Neuenfeldt, Pamela

Abstract Rationale Hospital readmission for chronic obstructive pulmonary disease (COPD) has attracted attention owing to the burden to patients and the health care system. There is a knowledge gap on approaches to reducing COPD readmissions. Objectives To determine the effect of comprehensive health coaching on the rate of COPD readmissions. Methods A total of 215 patients hospitalized for a COPD exacerbation were randomized at hospital discharge to receive either (1) motivational interviewing–based health coaching plus a written action plan for exacerbations (the use of antibiotics and oral steroids) and brief exercise advice or (2) usual care. Measurements and Main Results We evaluated the rate of COPD-related hospitalizations during 1 year of follow-up. The absolute risk reductions of COPD-related rehospitalization in the health coaching group were 7.5% (P = 0.01), 11.0% (P = 0.02), 11.6% (P = 0.03), 11.4% (P = 0.05), and 5.4% (P = 0.24) at 1, 3, 6, 9, and 12 months, respectively, compared with the control group. The odds ratios for COPD hospitalization in the intervention arm compared with the control arm were 0.09 (95% confidence interval [CI], 0.01–0.77) at 1 month postdischarge, 0.37 (95% CI, 0.15–0.91) at 3 months postdischarge, 0.43 (95% CI, 0.20–0.94) at 6 months postdischarge, and 0.60 (95% CI, 0.30–1.20) at 1 year postdischarge. The missing value rate for the primary outcome was 0.4% (one patient). Disease-specific quality of life improved significantly in the health coaching group compared with the control group at 6 and 12 months, based on the Chronic Respiratory Disease Questionnaire emotional score (emotion and mastery domains) and physical score (dyspnea and fatigue domains) (P < 0.05). There were no differences between groups in measured physical activity at any time point. Conclusions Health coaching may represent a feasible and possibly effective intervention designed to reduce COPD readmissions. Clinical trial registered with www.clinicaltrials.gov (NCT01058486).

Pulmonary rehabilitation (PR), following an acute exacerbation of chronic obstructive pulmonary disease (COPD), has been found effective in some studies in reducing readmission rates as and has recently been recommended by the PR guidelines. However, very recent reports suggested that PR is not feasible after a hospital admission for a COPD exacerbation. The objective of this study is to investigate the knowledge gap on the underlying reasons for nonparticipation in PR in the posthospitalization period. We qualitatively analyzed the responses of 531 patients hospitalized for a COPD exacerbation who were not interested in participating in either PR (home or center based) or physical activity monitoring program after being discharged from the hospital. The responses were coded thematically, and independent reviewers compiled the raw data into themes. The characteristics of the 531 subjects (45% male) who declined the intervention are as follows: age was 70 ± 10 years, mean forced expiratory volume in one second (FEV1%) predicted 40 ± 16, and age, dyspnea, and airflow obstruction index 6.0 ± 1.6 (scale 0–10). The themes for not attending include lack of interest (39%), the perception of “being too ill or frail or disabled” (24%), the perception of being “too busy or having too much to do” (11%), distance or the need of travel (11%), commitment issues (7%), comorbidities (6%), and lack of social support (2%). We identified barriers for PR or just physical activity programs after a hospitalization that may affect implementation of such programs. Implementing posthospitalizations program in COPD may require patient engagement and mindful and compassionate professionals who may individualize program components to focus specific deficits and particularly patients’ preferences.