Community-Based Exercise for Chronic Disease Management

Abstract

Although only a small proportion of older adults in the United States engage in recommended amounts of physical exercise, the health benefits of exercise for this population and the potential for lowering health care costs are substantial. However, access to regular exercise programs for the frail elderly and individuals with disabilities remains limited. In the context of health reform and emerging opportunities in developing integrated systems of care, the experience in Tuscany in implementing a community-based program of exercise for the elderly should be of interest.

Introduction

We have enormous need to improve outcomes for individuals with chronic disease. Management of chronic disease accounts for nearly 80% of our annual health care budget ¹ and there remains an urgent need to develop and evaluate models of care implemented in communities. Prevention, continuous monitoring of vulnerable patient groups, and coordinated management of chronic disease are cornerstones of the recently enacted Patient Protection and Affordable Care Act, ² but there are few established models to draw upon. Adaptation and careful evaluation of community-based service models developed in other countries may be very useful in achieving these ends, and may help providers in developing models of care to respond to new initiatives from health care payers. ³ New standards adopted by the Commission on Accreditation of Rehabilitation Facilities (CARF) ⁴ for the comprehensive secondary and tertiary prevention of stroke and related cardiometabolic risk factors now include management plans for promoting physical activity and preventing physical deconditioning at discharge and transitions in care. Medicare has statutory caps for outpatient therapies and the exception process for continuing therapies for beneficiaries beyond the statutory caps will end in 2014 unless Congress revises the legislation. ⁵ The findings of Taricco et al, ⁶ in this issue, demonstrate a practical strategy that could be used by rehabilitation providers to implement CARF standards and provide a new model for community-based chronic disease management.

Background

Adapted Physical Activity (APA) was initially developed in the Health Authority of Empoli (neighboring Florence) to provide a community-based, progressive, supervised group exercise for elderly, sedentary citizens and people with disabilities. General practitioners are the primary referral source. They are encouraged to refer all elderly patients whom they deem adequately medically stable to participate in exercise. The Health Authority staff coordinate patient assignment to participating local gymnasiums. Key features of APA are as follows: inclusion of participants by functional status rather than diagnosis; referral by general practitioners; exercise supervised by exercise trainers; use of private and public gyms; training of trainers, screening of participants, monitoring, and coordination by Health Authority professionals; financing by session cost of €2.20 per participant (approximately $3.00, pegged to the cost of a cappuccino and a brioche). Participants cover the entire cost of the program, except coordination, which is provided by the Health Authority. If trainers note a participant’s decrease in function, or receive from them a report of decreased health status, they contact the health authority medical staff promptly. The participant then receives physical therapy or physician evaluations to address the problem.

The characteristics of rehabilitation and APA differ. These differences are not absolute, but rather reflect the fact that rehabilitation and APA are at opposite ends of the continuum of care. Rehabilitation programs are designed for patients with specific diagnoses and impairments and focus on restoring function and helping patients compensate for those functions that cannot be restored. Thus, rehabilitation is directed by medical professionals and requires intense interaction between therapists and patients. In contrast, APA is designed to provide opportunities for individuals with chronic impairments to participate in regular exercise. Through regular exercise, the functional capacity of this population is maintained or improved, that is, fitness is improved and the deleterious effects of a sedentary life style (sarcopenia, osteoporosis, deconditioning, etc) are decreased. APA classes are group classes run by exercise instructors with therapist consultation available for participants who experience problems. Participants are encouraged to participate and progress in the group exercises to the extent they feel comfortable. However, the class exercises are not designed specifically for each individual as they would be in a physical therapy program.

The initial APA program was designed for people with musculoskeletal complaints. General practitioners and patients were pleased with the program. An observational study demonstrated that adherence to the APA protocol was the best single predictor for improved pain stuatus. ⁷ The Health Authority then began developing an APA program for patients with chronic neurological deficits secondary to stroke. These patients have significantly impaired function, and thus require a different program of exercises, and smaller classes than those in the original program. Significant concerns were raised regarding the safety and efficacy of this approach for patients with chronic hemiparesis. Through the auspices of a joint Memorandum of Understanding for research collaborations between the US National Institutes of Health and its Italian counterpart, the Istituto Superiore di Sanità, we carried out a clinical trial with geographic control to determine the efficacy of APA for chronic stroke. No serious adverse clinical events occurred during the exercise intervention. After 6 months, the intervention group improved whereas controls declined in gait velocity, balance, Short Physical Performance Battery, and Stroke Impact Scale social participation domains. ⁸

The steady growth of APA enrollments, demonstrated consumer satisfaction, and the results of the clinical trial on APA for chronic stroke led to the Tuscan Regional Government Deliberation 459 (March 2009) establishing APA as a cornerstone of health policy in Tuscany for the prevention and management of chronic disease. Recently, the Tuscan Regional Health Authority established benchmarks for APA enrollment for all of the twelve Health Authorities in Tuscany and incorporated these benchmarks into the performance plans for the senior executive managers of the Health Authorities. ⁹ As of June 2013, Tuscany had a total of approximately 20 500 participants enrolled in 1303 APA classes or 2.3% of the population aged 65 years or older. ¹⁰ The success of the Tuscany APA experience led the Italian Ministry of Health to include APA within the national guidelines for the organization of rehabilitation services. ¹¹

Important factors in the successful development and implementation of APA in Tuscany include interest and continuity of administrative and medical leadership, financial incentives for change, ongoing data collection and analysis for decision support, establishment of clear benchmarks to measure performance, support of the medical community, and collaboration with funding agencies and an international team of investigators. Support of the medical community (physicians and physical therapists) was obtained through an extensive series of meetings. Providers were assured that the APA programs would not divert patients from medical care, and that patients participating in the APA programs would be promptly referred back to their medical providers for treatment of intervening problems. ¹²

While the APA intervention appears to be low risk, the boldness of the Tuscan Region in promoting prevention for the elderly should be recognized. We do not yet know whether implementation of APA programs will result in measurable long-term improvements in community health or in reductions in health care utilization—the region is collecting data prospectively that will answer these questions. However, other regions in Italy are already implementing APA, based on the protocols developed in Empoli. ¹³

Translation?

The article in this issue by Taricco, et al, ⁶ documents the effectiveness of APA plus an educational intervention in improving outcomes for patients with stroke following discharge from acute rehabilitation. Their findings, especially that improvements in performance extend at least 2 months after the end of the APA intervention, give further confidence that the approach is useful and can be implemented broadly. Furthermore, this study illustrates how rehabilitation hospitals can foster secondary and tertiary prevention, improving the transition from rehabilitation therapies to healthy lifestyles, consistent with CARF standards.

A randomized controlled trial, funded by the Department of Veterans’ Affairs (VA), is in progress to compare the effects of APA for chronic stroke patients with a seated exercise program and to translate the concept into a US context. ¹⁴ This trial is being conducted in community sites through a collaboration between the VA Maryland Exercise and Robotics Center of Excellence, the Howard County Maryland Office on Aging and National Rehabilitation Hospital in Washington, DC. As in Italy, the APA intervention has been safe and well received by participants. Dissemination to other community sites is ongoing. The English version of the APA stroke protocol is available at http://ifr.umbc.edu/adaptive-physical-activity-program/.

Can the Italian experience with APA be replicated widely in the United States? Some aspects of the Italian experience may have facilitated the translation of APA from the laboratory to widespread adoption and deserve careful attention. More than 95% of health care expenditures in Tuscany, including services of general practitioners, are financed through the regional Health Authorities. Thus, Health Authorities can receive and measure the possible fiscal benefits produced by their relatively modest investments in coordinating and promoting APA programs. We also note that the widespread success of the APA financial model in Italy rests on a large cohort of participants without significant functional limitations for whom community providers can run large classes using the original APA protocol, as opposed to participants with stroke, Parkinson’s disease and other neurological disorders who require smaller classes with more assistance.

Challenges for sustainability in the United States include integration with primary care, transportation, management of risk and liability, and measurement of outcomes in a uniquely fragmented health financing system. ^15,16 In the context of developing new, integrated systems for management of chronic disease (Accountable Care Organizations), providers of stroke care may wish to consider implementing community-based exercise programs such as APA. Nonpharmacological lifestyle interventions reduce the risk of death in patients with established cardiovascular disease by 18% ¹⁷ and compare very well with medical interventions for cost-effectiveness. ¹⁸ Even modest exercise can result in significant improvements in cardiorespiratory fitness for patients after stroke. ¹⁹ Tapping these potential benefits will require adaptation to local conditions, measurement of outcomes and costs, and experimentation with financial incentives and business models. Established normative values for physical performance in the elderly^20,21 and the success of home-based exercise interventions for the frail elderly in the United States^22,23 provide additional support to the feasibility of community-based exercise interventions for stroke patients. The absence of serious adverse events and the widespread community support for APA in Italy suggest that the gains in quality of life for stroke patients will be well worth the effort of implementation.