Discussion
lung disease, fatigue, ’, stage lung disease, COPD
LUNG DISEASE, ADVERSE EVENTS, DISEASE, RECRUITMENT, COPD, SECONDARY
TelePR is equivalent to SPR in terms of QOL and exercise capacity, and superior in terms of patient adherence to PR. Stickland et al. [Using the RE-AIM framework we demonstrate that TelePR was able to reach the intended population; was not comparatively superior to those referred to SPR; was effective in improving health outcomes when evaluating pre-and post- health metrics for those who completed TelePR including improved COPD knowledge and management skills, decreased fatigue and improved functional capacity; had low rates of adoption due to perceived benefit of exercise and social challenges largely related to comorbidities and needing in-person medical clearance appointments – although there was higher adoption compared to those referred to SPR; was able to be successfully implemented in patients’ homes; and had low maintenance rates after the program was discontinued. Several participants stated they were continuing to engage in some form of exercise (eg, walking) but those who were no longer engaging in physical activity cited during the interviews that a lack of access either to a PR facility or to the exercise equipment as barriers to continued physical activity.It is possible to successfully conduct TelePR sessions for people with advanced stage COPD with multiple comorbidities who were recently hospitalized, and for people who are from typically underserved Spanish-only speaking and/or Black communities. Many TelePR participants stated that watching other patients with similar health problems as themselves via teleconference motived them to push themselves to stay on the same exercise level or, at times, be better. Because of the various comorbidities that individuals with COPD face, social isolation is a common factor [We identified several barriers to adoption of TelePR by patients, the most significant of which was beliefs about the importance of exercise compared to other types of disease management such as medication. This sometimes led to deliberative and informed decisions not to take part in PR despite the support of a social worker and study team. Our recruitment videos attempted to address beliefs about exercise futility using patient-testimonials. However, effective messaging must come from multiple outlets to influence social norms about exercise in advanced stage lung disease. This includes buy-in from primary care physicians about the feasibility and safety of PR for these patients.For those who accepted a referral to TelePR, the most significant barrier to starting was the requirement for in-person medical clearance. It is possible that with the increasing prevalence of telehealth visits, preliminary clearance could be obtained before hospital discharge, with a follow up via telehealth prior to initiating the first TelePR session. Several hospitalists, primary care and even some pulmonary clinicians were reluctant to ‘clear’ patients with such advanced lung disease for exercise, fearing adverse events during exercise. The same reluctance was not encountered among cardiologists. This may be an area of necessary education regarding the relative benefit of exercise therapy and the other components of PR – education and socialization- that outweigh harms. In fact, there were no serious adverse events related to PR in our study.A particularly important lesson learned is the lack of maintenance of exercise once people completed the 8-week program and the clear necessity for maintenance PR to be available for people with advanced stage COPD to prolong the achieved health improvements. Unfortunately, improvements seen in secondary outcomes did not persist at 6 and 12 months, which was not unexpected, because few, if any, patients had access to PR beyond the research study. This is a known limitation of PR programs, wherein, due to insurance reimbursement constraints and long wait lists for new PR participants, there is a limited number of PR sessions available to patients. Although preparation to transition out of the PR program includes conversations about the importance of maintaining exercise to preserve the gains made during the program, many patients do not continue exercise, as evidenced by the follow-up phone calls. Participants frequently stated they would have liked to continue attending the PR sessions (both TelePR and SPR) but that they were unable to do so due to transportation and financial difficulties. Patients in real-world PR programs are invited to continue in a maintenance program such as once-weekly sessions; however, there are long waitlists and one main barrier to PR maintenance is that many insurance policies limit the number of PR sessions to 72 sessions within a lifetime, if they cover it at all – having people pay out of pocket. Prior studies have shown significant benefit while in a PR maintenance program for 4–5 years compared to short-term PR in individuals with COPD [In summary, while we were able to reach our intended target population and to implement a TelePR intervention that maintained high fidelity to standard PR, we faced multiple barriers to adoption and maintenance at both patient and provider levels. Therefore, we recommend increased messaging from primary care providers and community-based outlets about the benefits of PR, facilitating referrals and medical clearances for PR, supporting wide-scale TelePR availability, and supporting reimbursement for maintenance PR programs.