Community-based pulmonary rehabilitation (PR) programs preserve essential PR elements such as exercise, disease education, and social support while addressing barriers to cost and transportation by offering low equipment options and flexible location delivery. We evaluated the feasibility of a 10-week community-based PR program, COPD Wellness, with and without Health Advocates (HA), who assist with unmet social needs in patients with COPD receiving care within a safety-net health care setting.
Methods:
In this single-center feasibility study (September 2017 to January 2020), participants with moderate-to-severe COPD were randomized to COPD Wellness alone or with HA support. The program included 10 weekly supervised 90-min sessions. Feasibility outcomes included recruitment rates, attendance, and adherence (≥6 sessions). Clinical outcomes included COPD Assessment Test (CAT) scores, 6-min walk distance (6MWD), depressive symptoms (PHQ-8), and exacerbation, analyzed using paired t-tests for within-group comparisons and independent t-tests for exploratory between-group analyses.
Results:
In total, 39 participants were enrolled (61% acceptance rate), with 19 randomized to COPD Wellness alone and 20 to COPD Wellness with HA. Median session attendance was higher in the HA group (6 vs 4 sessions), with greater adherence (53% vs 37%). CAT scores improved significantly overall (mean improvement 3.2, P = .01), with greater improvements among participants in the HA group (5.6-point reduction, P = .01). No significant changes were observed in the 6MWD, D-12 score, PHQ-8, or exacerbation rates. No adverse events were reported.
Conclusions:
The COPD Wellness program demonstrated feasibility, safety, and acceptability within a safety-net health care setting. The integration of HA addressed key social barriers, improving adherence and leading to greater improvements in COPD symptom burden compared with the COPD Wellness program alone. Future studies should explore scaling this model and assessing its long-term benefits in resource-limited environments.
MurrayCJ, LopezAD. Alternative projections of mortality and disability by cause 1990–2020: Global Burden of Disease Study. Lancet, 1997; 349(9064):1498–1504; doi: 10.1016/S0140-6736(96)07492-2
2.
CrinerRN, HanMK. COPD care in the 21st century: A public health priority. Respir Care, 2018; 63(5):591–600; doi: 10.4187/respcare.06276
3.
PfuntnerA, WierLM. Most Frequent Conditions in U.S. Hospitals, 2010. Healthcare Cost and Utilization Project (HCUP) Statistical Briefs. Rockville, Maryland: Agency for Healthcare Research and Quality (US); 1997; 11.
4.
MurphySL. Mortality in the United States, 2020. NCHS Data Brief, 2021; 427:8.
McCarthyB, CaseyD, DevaneD, et al.Pulmonary rehabilitation for chronic obstructive pulmonary disease. Cochrane Database Syst Rev, 2015;(2):CD003793; doi: 10.1002/14651858.CD003793.pub3
7.
SpitzerKA, StefanMS, PriyaA, et al.Participation in pulmonary rehabilitation after hospitalization for chronic obstructive pulmonary disease among medicare beneficiaries. Ann Am Thorac Soc, 2019; 16(1):99–106; doi: 10.1513/AnnalsATS.201805-332OC
8.
SteinerMC, LoweD, BeckfordK, et al.Socioeconomic deprivation and the outcome of pulmonary rehabilitation in England and Wales. Thorax, 2017; 72(6):530–537; doi: 10.1136/thoraxjnl-2016-209376
9.
KeatingA, LeeA, HollandAE. What prevents people with chronic obstructive pulmonary disease from attending pulmonary rehabilitation? A systematic review. Chron Respir Dis, 2011; 8(2):89–99; doi: 10.1177/1479972310393756
10.
KeatingA, LeeAL, HollandAE. 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(3):183–190; doi: 10.1016/S1836-9553(11)70040-6
11.
LewinME, AltmanSH, Institute of Medicine (US) Committee on the Changing Market MC. America’s health care safety net: intact but endangered. Washington, District of Columbia: Institute of Medicine; 2000.
12.
CecinsN, LandersH, JenkinsS. Community-based pulmonary rehabilitation in a non-healthcare facility is feasible and effective. Chron Respir Dis, 2017; 14(1):3–10; doi: 10.1177/1479972316654287
13.
GodtfredsenN, SørensenTB, LavesenM, et al.Effects of community-based pulmonary rehabilitation in 33 municipalities in Denmark—Results from the KOALA project. Int J Chron Obstruct Pulmon Dis, 2019; 14:93–100; doi: 10.2147/COPD.S190423
14.
de OliveiraTMD, PereiraAL, CostaGB, et al.Embedding pulmonary rehabilitation for chronic obstructive pulmonary disease in the home and community setting: a rapid review. Front Rehabil Sci, 2022; 3:780736; doi: 10.3389/fresc.2022.780736
15.
BarbosaM, AndradeR, de MeloCA, et al.Community-based pulmonary rehabilitation programs in individuals with COPD. Respir Care, 2022; 67(5):579–593; doi: 10.4187/respcare.09627
16.
PuhanMA, Gimeno-SantosE, CatesCJ, et al.Pulmonary rehabilitation following exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev, 2016; 12(12):CD005305; doi: 10.1002/14651858.CD005305.pub4
17.
BaumannHJ, KlugeS, RummelK, et al.Low intensity, long-term outpatient rehabilitation in COPD: a randomised controlled trial. Respir Res, 2012; 13(1):86; doi: 10.1186/1465-9921-13-86
18.
CambachW, Chadwick-StraverRV, WagenaarRC, et al.The effects of a community-based pulmonary rehabilitation programme on exercise tolerance and quality of life: a randomized controlled trial. Eur Respir J, 1997; 10(1):104–113; doi: 10.1183/09031936.97.10010104
19.
OatesGR, HambyBW, StepanikovaI, et al.Social determinants of adherence to pulmonary rehabilitation for chronic obstructive pulmonary disease. Copd, 2017; 14(6):610–617; doi: 10.1080/15412555.2017.1379070
20.
OatesGR, NiranjanSJ, OttC, et al.Adherence to pulmonary rehabilitation in copd: a qualitative exploration of patient perspectives on barriers and facilitators. J Cardiopulm Rehabil Prev, 2019; 39(5):344–349; doi: 10.1097/HCR.0000000000000436
21.
MoffattS, KohlerN. Conceptualizing the built environment as a social–ecological system. Building Research & Information, 2008; 36(3):248–268; doi: 10.1080/09613210801928131
AlbertoJ, JoynerB. Hope, optimism, and self-care among Better Breathers Support Group members with chronic obstructive pulmonary disease. Appl Nurs Res, 2008; 21(4):212–217; doi: 10.1016/j.apnr.2006.12.005
BilliouxA, VerlanderK, AnthonyS, et al.; Centers for Medicare and Medicaid Services. Standardized screening for health-related social needs in clinical settings: the accountable health communities screening tool. NAM Perspect, 2017; 7(5); doi: 10.31478/201705b
27.
Serpa-AnayaDC, Hoyos-QuinteroAM, HernandezNL. [Adherence to pulmonary rehabilitation: An exploratory review]. Rehabilitacion (Madr), 2021; 55(2):138–152; doi: 10.1016/j.rh.2020.09.007
28.
KonSSC, CanavanJL, JonesSE, et al.Minimum clinically important difference for the COPD Assessment Test: a prospective analysis. Lancet Respir Med, 2014; 2(3):195–203; doi: 10.1016/S2213-2600(14)70001-3
29.
PuhanMA, MadorMJ, HeldU, et al.Interpretation of treatment changes in 6-minute walk distance in patients with COPD. Eur Respir J, 2008; 32(3):637–643; doi: 10.1183/09031936.00140507
30.
PolkeyMI, SpruitMA, EdwardsLD, et al.; Evaluation of COPD Longitudinally to Identify Predictive Surrogate Endpoints (ECLIPSE) Study Investigators. 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(4):382–386; doi: 10.1164/rccm.201209-1596OC
31.
von SiemensSM, JörresRA, BehrJ, et al.; COSYCONET study group. Effect of COPD severity and comorbidities on the result of the PHQ-9 tool for the diagnosis of depression: results from the COSYCONET cohort study. Respir Res, 2019; 20(1):30; doi: 10.1186/s12931-019-0997-y
32.
YorkeJ, MoosaviSH, ShuldhamC, et al.Quantification of dyspnoea using descriptors: development and initial testing of the Dyspnoea-12. Thorax, 2010; 65(1):21–26; doi: 10.1136/thx.2009.118521
33.
EldridgeSM, LancasterGA, CampbellMJ, et al.Defining feasibility and pilot studies in preparation for randomised controlled trials: development of a conceptual framework. PLoS One, 2016; 11(3):e0150205; doi: 10.1371/journal.pone.0150205
34.
FioriKP, HellerCG, RehmCD, et al.Unmet social needs and no-show visits in primary care in a US Northeastern Urban Health System, 2018–2019. Am J Public Health, 2020; 110(S2):S242–S250; doi: 10.2105/AJPH.2020.305717
35.
LooS, AndersonE, LinJG, et al.Evaluating a social risk screening and referral program in an urban safety‐net hospital emergency department. J Am Coll Emerg Physicians Open, 2023; 4(1):e12883; doi: 10.1002/emp2.12883
36.
GottliebLM, AdlerNE, WingH, et al.Effects of in-person assistance vs personalized written resources about social services on household social risks and child and caregiver health: A Randomized Clinical Trial. JAMA Netw Open, 2020; 3(3):e200701; doi: 10.1001/jamanetworkopen.2020.0701
37.
GottliebLM, HesslerD, LongD, et al.Effects of social needs screening and in-person service navigation on child health: A Randomized Clinical Trial. JAMA Pediatr, 2016; 170(11):e162521; doi: 10.1001/jamapediatrics.2016.2521
38.
KangoviS, MitraN, GrandeD, et al.Evidence-based community health worker program addresses unmet social needs and generates positive return on investment. Health Aff (Millwood), 2020; 39(2):207–213; doi: 10.1377/hlthaff.2019.00981
39.
GottliebLM, WingH, AdlerNE. A systematic review of interventions on patients’ social and economic needs. Am J Prev Med, 2017; 53(5):719–729; doi: 10.1016/j.amepre.2017.05.011
40.
WatsonJ, JordanRE, AdabP, et al.; Cochrane Airways Group. Interventions to promote referral, uptake and adherence to pulmonary rehabilitation for people with chronic obstructive pulmonary disease (COPD). Cochrane Database of Systematic Reviews, 2017; 2023(4); doi: 10.1002/14651858.CD012813
41.
AlghamdiSM, Janaudis-FerreiraT, AlhasaniR, et al.Acceptance, adherence and dropout rates of individuals with COPD approached in telehealth interventions: a protocol for systematic review and meta-analysis. BMJ Open, 2019; 9(4):e026794; doi: 10.1136/bmjopen-2018-026794
42.
JonesPW, HardingG, BerryP, et al.Development and first validation of the COPD Assessment Test. Eur Respir J, 2009; 34(3):648–654; doi: 10.1183/09031936.00102509
43.
RochesterCL, AlisonJA, CarlinB, et al.Pulmonary rehabilitation for adults with chronic respiratory disease: an official american thoracic society clinical practice guideline. Am J Respir Crit Care Med, 2023; 208(4):e7–e26; doi: 10.1164/rccm.202306-1066ST
44.
BeauchampMK, FrancellaS, RomanoJM, et al.A novel approach to long-term respiratory care: Results of a community-based post-rehabilitation maintenance program in COPD. Respir Med, 2013; 107(8):1210–1216; doi: 10.1016/j.rmed.2013.04.014
45.
MachadoA, OliveiraA, ValenteC, et al.Effects of a community-based pulmonary rehabilitation programme during acute exacerbations of chronic obstructive pulmonary disease—A quasi-experimental pilot study. Pulmonology, 2020; 26(1):27–38; doi: 10.1016/j.pulmoe.2019.05.004
46.
ManWD-C, PolkeyMI, DonaldsonN, et al.Community pulmonary rehabilitation after hospitalisation for acute exacerbations of chronic obstructive pulmonary disease: randomised controlled study. Bmj, 2004; 329(7476):1209; doi: 10.1136/bmj.38258.662720.3A
Jiménez-RuizCA, AndreasS, LewisKE, et al.Statement on smoking cessation in COPD and other pulmonary diseases and in smokers with comorbidities who find it difficult to quit. Eur Respir J, 2015; 46(1):61–79; doi: 10.1183/09031936.00092614
49.
AlmojaibelAA. Delivering pulmonary rehabilitation for patients with chronic obstructive pulmonary disease at home using telehealth: a review of the literature. Saudi J Med Med Sci, 2016; 4(3):164–171; doi: 10.4103/1658-631X.188247
50.
InskipJA, LauscherHN, LiLC, et al.Patient and health care professional perspectives on using telehealth to deliver pulmonary rehabilitation. Chron Respir Dis, 2018; 15(1):71–80; doi: 10.1177/1479972317709643
Supplementary Material
Please find the following supplemental material available below.
For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.
For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.
