Maintaining the Benefits after Completing Pulmonary Rehabilitation

Northern Sydney Central Coast Area Health Service

Abstract

Pulmonary Rehabilitation is one of the few interventions proven to result in increased exercise capacity⁹, improved quality of life¹, and decreases in the use of health care resources^{2, 3, 4, 5}.

Following completion of Pulmonary Rehabilitation, many patients find it difficult to continue with recommendations to exercise without ongoing support from a structured program. The benefits gained in exercise programs are therefore often lost^{6, 7}.

The Northern Sydney Step Out Pulmonary Rehabilitation team consequently developed and trialed a self-sustaining, low-cost, exercises group, the “HORNSBY HUFFERS”. The group was trialed and evaluated over a six-month period and it was determined that on average, participants significantly improved their exercise tolerance and maintained their quality of life.

Aim

To facilitate the development and implementation of a safe, low cost, self-sustaining, exercise group for people who have completed Pulmonary Rehabilitation, utilising finite health resources.

Nature of the Problem

A Greater Metropolitan Clinical Taskforce Survey (2007) highlighted significant under-supply of maintenance programs for patients who had completed pulmonary rehabilitation programs, including lack of access to “appropriate exercise” options following completion of rehabilitation programs.

Consultation with consumers, stakeholders and respiratory specialists determined available options in the local community were too expensive, did not offer appropriate exercise modalities or intensity to sustain benefits gained during Pulmonary Rehabilitation. Further barriers to attending unstructured community programs included lack of oxygen availability for use during exercise and perception that lay instructors were not aware of requirements particular to patients with a chronic deteriorating condition.

Extent of the Problem

Between January 2005-December 2007, 1390 individuals with chronic respiratory disease participated in the Pulmonary Rehabilitation program. Of these patients, 15% repeated the program, with some up to five admissions.  This has led to an increase in waiting periods of up to 13 weeks for Pulmonary Rehabilitation in Northern Sydney.

On re-assessment consumers identified a lack of continuing support or options for exercise as reasons for wanting to re-attend.  This has been further corroborated by a survey undertaken by the Australian Lung Foundation in 2007¹⁰.  The survey found that in 50% of cases consumers were not referred onto maintenance exercise groups due to a lack of availability.  The survey also found that over two thirds of pulmonary rehabilitation programs in New South Wales conducted maintenance programs as part of the hospital service.  This could be interpreted as creating a drain on health resources.

Strategic Importance

In alignment with NSW Health strategic planning¹³, this project focused on sustaining the benefits gained during Pulmonary Rehabilitation and subsequent prevention of:

• avoidable hospital admissions; consumers being unable to maintain healthy lifestyle changes; and
• prevention of resources being utilised for maintenance purposes.

The project also had an important focus on collaboration between consumers, stakeholders, health professionals, managers and organisations, with a view to breaking down barriers of accessibility to maintenance exercise programs.  “Live Life Well” is a concept of New South Wales Health‘s principle of prevention and this project encompasses all facets of the principle.

Planning and Implementing Solutions

A service delivery agreement between the Royal Rehabilitation Centre Sydney’s Step Out Pulmonary Rehabilitation team and the Bernard Curren Rehabilitation Unit, Hornsby Hospital was developed.  The group was also registered as a LungNet support group.

Patients discharged from Pulmonary Rehabilitation interested in attending a maintenance exercise group attended a meeting to discuss and contribute to the planned trial group.  Consent and medical clearance was gained from all participants prior to joining the group. 

A competency training program was developed by the Pulmonary Rehabilitation Team for completion by the exercise group instructors along with a period of initial supervision to ensure their skills met the needs of people with chronic respiratory disease.  A resource file including specific policies and procedures relating to the group was developed for the instructor and orientation to the unit and safety procedures provided.   A member of the Pulmonary Rehabilitation team regularly visited the group to monitor the instructor and participants and to resolve any issues.

On commencement and completion of the group outcome measure were assessed.  These included, exercise tolerance, quality of life, number of hospital admissions in previous 12 months.  Attendance figures were monitored.  A class evaluation was completed at the end of the six months.

Midway through the trial, the group had a further meeting to discuss issues and the group’s future.  Participants made it clear that they were keen for the group to continue and that they were benefiting from attendance.  Following this, negotiation commenced with the area’s Health Promotion team, “HEALTHY LIFESTYLE” in order that they would continue with the group’s organisation.

This project also embraces the recommendations from the NSW Chronic Care program, that staff of chronic disease rehabilitation should be involved in the development of community led programs to provide ongoing support and maintain benefits over the long term^11.

Outcomes and Evaluation

Attendance

Fourteen participants originally joined the group. Attendance at each session was above 70% during 21 sessions over a 6-month period. 

Graph A: Attendance at Hornsby Huffers

Exercise Tolerance

On commencement of the program, exercise tolerance was assessed using a 6-minute walk test (6MWT). On average, a 4% reduction was found when compared with previous measures taken at Pulmonary Rehabilitation.  On completion of the group, an average 9% (33m) was found, demonstrating a significant improvement in exercise tolerance¹². 

Graph B: Exercise Tolerance

Quality of Life

Quality of Life (QOL) was measured using a St George’s Respiratory Questionnaire (SGRQ). There was no reduction in QOL over the 6-month period. In a chronically ill, ageing population this was considered to be a good outcome.

An evaluation at the end of the trial period indicated that consumers were very satisfied with the group. When asked what people liked most about the class, replies included  “the chance to improve my health”, “the camaraderie of fellow sufferers” and “the feeling of safety”.  The changes people had noticed since starting the group included ”feeling better and looking better”, “breathing more easily”, “having more energy", and “having more confidence to exercise”.

Sustaining Change

Collaboration between Hornsby Hospital, Northern Sydney Area Step Out Pulmonary Rehabilitation, and Northern Sydney Area Health Promotion Team during the trial period determined the viability and sustainability of the project. 

The exercise group is now community led and has expanded to two groups under the coordination of “HEALTHY LIFESTYLE”.  There are four “HORNSBY HUFFERS” support group meetings planned for the year in order to gain consumer feedback and to provide ongoing education and support.

The Step Out Pulmonary Rehabilitation team and Bernard Curren Unit staff of Hornsby Hospital continue to provide assistance and direction for the group with minimal input.

Future Scope

The lessons learned from this project are that with enthusiasm, creative thinking and collaboration between different services the “Live Life Well” concept of NSW Health can be implemented. In doing so, a prevention in deterioration in quality of life for people living with chronic conditions and sustained levels of physical activity can be achieved.

The long-term aim is to develop a network of similar low cost exercise groups for people with various chronic diseases across the Northern Sydney area so that it is possible to support lifestyle changes for the long term with minimal use of finite health resources.

References

1. Ries AL (2005):  Pulmonary rehabilitation and COPD.  Seminars in Respiratory and Critical Care Medicine, 26:133-41.
2. California Pulmonary Rehabilitation Group (2004):  Effects of pulmonary rehabilitation on dyspnoea, quality of life, and healthcare costs in California.  Journal of Cardiopulmonary Rehabilitation, 24:52-62.
3. Hui KP and Hewitt AB (2003):  A simple pulmonary rehabilitation program improves health outcomes and reduces hospital utilization in patients with COPD.  Chest, 124:94-7.
4. Griffiths TL, Burr ML, Campbell IA, Lewis-Jenkins V, Mullins J, Shiels K, Turner-Lawlor PJ, Payne N, Newcombe RG, Ionescu AA, Thomas J, Tunbridge J (2000): Results at 1 year of outpatient multidisciplinary pulmonary rehabilitation: a randomised controlled trial.  Lancet. 355:362-8.
5. Scherer YK and Schmieder LE (1998):  Pulmonary rehabilitation: is it cost effective?  Journal of the New York State Nurses Association, 29:16-20.
6. Reis AL, Kaplan RM, Limberg TM, Prewitt L: effects of pulmonary rehabilitation physiological and psychological outcomes in patients with chronic obstructive pulmonary disease. Ann Intern Med 1995, 122:823-32
7. Troosters T, Gosslink R, Decramer M: Short and long term effects of outpatient rehabilitation in patients with chronic obstructive pulmonary disease: a randomised trial.  AM J Med 2000, 109:207-212
8. GMCT Survey of Pulmonary Rehabilitation Programs, Policy and Practice in NSW Hospitals (2007).
9. Lacasse Y, Brosseau L, Milne S, Martin S, Wong E, Guyatt GH, Goldstein RS & White J: Pulmonary Rehabilitation for chronic obstructive pulmonary disease.
10. Cochrane Library 2004, Issue 4
11. Market Research Report.  The Australian Lung Foundation – Pulmonary Rehabilitation survey. 2007
12. Redelmeier DA, Bayoumi AM, Goldstein RS, Guyatt GH.  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
13. NSW Department of Health State health Plan (2007). http://www.health.nsw.gov.au/pubs/2007/pdf/state_health_plan.pdf .

Contact

This project was entered in the 2008 NSW Health Awards, Making Prevention Everybody's Business category.

More about the 2008 NSW Health Awards