Hybrid pulmonary rehabilitation: alternative models to support centre-based pulmonary rehabilitation

Extract

Pulmonary rehabilitation (PR) is a recommended, multidisciplinary intervention for patients with chronic respiratory diseases [1]. To cope with poor access and uptake of PR, novel and intuitively more accessible forms of rehabilitation have been studied successfully in clinical trials [2]. However, the context of a clinical trial does not ensure adoption in real life. The paper by Jenkins et al. [3] tests the real-world implementation of a hybrid digital PR programme. Traditionally, PR is provided during supervised, centre-based programmes (including inpatient, outpatient or community-based programmes) and leads to significant increases in exercise capacity and health-related quality of life compared to usual care [4].

Shareable abstract

Hybrid modalities of pulmonary rehabilitation (PR) have the potential to address some of the existing barriers associated with conventional centre-based PR. These models can be used to complement, and not only replace, centre-based PR. https://bit.ly/4nFtySE

Pulmonary rehabilitation (PR) is a recommended, multidisciplinary intervention for patients with chronic respiratory diseases [1]. To cope with poor access and uptake of PR, novel and intuitively more accessible forms of rehabilitation have been studied successfully in clinical trials [2]. However, the context of a clinical trial does not ensure adoption in real life. The paper by Jenkins et al. [3] tests the real-world implementation of a hybrid digital PR programme. Traditionally, PR is provided during supervised, centre-based programmes (including inpatient, outpatient or community-based programmes) and leads to significant increases in exercise capacity and health-related quality of life compared to usual care [4]. PR can be provided in several settings, each with specific advantages and disadvantages (figure 1). These settings result in effects that are similar to those of centre-based PR programmes [4–6]. Combining settings, in a hybrid modality, has the potential to optimise advantages.

FIGURE 1.

An overview of the possible settings in which to provide pulmonary rehabilitation (PR). The efficacy of programmes is provided for centre-based based programmes [4], telerehabilitation [5] and home-based rehabilitation [6]. 6MWD: 6-min walk distance; CRDQ: Chronic Respiratory Disease Questionnaire.

The use of technology-enabled models of PR as an alternative to conventional, centre-based PR has been a major research question and a topic of debate in recent years. Although the effectiveness of telerehabilitation has been found to be equivalent to centre-based PR [5], recommendations on how to implement these models of care differ across guidelines. While the American Thoracic Society recommendations conclude that telerehabilitation is an acceptable alternative modality, the British Thoracic Society clinical guidelines suggest digital PR as an alternative only for patients who cannot attend centre-based PR [7, 8].

The article by Jenkins et al. [3] in this issue of ERJ Open Research took a unique approach by testing digital PR as part of a hybrid intervention to support, rather than replace, centre-based PR. The rationale was to improve the accessibility and flexibility of PR while maintaining the benefits of supervision by skilled healthcare professionals in a hybrid programme. In their approach, digital PR could serve several purposes. First, digital PR could be used to provide additional home-based exercise sessions in addition to supervised training. Second, digital PR could replace part of the in-person PR sessions. Finally, patients could switch to digital PR after an initial centre-based programme. To facilitate digital competence, individuals received a 60-minute onboarding session where they were taught how to work with the application as part of the digital PR.

This approach was tested in a real-world setting at an expert PR centre. Contrary to the hypothesis, the uptake was low. Overall, while 86% of patients activated the pulmonary rehabilitation app at least once, only 35% of patients logged in at least once per week, and only 12% of participants ever accessed the pre-recorded exercise videos. Only one patient switched to digital PR, and the main reasons for declining digital PR were “enjoying centre-based PR” (66% of patients) and “being unable to use the digital PR independently” (33%). Despite a pragmatic inclusion strategy and introducing an onboarding session to improve digital literacy, the authors refer to poor digital literacy as an important barrier to uptake of and engagement with digital PR. Furthermore, of eligible participants for the hybrid programme, 53% were not recruited due to digital hesitancy. At the start of the PR programme, the vast majority of patients preferred centre-based PR. This data is in line with a previous study exploring patients' preference in choosing the modality of care [9]. It also underpins the importance of including patient preferences into the options for rehabilitation. While in trials digital programmes show equal benefits, the current COPD patient population seems not to prefer the option frequently.

We agree with the authors that other modes of care can support centre-based PR as part of a hybrid programme. In these hybrid solutions, the other modes can be used 1) to add sessions in addition to the centre-based sessions; 2) to replace part of the sessions; 3) as an alternative for centre-based sessions; or 4) to be used as a maintenance programme. In this approach, several settings can be investigated, not only digital PR. Our research group examined the possibility of replacing some of the centre-based sessions to support centre-based PR [10]. In that study, we replaced two group-based centre-based PR exercise sessions per week with one-on-one exercise sessions led by primary care-based physiotherapists. This decreased patients’ travel distance while maintaining guidance from an expert centre and contact with the multidisciplinary team. Other groups have already successfully demonstrated the effectiveness of digital PR in maintaining the effects of centre-based PR [11, 12]. Which PR model can support centre-based PR depends on digital literacy, patients’ preferences and the healthcare system in which patients live, as well as how close centre-based programmes are available, the complexity of the patient's disease and the need for multidisciplinary care.

A goal of the study by Jenkins et al. [3] was to alleviate the burden on the multidisciplinary staff to accompany the additional costs of digital PR compared to centre-based PR. However, numerically, the digital PR group required approximately 100 min more staff time per patient, mainly due to the 60-minute onboarding session. Increased time demand was also a concern reported by the treating staff during the qualitative interview. These findings highlight the need for careful consideration of resource use in emerging care models. Economic evaluations, such as cost-minimisation analyses, are essential to fully assess the feasibility and potential benefits of implementing digital PR in routine practice [13].

In all novel models of PR, whether other settings are used to support, replace or maintain centre-based PR, it is imperative that the training principles are followed to guarantee the intervention's effectiveness [14]. As an example, one study that tested PR in a primary care setting showed larger improvements in exercise tolerance when the programme was offered at appropriate intensity, compared to a “sham” programme at low intensity [15]. As another example, we recently demonstrated, contrary to our hypothesis, that increasing the amount of (mainly light-intensity) physical activity alone will not lead to maintenance of training effects gained during a centre-based PR programme [16]. Patients need to be prescribed an exercise training programme with adequate training intensity; light-intensity programmes will not lead to sufficient intervention effect.

Overall, we believe hybrid modalities of PR could have the potential to help address some of the existing barriers associated with conventional centre-based PR. These models should be designed to complement, rather than replace, centre-based PR. Future prospective studies should provide transparent reporting of training interventions (CERT (Consensus on Exercise Reporting Template) guidelines [17]), and should include assessments of long-term effectiveness, cost-effectiveness and the experiences of both healthcare professionals and patients. Rather than a uniform model, the future of PR lies in a more flexible, personalised approach.