Pulmonary rehabilitation (PR) is an effective intervention for the management of people with chronic obstructive pulmonary disease (COPD). However, available resources are often limited, and many patients bear with poor availability of programmes. Sustaining PR benefits and regular exercise over the long term is difficult without any exercise maintenance strategy. In contrast to traditional centre-based PR programmes, telerehabilitation may promote more effective integration of exercise routines into daily life over the longer term and broaden its applicability and availability. A few studies showed promising results for telerehabilitation, but mostly with short-term interventions. The aim of this study was to compare long-term telerehabilitation and unsupervised exercise training at home with standard care.
An international multicentre randomised controlled trial was conducted across sites in three countries (Norway, Denmark and Australia). A total of 120 patients with COPD were recruited and randomly assigned to three groups: telerehabilitation, treadmill and control. Participants were followed up for 2 years. The telerehabilitation group consisted of individualised exercise training at home on a treadmill, telemonitoring by a physiotherapist via videoconferencing using a tablet computer, and self-management via a customised website. Patients in the treadmill group were provided with a treadmill only to perform unsupervised exercise training at home. Patients in the control group were offered standard care. The primary outcome was the number of hospitalisations and emergency department presentations. Secondary outcomes were changes in health status, quality of life, anxiety and depression, self-efficacy, subjective impression of change, physical performance, level of physical activity, and personal experiences in telerehabilitation.
A total of 120 participants were recruited and randomized into telerehabilitation (n=40), treadmill (n=40) and control group (n=40). The baseline characteristics of the participants were similar among groups. The hypothesis was that telerehabilitation and treadmill groups are superior to the control group. Moreover, it was expected that participants in the telerehabilitation group would gain additional benefits compared to the treadmill group due to the remote follow up provided by a physiotherapist.
Results for the primary outcome confirmed that both telerehabilitation and treadmill groups were superior to the control group. The total number of hospitalizations and ED presentations in the telerehabilitation group (1.18 per person year) and treadmill group (1.14 per person year) was significantly lower than in the control group (1.88 per person year).
Results from the secondary outcomes show that participants in both telerehabilitation and treadmill groups experienced an improvement in functional exercise capacity measured with the 6-minute walking distance (6MWD) during the 2-year participation in the study. The difference with the value at baseline for both groups exceeded the minimal important difference (30 metres) in COPD for all follow up visits. On the contrary, participants in the control group experienced a decline. Participants in both telerehabilitation and treadmill groups also improved their symptoms in the short term. The differences in MMRC Dyspnoea Scale and COPD Assessment Test (CAT) at 6 months were statistically significant for both telerehabilitation (p=0.037 and p=0.037) and treadmill group (p=0.027 and p=0.002). Moreover, participants in the treadmill group maintained gains related to the MMRC for 2 years (p=0.008), and those related to the CAT for 1 year (p=0.047). Time-to-first hospitalization and mortality rates were similar among groups.
Results show that long-term telerehabilitation is a cost-effective strategy for the follow-up of patients with COPD and can reduce the number of hospital accesses for patients with COPD. Patients who participated in telerehabilitation had, on average, 0.7 fewer hospital accesses per year, with consequent potential savings up to NOK 28000 per patient per year. Telerehabilitation has the potential to reduce significantly health service expenditures and the overall burden for the healthcare system. This study also provides evidence that a simpler, and less expensive, intervention consisting of unsupervised exercise training at home with at treadmill is effective in reducing the number of hospital accesses for patients with COPD. In addition to benefits for the healthcare system, these interventions produced clinical benefits for patients with COPD, who experienced improved functional exercise capacity, reduced symptoms of dyspnea and better health status. Finally, the delivery of telerehabilitation services will broaden the availability of PR and maintenance strategies, especially to those living in remote areas and with no access to centre-based exercise programmes.
Resultatene viser at telerehabilitering er en kostnadseffektiv strategi for oppfølging av pasienter med KOLS og kan bidra til å redusere antall sykehusinnleggelser. Pasienter som deltok i telerehabilitering hadde i gjennomsnittet 0,7 færre sykehusinnleggelser per år. Dette betyr at det er mulig å bespare opptil kr 28000 per pasient per år. Telerehabilitering kan derfor bidra til å redusere utgiftene for helsetjenesten betydelig. En enklere og billigere intervensjon bestående av egentrening hjemme med tredemølle også er effektiv til å redusere antall sykehusinnleggelser. I tillegg til fordeler for helsevesenet, ga disse intervensjonene kliniske fordeler for pasienter med KOLS, som opplevde forbedret funksjonell treningskapasitet, reduserte symptomer på dyspné og bedre helsetilstand. Telerehabilitering gir mulighet til å utvide tilgjengeligheten av lungerehabilitering og vedlikeholdsstrategier, særlig for de som bor i distrikter og som ikke har tilgang til treningsprogrammer.
This research project aims to compare long-term telerehabilitation of COPD patients consisting of exercise training at home, telemonitoring, and education/self-management, with standard care.
An international multi-center prospective RCT in which 120 COPD patients will participate and followed up for 2 years. Patients will be randomly assigned to 3 arms in a 1:1:1 ratio. Patients in the intervention arm (GROUP A) will be offered an integrated telerehabilitation programme consisting of exercise training at home, telemonitoring, and education/self-management. Two control arms will be set up to isolate the effects of the telemedicine components from those of exercise training. Patients in the first control arm (GROUP C) will be offered s tandard care, while patients in the second control arm (GROUP B) will be offered in addition the equipment to perform exercise training at home, but without supervision via telemedicine.
COPD is a chronic disease that poses a substantial so cietal, economic and personal burden. This RCT will demonstrate the effects of long-term integrated telerehabilitation of COPD patients, including clinical, psychological and economic benefits. This intervention has the potential to promote a better healt h in COPD, to reduce geografical barriers and access inequalities to healthcare services, thus ensuring a more cost-efficient utilisation of the healtcare resoruces.
POSSIBLE APPLICATION OF PROJECT RESULTS
This telerehabilitation service has the potentia l to be extended not only to other centres offering pulmonary rehabilitation, but also to municipalities, thus creating a national network for the management of COPD patients and strengthening the Coordination Reform. If the intervention will be cost-effe ctive, we also expect a revision of the reimbursement system in order to include low-intensity telerehabilitation as alternative to to inpatient or outpatient rehabilitation.