Abstract
Objective
To examine predictors of uptake (never start), adherence (drop out), and completion
of pulmonary rehabilitation (PR), as well as PR treatment response based on minimal
clinically important difference (MCID) on the 6-minute walk test (6MWT) distance and
Chronic Respiratory Questionnaire–Self-Report (CRQ-SR).
Design
Retrospective, cohort study.
Setting
Veterans Health Administration.
Participants
U.S. veterans with chronic obstructive pulmonary disease (COPD) (N=253) referred to
PR between 2010 and 2018.
Interventions
Outpatient PR program.
Main Outcome Measures
Participants completed baseline (time 1) measures of depression (Beck Depression Inventory-II),
health-related quality of life (CRQ-SR), self-efficacy (Exercise Self-Regulatory Efficacy
Scale [Ex-SRES]), and COPD knowledge. Exercise capacity was assessed with the 6MWT.
Participants who completed all 18 sessions of PR repeated assessments (time 2). Logistic
regression models examined predictors of uptake, adherence, and completion of PR as
well as treatment response based on MCID.
Results
Participants were referred to PR with 24.90% never starting, 28.90% dropping out,
and 46.20% completing. No differences emerged between never starters and dropouts.
Having a history of any cancer increased the likelihood of completing PR (vs never
starting; odds ratio [OR], 3.18; P=.003). Greater CRQ-SR dyspnea score, indicating less dyspnea, was associated with
increased likelihood of completing PR (OR, 1.12; P=.006). Past smoking compared with current smoking was associated with increased likelihood
of completion (OR, 3.89; P≤.002). Those without a history of alcohol use disorder had increased likelihood of
completing PR (OR, 2.23; P=.048). Greater baseline 6MWT distance was associated with lower likelihood of achieving
MCID in 6MWT (OR, 0.99; P<.001). Greater Ex-SRES was associated with decreased likelihood of achieving 6MWT
MCID (OR, 0.98; P=.023).
Conclusions
Findings suggest that early psychoeducation on dyspnea management and smoking and
alcohol cessation may increase completion of PR.
Keywords
List of abbreviations:
ANOVA (analysis of variance), AUD (alcohol use disorder), COPD (chronic obstructive pulmonary disease), CRQ-SR (Chronic Respiratory Questionnaire–Self-Report), Ex-SRES (Exercise Self-Regulatory Efficacy Scale), FEV1 (forced expiratory volume in first second of expiration), FVC (forced vital capacity), MCID (minimal clinically important difference), mMRC (Modified Medical Research Council), OR (odds ratio), PR (pulmonary rehabilitation), PTSD (posttraumatic stress disorder), 6MWT (6-minute walk test), US (United States), VHA (Veterans Health Administration)To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to Archives of Physical Medicine and RehabilitationAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- Burden of chronic obstructive pulmonary disease: healthcare costs and beyond.Allergy Asthma Proc. 2015; 36: 4-10
- Burden of COPD in a government health care system: a retrospective observational study using data from the US Veterans Affairs population.Int J Chron Obstruct Pulmon Dis. 2010; 5: 125
- Disproportionate utilization of healthcare resources among veterans with COPD: a retrospective analysis of factors associated with COPD healthcare cost.Cost Eff Resour Alloc. 2013; 11: 1-10
- High prevalence of chronic obstructive pulmonary disease among veterans in the urban midwest.Mil Med. 2011; 176: 552-560
- An official American Thoracic Society/European Respiratory Society policy statement: enhancing implementation, use, and delivery of pulmonary rehabilitation.Am J Respir Crit Care Med. 2015; 192: 1373-1386
- Lower mortality after early supervised pulmonary rehabilitation following COPD-exacerbations: a systematic review and meta-analysis.BMC Pulmon Med. 2018; 18: 1-18
- A geographic analysis of racial disparities in use of pulmonary rehabilitation after hospitalization for COPD exacerbation.Chest. 2020; 157: 1130-1137
- Association between initiation of pulmonary rehabilitation after hospitalization for COPD and 1-year survival among Medicare beneficiaries.JAMA. 2020; 323: 1813-1823
- Pulmonary rehabilitation: overwhelming evidence but lost in translation?.Physiother Can. 2010; 62: 368-373
- Lack of perceived benefit and inadequate transport influence uptake and completion of pulmonary rehabilitation in people with chronic obstructive pulmonary disease: a qualitative study.J Physiother. 2011; 57: 183-190
- What prevents people with chronic obstructive pulmonary disease from attending pulmonary rehabilitation? A systematic review.Chron Respir Dis. 2011; 8: 89-99
- Barriers to pulmonary rehabilitation: characteristics that predict patient attendance and adherence.Respir Med. 2013; 107: 401-407
- Participation in pulmonary rehabilitation by veterans health administration and medicare beneficiaries after hospitalization for chronic obstructive pulmonary disease.J Cardiopulm Rehabil Prev. 2018; 38: 406-410
- Pulmonary rehabilitation in chronic obstructive pulmonary disease: predictors of program completion and success.COPD. 2012; 9: 538-545
- Association of change in depression and anxiety symptoms with functional outcomes in pulmonary rehabilitation patients.J Psychosom Res. 2011; 71: 45-49
- Patient anxiety and depression moderate the effects of increased self-management knowledge on physical activity: a secondary analysis of a randomised controlled trial on health-mentoring in COPD.COPD. 2015; 12: 502-509
- Prevalence, comorbidity, and prognosis of mental health among US veterans.Am J Public Health. 2015; 105: 2564-2569
- Lifetime and 12-month prevalence of psychiatric disorders in 8,169 male Vietnam War era veterans.Mil Med. 2004; 169: 896-902
- Smoking prevalence among US veterans.J Gen Intern Med. 2010; 25: 147-149
- British Thoracic Society guideline on pulmonary rehabilitation in adults: accredited by NICE.Thorax. 2013; 68 (Suppl): ii1-i30
- The rational clinical examination: evidence-based clinical diagnosis.McGraw Hill Professional, New York2008
- Six-minute-walk test in chronic obstructive pulmonary disease: minimal clinically important difference for death or hospitalization.Am J Respir Crit Care Med. 2013; 187: 382-386
- Interpreting small differences in functional status: the six minute walk test in chronic lung disease patients.Am J Respir Crit Care Med. 1997; 155: 1278-1282
- Measurement properties and interpretability of the Chronic Respiratory Disease Questionnaire (CRQ).COPD. 2005; 2: 81-89
- Modified Medical Research Council scale vs Baseline Dyspnea Index to evaluate dyspnea in chronic obstructive pulmonary disease.Int J Chron Obstruct Pulmon Dis. 2015; 10: 1663
- Bristol COPD Knowledge Questionnaire (BCKQ): testing what we teach patients about COPD.Chron Respir Dis. 2006; 3: 123-131
- Reliability and validity of the Chronic Respiratory Questionnaire (CRQ).Thorax. 1994; 49: 465-467
- Diagnostic and statistical manual of mental disorders: DSM-5.American Psychiatric Association, Arlington, VA2013
- A psychometric evaluation of the Beck Depression Inventory-II.Psychol Assess. 1998; 10: 83
- Reliability and validity of the Exercise Self-Regulatory Efficacy Scale for individuals with chronic obstructive pulmonary disease.Heart Lung. 2007; 36: 205-216
- Missing data: our view of the state of the art.Psychol Methods. 2002; 7: 147
- Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary.Am J Respir Crit Care Med. 2007; 176: 532-555
- An internet-mediated pedometer-based program improves health-related quality-of-life domains and daily step counts in COPD.Chest. 2015; 148: 128-137
- Telehealth pulmonary rehabilitation: a review of the literature and an example of a nationwide initiative to improve the accessibility of pulmonary rehabilitation.Chron Respir Dis. 2018; 15: 41-47
- Preparedness and cancer-related symptom management among cancer survivors in the first year post-treatment.Ann Behav Med. 2017; 51: 587-598
- Illness perceptions and coping with disease in chronic obstructive pulmonary disease: effects on health-related quality of life.J Health Psychol. 2017; 22: 1570-1581
- Interventions to increase referral and uptake to pulmonary rehabilitation in people with COPD: a systematic review.Int J Chron Obstruct Pulmon Dis. 2018; 13: 3571
- Dyspnea perception in COPD: association between anxiety, dyspnea-related fear, and dyspnea in a pulmonary rehabilitation program.Chest. 2011; 140: 618-625
- Barriers and enablers of physical activity engagement for patients with COPD in primary care.Int J Chron Obstruct Pulmon Dis. 2017; 12: 1019
- A systematic review of the content and delivery of education in pulmonary rehabilitation programmes.Respir Med. 2018; 145: 161-181
- Social determinants of adherence to pulmonary rehabilitation for chronic obstructive pulmonary disease.COPD. 2017; 14: 610-617
- The importance of components of pulmonary rehabilitation, other than exercise training, in COPD.Eur Respir Rev. 2013; 22: 405-413
- Psychopathology and illness beliefs influence COPD self-management.J Psychosom Res. 2004; 56: 333-340
- Drop-out and attendance in pulmonary rehabilitation: the role of clinical and psychosocial variables.Respir Med. 2009; 103: 1564-1571
- Clinical predictors of the efficacy of a pulmonary rehabilitation programme in patients with COPD.Respir Med. 2009; 103: 1224-1230
- An evaluation of factors associated with completion and benefit from pulmonary rehabilitation in COPD.BMJ Open Respir Res. 2014; 1e000051
- Changes in personal control as a predictor of quality of life after pulmonary rehabilitation.Patient Educ Couns. 2006; 61: 99-108
- Self efficacy measurement and goal attainment after pulmonary rehabilitation.Int J Chron Obstruct Pulmon Dis. 2008; 3: 791
- Exercise self-efficacy in older adults: social, affective, and behavioral influences.Ann Behav Med. 2003; 25: 1-7
- Effectiveness, attendance, and completion of an integrated, system-wide pulmonary rehabilitation service for COPD: prospective observational study.COPD. 2012; 9: 546-554
- Improving understanding of and adherence to pulmonary rehabilitation in patients with COPD: a qualitative inquiry of patient and health professional perspectives.PLoS One. 2014; 9e110835
- Acceptability and feasibility of pulmonary rehabilitation for COPD: a community qualitative study.Prim Care Respir J. 2012; 21: 419-424
- We are not worthy”–understanding why patients decline pulmonary rehabilitation following an acute exacerbation of COPD.Disabil Rehabil. 2015; 37: 750-756
- Systematic review of interventions to improve patient uptake and completion of pulmonary rehabilitation in COPD.ERJ Open Res. 2017; 3: 00089-02016
Article info
Publication history
Published online: November 28, 2021
Accepted:
October 11,
2021
Received in revised form:
September 3,
2021
Received:
June 16,
2021
Footnotes
Disclosures: none
Identification
Copyright
Published by Elsevier Inc. on behalf of the American Congress of Rehabilitation Medicine.
