NASHVILLE, Tenn. — The first multicenter randomized controlled trial of a home-based rehabilitation program for patients with chronic obstructive pulmonary disease (COPD) showed highly positive results, according to findings presented at the CHEST 2022 annual meeting.
At the end of 12 weeks, those randomly assigned to the intervention had a significant and clinically meaningful improvement in all domains of the Chronic Respiratory Questionnaire (CRQ), including activity levels and emotional well-being, reported Roberto P. Benzo, MD, a consultant in the Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota.
Presenting soon-to-be-published data, Benzo said that the intervention is based on a tablet-based app. On the tablet, the patient finds a daily schedule of exercises and videos to guide performance. The tablet is programmed to upload data captured from an activity monitor and pulse oximeter. Along with documentation of app usage, the remote coach can then download this information to review with the patient.
The primary outcome of the randomized study were the physical and emotional domains of the CRQ quality of life, but a long list of secondary outcomes — including physical activity, symptoms of depression, sleep quality, and healthcare utilization, such as emergency room visits — was also analyzed.
In addition to the significant benefit on the primary outcomes, the home-based rehabilitation program relative to a wait list for intervention was associated with benefit or a trend for benefit on essentially every outcome measured. Healthcare utilization was a possible exception, but even then, the absolute number of visits was lower in the treatment arm.
"With a study period of only 12 weeks, we were limited to our ability to show a difference in emergency room visits," said Benzo, who also noted that the study was conducted during the COVID-19 pandemic, when hospital visits were already occurring at a lower than usual rate. Based on the other findings, he suspects that a reduction in healthcare utilization could also be shown in more typical circumstances, particularly with a longer follow-up.
In the study, 375 patients with COPD were randomly assigned to a home healthcare regimen delivered by an app with remote coaching or to a wait list and usual care. The median age was 69 years. Fifty-nine percent were women. The median FEV1 at enrollment was 45% of predicted.
The patients were able to access their own data to monitor their progress at any time, not just at the time of coaching, but contact with the remote coach occurred on a weekly basis. Patients rated their level of energy, how they felt generally, and their progress toward daily goals, which was also captured on the app and could be discussed with the coach during the review of the previous week’s activity.
At 12 weeks, the favorable 0.54-point change (P < .001) and 0.51 change (P < .001) in the physical and emotional summary scores, respectively, met the criteria for a clinically meaningful change, Benzo reported. There were also significantly favorable changes from baseline and relative to controls in CRQ domains of self-management, sleep quality, and depression (all P ≤ .01).
Other data collected are supportive. For example, Benzo reported that those in the rehabilitation group took 624 more steps on average per day than those in the control group. The experimental group also spent nearly an hour more performing moderate or greater levels of activity.
"The app promotes behavioral change," said Benzo, who said that this "completely home-based model" of rehabilitation is likely to be cost-effective given the relatively low costs of remote coaching and reasonable costs of the activity monitor, tablet, and other equipment.
Importantly, home-based rehabilitation is a billable practice under currently available CPT codes, according to Benzo, who believes this approach is not only effective but "feasible and practical."
Two clinicians active in the care of patients with COPD believe this approach could fulfill an unmet need if further validated. Andrew Berman, MD, professor of medicine, Rutgers New Jersey Medical School, Newark, New Jersey, thinks the premise is sound.
"Digital competency is still a big issue as is access to adequate quality internet, but this could be a very useful approach for many individuals, and it avoids visits to a center, which could be a big advantage for patients," Berman said.
Abebaw M. Johannes, PhD, a professor of physical therapy at Azusa Pacific University, Azusa, California, agreed. He said that home-based remote coaching could be a way of overcoming the current hurdles of participating in institutional-based programs
"This is clearly an unmet need in COPD," he said.
The development of more effective and patient-friendly programs is what was driving this research, according to Benzo. He cited data suggesting that only about 30% of patients with COPD are participating in rehabilitation programs once discharged from the hospital despite the evidence that they can improve quality of life. For many of these patients, a home-based program might be the answer.
Benzo, Berman, and Johannes reported no relevant financial relationships.
CHEST 2022 Annual Meeting. Presented October 17, 2022.