 40 anni e con diagnosi di BPCO sono stati divisi in tre gruppi in maniera randomizzata (50 pazienti assegnati al gruppo della tele-riabilitazione, 50 al gruppo di riabilitazione ambulatoriale in ospedale e 50 al gruppo dell’assistenza di base). La tele-riabilitazione comprendeva esercizi personalizzati con monitoraggio a distanza, accesso ad un call center 5 giorni alla settimana, supporto psicologico e consigli nutrizionali. Il programma riabilitativo ambulatoriale in ospedale includeva un training all’esercizio, fisioterapia e supporto psicologico. L’assistenza di base includeva invece farmacoterapia ed ossigeno terapia, vaccino contro lo Streptococco Pneumoniae, l’influenza e un follow-up regolare.

    In seguito al completamento di un programma di base di due mesi di riabilitazione respiratoria, questo studio ha messo dunque a paragone 12 mesi di tele-riabilitazione a casa (47 pazienti) con 12 mesi di riabilitazione ambulatoriale in ospedale (50 pazienti) e 12 mesi di assistenza di base senza i due mesi di riabilitazione respiratoria iniziali. (50 pazienti).

    In un’analisi multivariata durante il follow-up di 12 mesi, la tele-riabilitazione di mantenimento è risultata efficace tanto quanto la riabilitazione respiratoria ambulatoriale in ospedale, ed entrambe sono state associate ad un rischio inferiore di: 1) riacutizzazioni di BPCO (Incidence Rate Ratio (IRR) 0.517, 95%  e Capacità inspitatoria (CI) 0.389–0.687, ed IRR 0.635, 95% e CI 0.473–0.853, rispettivamente, e 2) ospedalizzazioni per riacutizzazioni di BPCO (IRR 0.189, 95% CI 0.100–0.358, e IRR 0.375, 95% CI 0.207–0.681), rispettivamente. Tuttavia, solo la teleriabilitazione a casa e non quella ambulatoriale è stata associata ad un numero inferiore di accessi al pronto soccorso (IRR 0.116, 95% CI 0.072–0.185).

    La teleriabilitazione a casa è efficace quanto la riabilitazione polmonare di mantenimento ambulatoriale nel ridurre i rischi di riacutizzazioni in BPCO ed ospedalizzazione. Inoltre, porta ad un rischio inferiore di accessi al pronto soccorso per riacutizzazioni, costituendo una strategia alternativa potenzialmente efficace alla riabilitazione respiratoria ambulatoriale.

    Bibliografia

    1. Garvey, C., Singh, S.J., Spruit, M.A., et al. (2013). An official American Thoracic Society/European Respiratory Society statement: key concepts and advances in pulmonary rehabilitation – Am J Respir Crit Care Med, 188: e13–e64.
    2. Singh, S.J., Spruit, M.A. (2013). Maintenance programs after pulmonary rehabilitation: how may we advance this field? – Chest, 144: 1091–1093.
    3. Beauchamp, M.K., Evans, R., Janaudis-Ferreira, T., et al. (2013). Systematic review of supervised exercise programs after pulmonary rehabilitation in individuals with COPD – Chest, 144: 1124–1133.
    4. Ambrosino, N., Bianchi, L., Foglio, K. (2001). Is it really useful to repeat outpatient pulmonary rehabilitation programs in patients with chronic airway obstruction? A 2-year controlled study – Chest, 119: 1696–1704.
    5. Hill, C.J., Holland, A.E., Mahal, A., et al. (2017).Home-based rehabilitation for COPD using minimal resources: a randomised, controlled equivalence trial – Thorax, 72: 57–65.
    6. Maltais F, Bourbeau J, Shapiro S, et al. Effects of home-based pulmonary rehabilitation in patients with chronic obstructive pulmonary disease: a randomized trial. Ann Intern Med 2008; 149: 869–878.
    7. Moore, E., Newson, R., Palmer, T., et al. (2016). Pulmonary rehabilitation as a mechanism to reduce hospitalizations for acute exacerbations of COPD: a systematic review and meta-analysis – Chest, 150: 837–859.
    8. Holland, A.E., Rochester, C.L., Vogiatzis, I., et al. (2015). An official American Thoracic Society/European Respiratory Society policy statement: enhancing implementation, use, and delivery of pulmonary rehabilitation – Am J Respir Crit Care Med, 192: 1373–1386.
    9. Brennan, D., Theodoros, D., Tindall, L., et al. (2010). A blueprint for telerehabilitation guidelines – Int J Telerehabil, 2: 31–34.
    10. Hill, C.J., Holland, A.E., Rochford, P., et al. (2013). Telerehabilitation for people with chronic obstructive pulmonary disease: feasibility of a simple, real time model of supervised exercise training – J Telemed Telecare, 19: 222–226.
    11. Goldstein, R.S., O’Hoski, S. (2014). Telemedicine in COPD: time to pause – Chest, 145: 945–949.
    12. Jourdain, T., Stickland, M., Wong, E.Y., et al. (2011). Using Telehealth technology to deliver pulmonary rehabilitation in chronic obstructive pulmonary disease patients – Can Respir J, 18: 216–220.
    13. Andreassen, H.K., Hoaas, H.,  Lien, L.A., et al. (2016). Adherence and factors affecting satisfaction in long-term telerehabilitation for patients with chronic obstructive pulmonary disease: a mixed methods study – BMC Med Inform Decis Mak, 16: 26.
    14. Aaroen Lien, L., Hoaas, H., Zanaboni, P., et al. (2017). Long-term exercise maintenance in COPD via telerehabilitation: a two-year pilot study – J Telemed Telecare, 23: 74–82.
    15. Holmner, A., Lundell, S., Rehn, B., et al. (2015). Telehealthcare in COPD: A systematic review and meta-analysis on physical outcomes and dyspnea – Respir Med, 109: 11–26.
    16. Brusse-Keizer, M., Tabak, M., van der Valk, P., et al. (2014). A telehealth program for self-management of COPD exacerbations and promotion of an active lifestyle: a pilot randomized controlled trial – Int J Chron Obstruct Pulmon Dis, 9: 935–944.
    17. Dubois, M.F., Larivee, P., Marquis, N., et al. (2015).Are improvements maintained after in-home pulmonary telerehabilitation for patients with chronic obstructive pulmonary disease? – Int J Telerehabil, 6: 21–30.
    18. Nanas, S., Terzis, G., Vogiatzis, I., et al. (2005).Skeletal muscle adaptations to interval training in patients with advanced COPD. Chest, 128: 3838–3845.
    19. Global Strategy for Diagnosis, Management, and Prevention of COPD. (2014). Available from: http://goldcopd.org/
    20. Kocsis, O., Tsopanoglou, A., Vasilopoulou, M., et al. (2015). Telemonitoring system for home rehabilitation of patients with COPD. The 5th IEEE International Conference on E-Health and Bioengineering – EHB, Iaşi, Romania, available from: http://ieeexplore.ieee.org/document/7391438/
    21. Standardization of Spirometry, 1994 Update. (1995). American Thoracic Society – Am J Respir Crit Care Med, 152: 1107–1136.
    22. ATS statement: guidelines for the six-minute walk test. (2002). Am J Respir Crit Care Med, 166: 111–117.
    23. Louvaris, Z., Rabinovich, R.A., Raste, Y., et al. (2013). Validity of physical activity monitors during daily life in patients with COPD – Eur Respir J, 42: 1205–1215.
    24. Louvaris, Z., Raste, Y., Van Remoortel, H., et al. (2012). Validity of six activity monitors in chronic obstructive pulmonary disease: a comparison with indirect calorimetry – PloS ONE, 7: e39198.
    25. Meijer, J.W., Stoop, W.A., van Ranst, D., et al. (2014). Reduction of exacerbation frequency in patients with COPD after participation in a comprehensive pulmonary rehabilitation program – Int J Chron Obstruct Pulmon Dis, 9: 1059–1067.
    26. Rochester, C.L., Spruit, M.A., Vogiatzis, I., et al. (2016). Increasing implementation and delivery of pulmonary rehabilitation: key messages from the new ATS/ERS policy statement – Eur Respir J, 47: 1336–1341.
    27. Belda, J., Casan, P., Guell, R., et al. (2000). Long-term effects of outpatient rehabilitation of COPD: A randomized trial – Chest, 117: 976–983.
    28. Ramis, F., Renom, F., Rubi, M., et al. (2010).Effectiveness of pulmonary rehabilitation in reducing health resources use in chronic obstructive pulmonary disease – Arch Phys Med Rehabil, 91: 364–368.
    29. Behnke, M., Jorres, R.A., Kirsten, D., et al. (2003).Clinical benefits of a combined hospital and home-based exercise programme over 18 months in patients with severe COPD – Monaldi Arch Chest Dis, 59: 44–51.
    30. Achelrod, D., Schreyogg, J., Stargardt, T. (2016). Health-economic evaluation of home telemonitoring for COPD in Germany: evidence from a large population-based cohort – Eur J Health Econ, in press [https://doi.org/10.1007/s10198-016-0834-x].
    31. Geitona, M., Hatzikou, M., Steiropoulos, P., et al. (2011). The cost of COPD exacerbations: a university hospital—based study in Greece – Respir Med, 105: 402–409.
    32. Gourgoulianis, K.I., Kerenidi, T., Stafyla, E. (2013). Chronic obstructive pulmonary disease exacerbation frequency and severity – Int J Chron Obstruct Pulmon Dis, 8: 533–535.
    33. Barberan-Garcia, A., Solberg, H.S., Vogiatzis, I., et al. (2014). Effects and barriers to deployment of telehealth wellness programs for chronic patients across 3 European countries – Respir Med, 108: 628–637.
    34. Holmner, A., Lundell, S., Rehn, B., et al. (2015). Telehealthcare in COPD: a systematic review and meta-analysis on physical outcomes and dyspnea – Respir Med, 109: 11–26.
    35. Colombo, F., Paneroni, M., Papalia, A., et al. (2015).Is Telerehabilitation a safe and viable option for patients with COPD? A feasibility study – COPD, 12: 217–225.
    36. Brooks, D., Cruz, J., Marques, A. (2014). Home telemonitoring in COPD: a systematic review of methodologies and patients’ adherence – Int J Med Inform, 83: 249–263.
    37. Bourbeau, J., Julien, M., Maltais, F., et al. (2003). Reduction of hospital utilization in patients with chronic obstructive pulmonary disease: a disease-specific self-management intervention – Arch Intern Med, 163: 585–591.
    38. Gill, D.P., Nguyen, H.Q., Wolpin, S., et al. (2009). Pilot study of a cell phone-based exercise persistence intervention post-rehabilitation for COPD – Int J Chron Obstruct Pulmon Dis, 4: 301–313.
    39. Oluboyede, Y., Walters, S.J., Waterhouse, J.C., et al. (2010). A randomised 2 × 2 trial of community versus hospital pulmonary rehabilitation, followed by telephone or conventional follow-up – Health Technol Assess, 14: i–v, vii–xi, 1–140.
    40. Antoniades, N.C., Pretto, J.J., Rochford, P.D., et al. (2012). Pilot study of remote telemonitoring in COPD – Telemed J E Health, 18: 634–640.
    41. Annandale, J.A., Lewis, K.E., Warm, D.L., et al. (2010).Home telemonitoring and quality of life in stable, optimised chronic obstructive pulmonary disease – J Telemed Telecare, 16: 253–259.
    42. Polkey, M., Troosters, T., van der Molen, T., et al. (2013). Improving physical activity in COPD: towards a new paradigm – Respir Res, 14: 115.
    43. Balcells, E., Donaire-Gonzalez, D., Gimeno-Santos, E., et al. (2013). Physical activity in COPD patients: patterns and bouts – Eur Respir J, 42: 993–1002.
    44. Brondum, E., Martinez, G., Ringbaek, T., et al. (2010). Long-term effects of 1-year maintenance training on physical functioning and health status in patients with COPD: A randomized controlled study – J Cardiopulm Rehabil Prev, 30: 47–52.
    45. Bartlett S.J., Bourbeau, J. (2008). Patient adherence in COPD – Thorax, 63: 831–838.
    46. Sulaiman, I., Cushen, B., Greene, G., et al. (2016). Objective assessment of adherence to inhalers by COPD patients – Am J Respir Crit Care Med, in press [https://doi.org/10.1164/rccm.201604-0733OC].
    47. Papaioannou AI, Bartziokas K, Tsikrika S, et al. (2013). The impact of depressive symptoms on recovery and outcome of hospitalised COPD exacerbations – Eur Respir J, 41: 815–823.
    48. Bartziokas, K., Loukides, S., Papaioannou, A.I., et al. (2015). Cardiovascular comorbidities in hospitalised COPD patients: a determinant of future risk? – Eur Respir J, 46: 846–849.