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Wuytack F.1, Devane D.1, Stovold E.2, McDonnell M.3, Casey M.4, McDonnell T.4, Gillespie P.5, Raymakers A.5, Lacasse Y.6, McCarthy B.1
1National University of Ireland Galway, School of Nursing & Midwifery, Galway, Ireland, 2St George's University of London, Cochrane Airways Group, Population Health Research Institute, London, United Kingdom, 3Galway University Hospital, Galway, Ireland, 4St. Vincent's University Hospital, Dublin, Ireland, 5National University of Ireland Galway, Health Economics & Policy Analysis Centre (HEPAC), School of Business & Economics, Galway, Ireland, 6Laval University, Research Center Laval Hospital Institute of Cardiology and Pneumology, Quebec, Canada
Background: Chronic Obstructive Pulmonary Disease (COPD) affects about a tenth of the world's population and will become the fifth largest disease burden and the third greatest cause of death by 2020 according to the World Health Organisation. Pulmonary rehabilitation (PR) has been recommended as an important part of its management to relief symptoms, and to increase quality of life and exercise capacity; however, it is unclear what the optimal setting for PR is.
Purpose: To compare the effects of PR in different settings on Health-Related Quality of Life and functional and maximal exercise capacity in people with COPD.
Methods: We searched the Cochrane Airways Group Specialised Register, PubMed, the Epistemonikos database, and clinical trial registries on 05/07/2016.
We included randomised controlled trials (RCTs) that compared the effectiveness of two or more different settings of PR delivery to patients with stable COPD (absence of any acute exacerbation in the four weeks prior to the start of the programme). PR programmes had to include exercise therapy with or without any form of education and/or psychological support of at least four weeks. We assessed the outcomes Health-related Quality of Life (HRQoL), exercise capacity and cost-effectiveness. Two reviewers independently selected studies, assessed risk of bias, extracted data, and assessed the quality of evidence for each outcome (GRADE). Findings were presented as mean differences with 95% confidence intervals.
Results: We identified 3991 records of which nine RCTs were included, involving a total of 461 patients taking part in outpatient hospital-based PR, 294 in home-based PR, and 129 in community-based PR. Overall studies were at low risk of bias with the exception of performance bias where it was not possible to blind patients and personnel to PR and two studies had a high attrition rate (>20%).
Comparing hospital (outpatient) PR and home-based PR, there was moderate quality evidence that both settings were equally effective at improving HRQoL, measured by the four domains of the Chronic Respiratory Questionnaire (CRQ) as well as the St Georges Respiratory Questionnaire (SGRQ). Improvements in exercise capacity were also equal in the outpatient and home PR groups for both the 6-minute walking distance (6MWD) and incremental cycle ergometry (low quality evidence).
Similarly, hospital (outpatient) and community-based PR programmes were equally effective at improving HRQoL (low/moderate quality evidence) assessed using the CRQ. There was also no difference in change in incremental cycle ergometry, endurance shuttle walking distance and time walked (low quality evidence), all measures of exercise capacity.
Conclusion(s): Our review suggests that there is no difference in the effectiveness of PR when provided in a home-based, hospital-based or community-based setting. The cost-effectiveness of different settings remains unknown due to a lack of evidence.
Implications: In putting in place pulmonary rehabilitation programmes for patients with stable COPD, as recommended by current international guidelines, physical therapists, other healthcare professionals involved in the care patients with COPD and health services providers can choose the setting that best fits the local context.
Funding acknowledgements: This work was commisioned by the National Clinical Effectiveness Committee, Central Effectiveness Unit, Department of Health (Ireland).
Topic: Disability & rehabilitation
Ethics approval: No ethical approval was required due to the nature of systematic reviews (secondary research).
All authors, affiliations and abstracts have been published as submitted.
