Chronic Obstructive Pulmonary Disease Rehabilitation Class

Community Rehab COPD

Background information

Evidence for pulmonary rehabilitation

Eligibility for the proposed pulmonary rehabilitation program shall be in line the NICE COPD guideline (2010). This states that “pulmonary rehabilitation should be offered to all patients who feel functionally disabled by COPD” (NICE 2010).

“The opportunity for structured, on going exercise with peer and professional support, in a suitable venue, is perceived as important to people with COPD in facilitating a physically active lifestyle following pulmonary rehabilitation” (Hogg et al. 2012).

According to General Practice Airways group's sharing of best practice meeting (2005) and the American Thoracic Society/European Respiratory Society Statement on Pulmonary Rehabilitation (2006), at least one supervised session is required per week for effective pulmonary rehabilitation. It has also been suggested that two supervised sessions per week may have a better impact on health-related quality of life (Liddell and Webber 2010). Making it a regular weekly program would give the program a structure and would ensure that the participants have regular support which has been found to be important in exercise regimes, especially in this population (O'Shea et al. 2007). Therefore, to make this program as cost effective as possible, we suggest that it will contain two weekly exercise classes as a number of individual supervised rehabilitation sessions would be capital and labour intensive.

As is desirable, exercise sessions would be delivered by healthcare professionals, including a physiotherapist and physiotherapy technical instructor, both with experience in cardio-respiratory rehabilitation (Backley et al. 2005). The location of these sessions would be in the community as according to the COPD guidelines published by NICE, pulmonary rehabilitation classes should be held in locations which are easily accessed by participants to ensure their effectiveness (NICE 2010). In addition, it has been found that difficulties with transport is a barrier to completion of pulmonary rehabilitation (Keating et al. 2011). The NICE guideline also states that these are to be held at times which suit the participants (NICE 2010). These group sessions would be interspersed with exercise sessions which participants would do in their own time at home or in a local leisure facility. It is suggested that a minimum of four home sessions are completed per week (Backley et al. 2005).

As recommended by the American Thoracic Society/European Respiratory Society Statement on Pulmonary Rehabilitation (2006), a minimum of twenty exercise sessions would be included in this pulmonary rehabilitation program at a frequency of at least three per week, with one or two of these being supervised. According to the NICE COPD guideline (2010), duration of initial pulmonary rehabilitation should be between six and 12 weeks. To conform to both of these guidelines, we propose a 10 week pulmonary rehabilitation program consisting of two supervised sessions per week.

Although exercise of varied intensity has been shown to be beneficial for people with COPD, high intensity exercises would be encouraged in this rehabilitation program for greater physiological effects (Nici et al. 2006). In addition to the traditional lower limb training included in pulmonary rehabilitation, such as treadmill walking or cycling, upper limb exercises, such as arm ergometer or hand weights, will be included as a number of beneficial effects have been noted including reduce ventilator requirements while using the arms (Couser et al. 1993, Epstein et al. 1997). Ideally, the rehabilitation program would contain aerobic exercise at an intensity of between four and six on Borg dyspnoea scale or more than 60% of max workload for at least 30 minutes. For resistance exercise, between two and four sets of six to twelve repetitions at an intensity of 50-80% of 1RM (Nici et al. 2006).

In addition to the structured exercise class, an essential educational component will be included in the pulmonary rehabilitation program (Backley et al. 2005). This would include teaching participants the importance of exercise. This is of specific importance with people in this population as many individuals with COPD elect not to take up a referral to pulmonary rehabilitation as they think they would not experience any health benefits from attendance. Ensuring good attendance at pulmonary rehabilitation requires consideration of how information regarding the proven benefits of pulmonary rehabilitation can be conveyed to participants (Keating et al. 2011). It is also important to supply the participants with information on how to transfer exercise into environments outside the class, such as their home, as this will be required for between supervised sessions and once they have completed the program (Nici et al. 2006). Information on relaxation, anxiety management, medication and self management (Backley et al. 2005), including an action plan for exacerbations (Nici et al. 2006), would also be included as this seen as being essential in an effective pulmonary rehabilitation program.

Analysis of needs

SWOT

Strengths

• The location of our class will be in a location that is easy to access, increasing adherence
• The community setting of this program will, potentially, cause less anxiety for participants than hospital setting
• The setting of the program will have more available space than most hospitals thus more capacity for participants
• Since the rehabilitation program is not been run in the hospital, there is a lower chance of participants acquiring healthcare related infections
• Our program will have qualified staff including first aiders who are trained in defibrillator use
• Evidence shows that pulmonary rehabilitation gives numerous benefits to participants including improved quality of life
• There is an increasing body of evidence that pulmonary rehabilitation decreases long term costs to NHS
• The group exercise setting provides peer support which people in this population often need
• <Addresses the need for some women to exercise when men are not present?>

Weaknesses

• Some participants may find a gym to be an intimidating setting
• Exercise is a undesirable activity for some participants, especially in people with COPD where breathlessness may be an issue

Opportunities

• There is a large prevalence and incidence of COPD
• Increased referrals to the program will reduce demands on NHS’s limited resources
• Greater exposure of pulmonary rehabilitation in the community will increase public awareness of this treatment option
• <ADDRESSES THE NEED FOR PUL REHAB IN WOMEN?>

Threats

• Other pulmonary rehabilitation classes:
• Some gyms run pulmonary rehabilitation classes. However, these 1 to 1 sessions with a gym instructor so there is a lack of peer and group support. In addition, this rehabilitation program will have all the material delivered by health professionals with experience in respiratory care.
• Pulmonary rehabilitation is also often held in the hospital. We feel that our program setting is less intimidating and carries fewer negative connotations. There is also the additional benefit of more car parking facilities than what is available at most hospitals.

Contextual issues

Patients' Experience of Pulmonary Rehabilitaion Classes

Patient A’s Story

Back before I started at breath smart I couldn’t do a lot. I was heavily dependent on oxygen and practically house bound. I couldn’t use the stairs or do my gardening or go to the shops. I was actually wheeled into my 1st class at breath smart because I couldn’t walk far at all. I must have been in hospital 8 or 9 times the year before I started these classes. I’ve been coming twice a week for just over a year and now I don’t use any oxygen at all and I will gladly take the stairs without and trouble. I haven’t been admitted to hospital once this year. I can now use the treadmill for 25mins at a time at a speed of 5.5km/hr and an incline of 3.5. I never thought this would be possible. Breath smart has given me back my freedom I can’t begin to explain the changes it has made to my life. I am however still smoking. If I was able to improve this much while still smoking I can only imagine how much better I would be if I could give them up but I haven’t been able to as of yet.

Patient B’s Story 
Before starting breath smart I spent a lot of time in hospital, my breathing was very bad and my general health was very bad also. I used an awful lot of oxygen. Confidence was a big problem. It was hard to know what to do, that was very very difficult. I had been very very active all my life and then everything came to a standstill. My consultant suggested I come to breath smart. I’m here 2 years now, and the difference in my life is huge! I couldn’t even start to tell people how much of a difference it has made to my life, but I do tell people. My family have all seen the difference it has made to my life. I’m more active. Coming to breath smart gives you an incentive, it gives you the confidence, the people here are professional you trust them, I trust everyone here they are very very good, they explain to you and tell you if you are doing too much or doing too little. This is the 1st year that I haven’t been in hospital since I was diagnosed.

Option appraisal/Advantages and disadvantages

The British Thoracic Society issued a statement on the benefits of pulmonary rehabilitation declaring the enhancements in exercise tolerance and health related quality of life (HRQOL) in patients with chronic obstructive pulmonary disease (COPD) (Ward et al., 2002). However, a recent survey highlighted that it is only available in 25% of U.K. hospitals (Davidson and Morgan, 1998) meaning lack of availability limits the number of COPD patients that can benefit. The majorities of programs are hospital-based and include individual exercise programmes and educational talks, but a key factor is the sharing of experiences among participants and their spouses.

There are a variety of settings in which pulmonary rehabilitation services for patients with COPD can be provided. Traditionally services were based in hospital inpatient and outpatient settings, but there is growing interest in developing services in community and home settings making it easier for patients to attend and carry out. As pulmonary rehabilitation classes have been long established in hospital based settings it is the standard comparison for any other potential pulmonary rehabilitation class settings.

Location is stated as a core element in the full clinical guideline on COPD, it states that for pulmonary rehabilitation programs to be effective and to improve compliance, they should be held at times that suit patients, in buildings that are easy for patients to get to and have good access for people with disabilities (NICE, 2010). Pulmonary rehabilitation has been found to have a positive impact on lowering health care costs, mainly by reducing the number of exacerbations and hospital admissions (Guëll et al., 2008). Therefore, if more patients can take part in these pulmonary rehabilitation classes it would save the NHS money in the long term as well as improving the patient’s wellbeing.

Waterhouse et al. (2010) conducted a powered, randomized 2 x 2 trial of 240 patients comparing pulmonary rehabilitation in a hospital versus community setting, followed up by telephone or conventional follow up. They found no significant difference in the percentage change in the distance walked during the Endurance Shuttle Walk Test relative to baseline between the hospital and the community rehabilitation groups. There was also no significant difference between the groups in terms of the increase in the time that they were able to walk for post-rehabilitation. The absence of any significant differences in these outcomes continued at 6 month, 12 month and 18month follow ups. There also appeared to be no indication of an effect of telephone versus conventional follow up. An economic analysis also conducted by the authors indicated no cost advantage to either of the rehabilitation settings or to telephone follow up.

Guëll et al. (2008) demonstrates the improvement in exercise tolerance achieved by COPD patients with an unsupervised home pulmonary rehabilitation program is similar to the improvements of patients in a rigorous hospital based program. However the hospital program gave greater benefit on the HRQOL area of emotional function. Similar improvements in both exercise tolerance and symptoms (dyspnea) were accomplished with both the home and hospital programs. It can be seen that dyspnea and exercise tolerance improved in the home based program indicating compliance with the program. It could be speculated that the lack of improvement in HRQOL measurements in the unsupervised home group is down to the inadequate psychological and emotional support from the pulmonary rehabilitation staff as this was an aspect of care that was received by the hospital based group. Results indicate that home based pulmonary rehabilitation can provide an alternative to traditional programs allowing rehabilitation to be given for larger numbers of patients.

Khdour et al. (2011) undertook a cost-utility analysis of a pharmacy-led self-management programme for COPD using a single outpatient COPD clinic. A randomized controlled trial was used with participants either receiving pharmacy-led education and a self-management programme or usual care. One year costs were estimated and quality-adjusted life years were calculated based on responses to EQ-SD at baseline, 6 and 12 months. The mean differences in costs and effects between self-management and education programme and usual care was -£671.59 showing it was less costly and more effective.

Home based pulmonary rehabilitation programs have been introduced in recently, and evidence suggests that they may give similar benefits to those of hospital based rehabilitation (Guëll et al., 2008). However, much of the evidence to support home based programs used resource and exercise intensive methods that may not be feasible in some settings. Findings among the studies were similar finding no significant differences for clinical effectiveness between settings. The differences established in HRQOL scores are important and highlights the proven positive impact of group sessions.

Hospital 

Advantages	Disadvantages
Peer support	Difficulty parking – possible
No external costs, i.e. rent	Busy environment
Patients may deem hospital appointments more important	Lack of available, purposeful space
Qualified medical staff	Limited exercise equipment
Safe, controlled environment	May associate hospital with acute illness
Medical equipment available	Increased chance of contracting an infection
Exercise equipment available	Costly, even in outpatient setting
Cost comparison found most efficient form of delivery	Suffer from high drop out rates with 20% not completing the program
Found to be effective in improving exercise tolerance and QoL	Patients discouraged because of frequent journeys to hospital
Patients often have difficulty getting to a hospital

Community

Advantages	Disadvantages
Peer support	External costs i.e. rent, travel expenses, equipment, resources
Motivational environment encouraging compliance	Patients may want to take part more anonymously
Familiar, friendly atmosphere
Low drop out rates
Sufficient amount of exercise equipment
Available, purposeful space
More involved within the community
Qualified physiotherapists
Relaxed atmosphere so patients feel more comfortable raising questions/issues
Influence patients participation in physical activity
Greater choice of venue making it more accessible
Local ownership

Home

Advantages	Disadvantages
Cost effective	Safety
No supervision	Adherence
Patient may feel safer and more comfortable exercising in own home	Information clear and well instructed? Patient understands and carries out correctly?
Can do it at time that suits patient	No supervision
	No peer support
	Any issues that arise may not be addressed immediately
	Feasibility of resources and equipment – cost, availability
	Practicalities of having equipment in home i.e. space

So when we look at all the advantages and disadvantages of each setting we can clearly see that the community setting is the outright winner with more advantages than disadvantages. While, the hospital setting appears to have a similar amount of advantages than disadvantages and the home setting appears to have more disadvantages than advantages. This again reinforces our choice of a community setting.

Community v hospital v home

So after looking at the evidence we have chosen to hold our pulmonary rehabilitation class in a community setting more specifically in a leisure centre. Evidence proved pulmonary rehabilitation provided in a community setting has comparable benefits to that produced in a more customary hospital-based setting, with both settings producing significant improvements in exercise capacity and quality of life (Maltais et al., 2008: Guell et al., 2008: Waterhouse et al., 2010). The choice of venue has been found to be determined by local factors of convenience, current availability of resources and incremental costs as supported by Waterhouse et al. (2010). The rationale for the choice of venue is multifaceted as the sports equipment such as treadmills and exercise bikes are within the centre and there is plenty of purposeful space to utilise. With the class being out width a clinical setting it has a more relaxed atmosphere free from the negative thoughts and feeling commonly associated with a hospital environment as identified by Slovic et al. (2004). The chances of patients already having visited a local venue helps reduce anxiety as they are familiar with their surroundings. Those taking part in the classes will also benefit from the support and encouragement of meeting local people with the same condition (Ward et al. 2002: Guell et al., 2008). With a sports centre there is a motivational atmosphere as those there are investing in themselves either to be fitter, healthier, look better or to perform better which will influence the patient’s attitude. By influencing the patient’s awareness this will encourage compliance, influence participation in physical activity as well as allowing the patients to become more involved in the community, as many sports centres have notice boards in their reception areas alerting people to other opportunities. Staff characteristics may play a vital role in achieving best possible outcomes so care is required when recruiting and training staff (Ward et al., 2002: Waterhouse et al., 2010). When health economic analysis was considered by Waterhouse et al. (2010) it revealed that neither hospital nor community based programmes were preferential. We found when we looked at the advantages and disadvantages of each setting we found that there were no advantages to using a hospital and many more disadvantages to a home setting while the community setting had far more advantages than disadvantages supporting our choice to use a community setting. When comparing hospital, community and home settings there were no clinical differences however the benefits of having the class in a community setting aided attendance and compliance helping not only patients but in the long run saving the NHS money by preventing exacerbations and reducing hospital admissions. 

Evidence suggests that there appears to be no clinical or cost benefit of community based pulmonary rehabilitation programs over hospital based pulmonary rehabilitation and that the venue may be best determined by local access preferences and transport links. This evidence therefore reinforces current recommendations in NICE CG101 (Nice, 2010). So, our choice to hold our pulmonary rehabilitation classes in a community setting has been found to benefit the patients and the budget as supported by the evidence and may be more successful as it takes into consideration other influences on patient’s ability to attend.

Financing

Fixed Expenses:
Below is a table indicating the fixed costs of the “insert name” class by year and by month.

Table 4: Fixed Expenses

Expenses	Yearly	Monthly
Venue	3600	300
Staff (Band 5 Physiotherapist)	2027.52	168.96
Staff (Physiotherapist Assistant)	1110.24	92.52
Personal Indemnity Insurance	Covered by CSP Membership	Covered by CSP Membership
Total	£6737.76	£561.48

To calculate the staffing costs we used the following stepped equation:

1. Number of workable hours per year
• Number of weeks per year X hours worked per week
• 52 X 37.5= 1950

2. Number of hours worked per year
• Number of workable hours per year– (Holiday + bank holiday hours)
• 1950 – [(27 X 7.5) + (8 X 7.5)]
• 1950 – (203 + 60)
• 1950 – 263
• 1687

3. Cost per hour for staff
• (Salary + Employers Contribution to National Insurance [13.08% for 2012-2013]) ÷ Hours worked per year
• Physiotherapist = 21,000 + 2750= 22750, 22750 ÷ 1687 = 14.08.
• Physiotherapist Assistant= 11500 + 1504.2 = 13004.2, 13004.2 ÷ 1687 = 7.71

4. Monthly Cost
• Cost per hour X hours per week X hours per month
• 2 class per week @ 1hr each plus 15mins pre and post = 3hrs per week

5. Yearly Cost
• monthly cost X 12

Variable Expenses:
Below is a table indicating the variable costs of the “insert name” class by year and by month.

Table 5: Variable Expenses

Expenses	Once off	Yearly	Monthly
Stationary
Printer	49.99	16.66	1.39
Tea and Coffee		96	8
Paper Cups		48	4
Plastic Spoons		24	2
Milk		96	8
Total	£49.99	£340.68	£28.39

The cost of the printer was worked out as follows: 

1. Yearly cost
• Cost of printer (priced at PC World) ÷ 3 (estimated minimal life expectancy)

2. Monthly cost
• Yearly cost ÷ months per year

Capital Expenses:
Below is a table indicating the capital costs of the “insert name” class by year and by month.

Table 6: Capital Expenses

Expenses	Once Off	Yearly	Monthly
Blood Pressure Monitor X 4	160	53.33	4.44
Pulse Oximeter	198	66	5.50
Total	£358	£119.33	£9.94

The cost of all capital equipment was worked out as follows:

1. Three quotes were explored and the average cost was taken

2. Yearly Cost
• Cost of item ÷ 3 (estimated minimal life expectancy)

3. Monthly cost
• Yearly cost ÷ months per year

Overhead Cost:
Fixed Expenses + Variable Expenses
Yearly overheads = £7078.44
Monthly overheads = £589.87

Starting Up Costs:
Capital expenses + 1st 3 month’s overheads
358 + (589.87 X 3)
358 + 1769.61
£2127.61

Cost of Service per participant:
(Overhead costs + Capital expenses) ÷ Number of participants

Yearly
(7078.44 + 119.33) ÷ 16
£449.86 per participant per year

Monthly
(589.87 + 9.94) ÷ 16
£37,49 per participant per year

References

Backley, J., Bloom, J., Bott, J., Jones, R., Langley, C., Singh, S., Smith, J. and Till, J. 2005. A Summary of Recommendations of the Pulmonary Rehabilitation in Thecommunity- Sharing Best Practice Meeting. General Practice Airways Group pp.30/10/12. Available at: http://www.pcrs-uk.org/resources/gpiag_pul_rehab_bestpract_200306.pdf [Accessed 30/10/12].
Couser, J.I., Martinez, F.J. and Celli, B.R. 1993. Pulmonary rehabilitation that includes arm exercise reduces metabolic and ventilatory requirements for simple arm elevation. CHEST Journal, 103 (1) January 1, pp.37-41.
Epstein, S.K., Celli, B.R., Martinez, F.J., Couser, J.I., Roa, J., Pollock, M. and Benditt, J.O. 1997. Arm training reduces the VO2 and VE cost of unsupported arm exercise and elevation in chronic obstructive pulmonary disease. Journal of cardiopulmonary rehabilitation, 17 (3) May-Jun, pp.171-177.
Hogg, L., Grant, A., Garrod, R. and Fiddler, H. 2012. People with COPD perceive ongoing, structured and socially supportive exercise opportunities to be important for maintaining an active lifestyle following pulmonary rehabilitation: a qualitative study. Journal of Physiotherapy, 58 (3) 9, pp.189-195.
Keating, A., Lee, A.L. and Holland, A.E. 2011. Lack of perceived benefit and inadequate transport influence uptake and completion of pulmonary rehabilitation in people with chronic obstructive pulmonary disease: a qualitative study. Journal of Physiotherapy, 57 (3) 9, pp.183-190.
Liddell, F. and Webber, J. 2010. Pulmonary rehabilitation for chronic obstructive pulmonary disease: a pilot study evaluating a once-weekly versus twice-weekly supervised programme. Physiotherapy, 96 (1) 3, pp.68-74.
NICE. 2010. Chronic obstructive pulmonary disease, Management of chronic obstructive pulmonary disease in adults in primary and secondary care (partial update). NICE Clinical Guidelines, 101 (June) pp.1-61.
Nici, L., Donner, C., Wouters, E., Zuwallack, R., Ambrosino, N., Bourbeau, J., Carone, M., Celli, B., Engelen, M., Fahy, B., Garvey, C., Goldstein, R., Gosselink, R., Lareau, S., MacIntyre, N., Maltais, F., Morgan, M., O'Donnell, D., Prefault, C., Reardon, J., Rochester, C., Schols, A., Singh, S., Troosters, T. and on behalf of the ATS/ERS Pulmonary Rehabilitation Writing Committee. 2006. American Thoracic Society/European Respiratory Society Statement on Pulmonary Rehabilitation. American Journal of Respiratory and Critical Care Medicine, 173 (12) June 15, pp.1390-1413.
O'Shea, S.D., Taylor, N.F. and Paratz, J.D. 2007. [horizontal ellipsis]But Watch Out for the Weather: FACTORS AFFECTING ADHERENCE TO PROGRESSIVE RESISTANCE EXERCISE FOR PERSONS WITH COPD. Journal of Cardiopulmonary Rehabilitation & Prevention, 27 (3) May/June, pp.166-174.
 
British Thoracic Society. Standards of care committee on pulmonary rehabilitation. 2001. Thorax,  56, pp.827-834

Davidson, A.C. and Morgan, M.D.L. 1998. A UK survey of the provision of pulmonary rehabilitation. Thorax, 53, pp. 86

Guëll, M.R., Lucas, P., Gáldiz, J.B., Montemayor, T., González-Moro, J.M.R., Gorostiza, A., Ortega, F., Bellón, J.M. and Guyatt, G. 2008. Home vs hospital-based pulmonary rehabilitation for patients with chronic obstructive pulmonary disease: A Spanish multicenter trial. Archive Bronconeumol, 44 (10), pp.512-518

Khdour, M.R., Agus, A.M., Kidney, J.C., Smyth, B.M., Elnay, J.C. and Crealey, G.E. 2011. Cost-ultility analysis of a pharmacy-led self-management programme for patients with COPD. International Journal of Clinical Pharmacy, 33, pp. 665-673

Lacasse, Y., Goldstein, R., Lasserson, T.J. and Martin, S. 2006. Pulmonary rehabilitation for chronic obstructive pulmonary disease. Cochrane Database Systematic Review, CD003793

Maltais, F., Bourbeau, J., Shapiro, S., Lacasse, Y., Perrault, H., Baltzan, M., Hernandez, P., Rouleau, M., Julien, M., Parenteau, S., Paradis,  B., Levy, R.D., Camp, P., Lecours, R., Audet, R., Hutton, B., Penrod, J.R., Picard, D. and Bernard, S. 2008. Effects of home-based pulmonary rehabilitation in patients with chronic  obstructive pulmonary disease. Annals of Internal Medicine, 149, pp.869-878

Strijbos, J.H., Postma, D.S., van Altena, R., Gimeno, F. and Koëter, G.H. 1996. A comparison between an outpatient hospital-based pulmonary rehabilitation program and a home-care pulmonary rehabilitation program in patients with COPD. A follow up of 18 months. Chest, 109, pp. 366-372

Ward, J.A., Akers, G., Ward, D.G., Pinnuck, M., Williams, S., Trott, J. and Halpin, D.M.G. 2002. Feasibility and effectiveness of a pulmonary rehabilitation programme in a community hospital setting. British Journal of General Practice, 52, pp.539-542

Waterhouse, J.C., Walters, S.J., Oluboyede, Y. and Lawson, R.A. 2010. A randomized 2 x 2 trial of community versus hospital pulmonary rehabilitation for chronic obstructive pulmonary disease followed by telephone or conventional follow-up. Health Technology Assessment, 14, pp.1-164
Slovic, P., Finucane, M.L., Peters, E. and MacGregor, D.G. 2004. Risk as analysis and risk as feelings: some thoughts about effect, reason, risk and rationality. Risk Analysis, 24 (2), pp.311-322

 

Appendices

Appendix 1 - Sample pre-exercise health check sheet

File:Pre-exercise health check.pdf

Appendix 3 - Rate of preceived dyspoena

File:Rate of Perceived Dyspnea.pdf

Appendix 4 - Measure outcome for Quality of life

File:Sample EQ-5D-Y.pdf