Abstract
Objectives: To evaluate the effectiveness of pulmonary rehabilitation interventions based on the Kano model in discharge preparation services for patients with chronic obstructive pulmonary disease (COPD). Methods: Baseline characteristics of 100 patients with COPD (Kano group=50; control group=50) were collected. Outcome indicators included forced expiratory volume in 1s (FEV1), forced vital capacity (FVC), maximal voluntary ventilation (MVV), scores on the Readiness for Hospital Discharge Scale (RHDS), Quality of Discharge Teaching Scale (QDTS), and COPD Assessment Test (CAT). These parameters were analyzed and compared between the groups. Results: No statistical significances were observed between the two groups in baseline characteristics. After intervention, the FEV1 and MVV values were significantly higher in the Kano group than those in the control group (P<0.05). The total and subscale scores of the RHDS and QDTS were significantly higher in the Kano group (P<0.001). In the control group, the “content actually obtained” scores were lower than the “content needed for discharge” scores (P<0.05), whereas in the Kano group, the “content actually obtained” scores exceeded the “content needed for discharge” scores after the intervention (P<0.05). CAT scores were significantly lower in the Kano group compared to the control group (P<0.05). Conclusions: Pulmonary rehabilitation interventions based on the Kano model significantly improve lung function, discharge readiness, quality of discharge teaching, and quality of life in patients with COPD.
Keywords: Pulmonary rehabilitation, Kano model, discharge preparation service, chronic obstructive pulmonary disease
Introduction
Chronic obstructive pulmonary disease (COPD) is one of the leading causes of death worldwide, accounting for approximately 3.32 million deaths in 2019, with the highest burden observed in middle-income countries, according to the latest statistics from the World Health Organization [1]. Driven by the growth and aging of the global population, the prevalence of COPD is projected to rise continuously over the next four decades [2]. In China, the prevalence of COPD among individuals aged ≥40 years is approximately 13.7%, reaching 21.2% among those aged 60-69 years and 35.5% among those aged ≥70 years [3]. Due to its chronic course and recurrent exacerbations, COPD frequently leads to acute attacks, repeated hospitalizations, increased medical expenses, and even death, seriously impairing patients’ quality of life [4,5]. In 2017, COPD accounted for 95.29% of the disease burden among Chinese adults aged ≥40 years, making it a major contributor to reduced survival and disability in middle-aged and elderly people [6,7]. COPD patients also bear a huge economic burden: average direct medical cost per COPD patient is estimated at $12,552.3, with 24.4% to 24.8% of patients at very high economic risk [8]. On average, COPD patients experience 1-2 hospital admissions per year for acute exacerbations, and 46% have at least one exacerbation annually; the frequency of their readmission increases as their condition worsens [9]. Studies abroad have also shown that up to 20% of COPD patients are readmitted within 30 days of discharge due to acute exacerbations [10]. Therefore, reducing the unplanned readmissions among elderly COPD patients is of great significance for improving the quality of life and alleviating the socioeconomic burden of the disease [11,12].
Evidence suggests that discharge preparation services help ensure continuity of medical care after discharge and reduce re-hospitalization [13]. Appropriate discharge planning and timing can also enhance patient and family satisfaction with healthcare services. The 2020 Global Initiative for Chronic Obstructive Pulmonary Disease (GOLD) report proposed pulmonary rehabilitation as the cornerstone of nonpharmacological management for stable COPD, emphasizing its role in symptom control and exacerbation prevention [14]. Numerous studies have demonstrated that pulmonary rehabilitation significantly improves the long-term quality of life of COPD patients [14-16]. However, to date, no studies have explored the integration of pulmonary rehabilitation nursing with hospital discharge preparation services.
The KANO nursing model emphasizes the differentiated effects of various nursing service attributes on patient satisfaction, categorizing needs into basic, performance, and attractive dimensions. When applied to discharge education and management, it helps clarify which services are essential, which enhance satisfaction, and which provide additional value. Previous studies have shown that it can effectively distinguish between different types of care needs among cervical cancer patients undergoing chemotherapy, providing a scientific basis for prioritizing needs and allocating resources, thereby enhancing adherence and post-discharge quality of life [17]. Building on this evidence, the present study aims to investigate the application of pulmonary rehabilitation interventions based on the Kano model in discharge preparation services for patients with COPD.
Methods
Cases
This retrospective study included 100 patients with COPD who were admitted to Lu’an People’s Hospital between March 2023 and January 2024. Fifty patients who received Kano-based nursing care were assigned to the Kano group, while another 50 age-matched patients who underwent conventional treatment and nursing care served as the control group. Inclusion criteria: (1) Age over 40 years; (2) Hospitalized with a diagnosis of COPD according to the GOLD guidelines; (3) Clear consciousness with no cognitive or communication impairments. Exclusion criteria: (1) Speech, visual, or hearing impairment; (2) Recent myocardial infarction or unstable angina pectoris; (3) History of tumor or stroke; (4) Presence of severe primary diseases of the liver, kidney, or hematopoietic system, or psychiatric disorders; and (5) Recent activity limitation. The detailed patient inclusion process is illustrated in Figure 1. General demographic data, including age, sex, first hospitalization status, place of residence, and payment terms for hospitalization, were collected using a structured questionnaire. This study was approved by the Ethics Committee of Lu’an People’s Hospital.
Figure 1.
Flowchart of patient inclusion.
Evaluation strategies based on Kano model
As shown in Table 1, the Kano model divides healthcare service attributes into six categories, namely: (1) Must-be quality (M): Meeting this requirement does not increase satisfaction, but failing to meet it leads to dissatisfaction; (2) One-dimensional quality (O): Satisfaction increases when the requirement is fulfilled and decreases when it is not; (3) Attractive quality (A): Satisfaction markedly increases when the requirement is met but does not decrease when it is not; (4) Indifferent quality (I): Satisfaction is unaffected regardless of whether the requirement is met; (5) Reverse quality (R): The service is undesirable to the patient; and (6) Question quality (Q): Contradictory responses are given by the respondent.
Table 1.
Kano evaluation table
| Satisfied | Must-be | Neutral | Acceptable | Unsatisfied | |
|---|---|---|---|---|---|
| Satisfied | Q | A | A | A | O |
| Must-be | R | I | I | I | M |
| Neutral | R | I | I | I | M |
| Acceptable | R | I | I | I | M |
| Unsatisfied | R | R | R | R | Q |
Q: Questionable, A: Attractive, O: One-dimensional, R: Reverse, I: Indifferent, M: Must-be.
Each questionnaire item included five response options: satisfied, must-be, neutral, acceptable, and unsatisfied. The Cronbach’s alpha coefficient of the questionnaire was 0.725, and the validity was 0.83, both within the acceptable range of reliability and validity. Notably, must-be qualities (M) should be prioritized, followed by one-dimensional qualities (O) and attractive qualities (A), whereas reverse qualities (R) should be eliminated from the service list.
Pulmonary rehabilitation measures
The control group received routine respiratory nursing care delivered by ward nursing staff, including admission guidance, standard respiratory nursing guidance, and discharge counseling.
Kano group received pulmonary rehabilitation interventions based on the KANO model questionnaire [18], covering the following components: (1) Communication and psychological intervention: Upon admission, nurses established effective communication with patients to assess disease perception and emotional state. Psychological counseling and health education were provided to alleviate anxiety and depression, emphasizing disease controllability and the importance of rehabilitation. Family members were encouraged to participate to enhance treatment adherence; (2) Nutrition care: Individualized dietary guidance was provided according to nutritional assessments. A protein-rich diet with sufficient vitamins and trace elements was recommended, while high-salt and high-fat intake was restricted. For malnourished patients, nutritional supplementation or enteral support was arranged in collaboration with the nutrition department to ensure adequate energy and nutrient intake; (3) Expectoration care: Patients were instructed in effective airway clearance techniques, including postural drainage, chest percussion, pursed-lip breathing, and effective coughing. Nebulization or expectorant medications were used when necessary to maintain airway patency, reduce sputum retention, and minimize infection risk; (4) Respiratory exercise: A stepwise respiratory training program was implemented, including diaphragmatic breathing, pursed-lip breathing, and balloon-blowing exercises. When tolerated, light aerobic activities such as walking were gradually introduced to improve ventilation and exercise endurance; We also designed an eight-step vertical breathing training program for functional training, including: ① Head movement; ② Turning movement; ③ Chest expansion movement; ④ Lateral flexion movement; ⑤ Waist rotation movement; ⑥ Rotational trunk lift movement. Each step is repeated twice, twice daily, for 10-20 minutes per session. For bedridden patients, we developed a supine bicycle training method: Lie flat on your back with arms resting alongside the body. Position legs at a 30° angle to the ground with knees flexed. Keep the upper body stationary while alternately flexing and extending both legs. Perform slow, alternating bicycle pedaling motions in the air: 12 forward strokes per session. Conduct 2-3 sessions daily, completing 10-20 sets per session. (5) Complication management: Patients were closely monitored for common complications such as respiratory failure, infection, and cardiac dysfunction. Vital signs and oxygen saturation were regularly recorded, and any abnormalities were promptly reported and managed to reduce complication rates; (6) Disease observation and environmental care: Daily records were maintained for cough, sputum volume and color, and dyspnea severity. The ward environment was kept clean, well-ventilated, and maintained at a comfortable temperature and humidity, avoiding exposure to smoke or irritants. Patients were also educated to optimize their home environment through smoking cessation and adequate ventilation.
Outcome indicators
Pulmonary function index
Pulmonary function was assessed in both groups after the intervention, including forced expiratory volume in 1 s (FEV1), forced vital capacity (FVC) and maximal voluntary ventilation (MVV).
Readiness for Hospital Discharge Scale (RHDS)
Discharge readiness reflects the degree to which a patient is physically, functionally, cognitively, and emotionally prepared to manage post-discharge health and potential complications [19]. In this study, it referred to elderly COPD patients’ perceptions of their physical and psychological status at discharge, their confidence in self-managing the disease, and their expectations of family and community support after returning home. The RHDS scale consists of 3 dimensions-personal status, adaptive ability, and anticipated support-each with 4 entries, totaling 12 items. Each item is scored on a 10-point scale, with a maximum score of 120. A two-option preliminary question, ‘Are you ready to be discharged from the hospital?’ precedes the scale. The Cronbach’s α coefficient and content validity index (CVI) of the RHDS scale were 0.89 and 0.88, respectively.
Quality of Discharge Teaching Scale (QDTS)
The QDTS scale was initially developed by Weiss et al. [20] and later adapted into Chinese by Wang et al. [21]. The Chinese version was used in this study. The scale contains three dimensions, discharge information needed (six paired items), discharge information actually obtained (six paired items), and discharging teaching skills and effectiveness (12 items). The total QDTS score is the sum of scores from the second and third dimensions. Each item is rated on a 10-point scale, with a maximum score of 180. The Cronbach’s α coefficient and CVI of the overall scale were 0.924 and 0.98, respectively.
COPD assessment test (CAT)
The CAT was employed to evaluate patients’ health-related quality of life [22]. It consists of eight items assessing symptoms such as dyspnea, cough, sputum production, fatigue, chest discomfort, sleep quality, and overall daily functioning. Each item is rated on a 5-point Likert scale (1-5), yielding a total score ranging from 0 to 40. Lower scores indicate a greater impact of COPD on the patient’s quality of life.
Data acquisition
A general information questionnaire was completed for all participants. Pulmonary function indices (FEV1, FVC, and MVV), and the RHDS, QDTS and CAT scales were administered within 48 hours of admission. Additionally, the RHDS, QDTS and CAT scales were reassessed 24 hours prior to discharge. Pulmonary function tests were also repeated at that time.
Statistical analysis
All statistical analyses were performed using SPSS26.0. RHDS, QDTS, and CAT scores were continuous variables with normal distribution and were expressed as mean ± standard deviation (SD). Pulmonary function indices (FEV1, FVC and MVV) did not obey a normal distribution and were presented as median (interquartile range). Categorical variables were described as frequencies and percentages.
For normally distributed data, independent -samples t-tests were used for between-group comparisons, paired-samples t-tests for within-group comparisons, and repeated-measures analysis of variance (ANOVA) for variables measured more than twice. Non-normally distributed data were analyzed using the rank-sum test. Categorical data were compared using the chi-square test or Fisher’s exact test, as appropriate. A two-tailed P value <0.05 was considered statistically significant.
A post hoc power analysis was conducted using G*Power 3.1. Assuming a medium effect size (Cohen’s d=0.5), with α=0.05 and a total sample size of 100, the calculated statistical power was 0.80, indicating adequate sample size to detect between-group differences.
Results
Baseline characteristics
A total of 100 patients were enrolled in this study, including 50 in the control group and 50 in the Kano group. There was no significant difference in sex, age, first hospitalization, region of residence, payment terms for hospitalization, course of disease, smoking history, pulmonary function classification, or complications between the two groups (P>0.05), indicating good baseline comparability (Table 2).
Table 2.
Comparison of baseline characteristics between the two groups
| Variables | Total (N=100) | Group | χ2/t | p | |
|---|---|---|---|---|---|
|
| |||||
| Kano group (n=50) | Control group (n=50) | ||||
| Sex, n (%) | 0.258 | 0.615 | |||
| Male | 63 (63.00) | 32 (64.00) | 31 (62.00) | ||
| Female | 37 (37.00) | 18 (36.00) | 19 (38.00) | ||
| Age year, Mean ± SD | 75.37±8.69 | 74.80±9.25 | 75.94±8.24 | -1.160 | 0.247 |
| First hospitalization | 1.478 | 0.193 | |||
| Yes | 53 (53.00) | 26 (52.00) | 27 (54.00) | ||
| No | 47 (47.00) | 24 (48.00) | 23 (46.00) | ||
| Area of residence | 1.412 | 0.366 | |||
| Urban | 80 (80.00) | 41 (82.00) | 39 (78.00) | ||
| Rural | 20 (20.00) | 9 (18.00) | 11 (22.00) | ||
| Payment terms for hospitalization | 0.922 | 0.428 | |||
| Medical insurance | 69 (69.00) | 36 (72.00) | 33 (66.00) | ||
| Self-funded | 31 (31.00) | 14 (28.00) | 17 (34.00) | 0.683 | 0.573 |
| Course of disease, year (n) | 0.792 | 0.833 | |||
| 1-5 | 59 (59.00) | 31 (64.00) | 28 (56.00) | ||
| >5 | 41 (41.00) | 18 (36.00) | 23 (46.00) | ||
| Smoking history | 0.439 | 0.226 | |||
| Yes | 63 (63.00) | 32 (64.00) | 31 (62.00) | ||
| No | 37 (37.00) | 18 (36.00) | 19 (38.00) | ||
| Pulmonary function classification | 2.731 | 0.736 | |||
| I | 4 (4.00) | 1 (2.00) | 3 (6.00) | ||
| II | 46 (46.00) | 25 (50.00) | 21 (42.00) | ||
| III | 45 (45.00) | 23 (46.00) | 22 (44.00) | ||
| IV | 5 (5.00) | 1 (2.00) | 4 (8.00) | ||
| Complications | 0.683 | 0.573 | |||
| Yes | 64 (64.00) | 36 (72.00) | 28 (56.00) | ||
| No | 36 (36.00) | 14 (28.00) | 22 (44.00) | ||
Kano attributes classification of pulmonary rehabilitation interventions among COPD patients
As shown in Table 3, there were no significant differences in patients’ willingness toward the various pulmonary rehabilitation interventions, suggesting that participants showed neither particular satisfaction nor dissatisfaction with these nursing interventions prior to implementation.
Table 3.
Kano attributes classification of pulmonary rehabilitation interventions among COPD patients
| Nursing Interventions | A | O | M | I | R | Q | Final Kano category |
|---|---|---|---|---|---|---|---|
| Communication and psychological intervention | 5.1 | 27.1 | 15.3 | 52.5 | 0 | 5.1 | I |
| Nutritional support | 6.8 | 28.8 | 13.6 | 50.8 | 0 | 6.8 | I |
| Expectoration care | 6.8 | 30.5 | 18.6 | 39.0 | 0 | 5.1 | I |
| Respiratory exercise | 5.1 | 25.4 | 13.6 | 54.2 | 0 | 6.8 | I |
| Complication nursing | 3.4 | 11.8 | 10.2 | 72.9 | 1.7 | 3.4 | I |
| Disease observation and environmental care | 5.1 | 33.9 | 11.9 | 49.1 | 0 | 5.1 | I |
COPD: chronic obstructive pulmonary disease; Q: Questionable, A: Attractive, O: One-dimensional, R: Reverse, I: Indifferent, M: Must-be.
Pulmonary function indices
Before intervention, there were no significant differences between the two groups in terms of pulmonary function indices (P>0.05). After intervention, the FEV1 (34.66% vs 26.58%) and MVV (35.65% vs 29.60%) were significantly higher in the Kano group than those in the control group (P<0.05). No significant differences were found in FVC or FEV1/FVC between the two groups after intervention (P>0.05) (Table 4).
Table 4.
Comparison of pulmonary function indices between the two groups before and after interventio
| Time | Index | Group | statistic | p | |
|---|---|---|---|---|---|
|
| |||||
| Kano group (n=50) | Control group (n=50) | ||||
| Pre-intervention | FVC | 77 (63,92) | 75 (54,84) | 1.542 | 0.129 |
| FEV1 | 48 (32,66) | 42 (29,60) | 2.354 | 0.673 | |
| FEV1/FVC | 49 (40,59) | 49 (40,61) | 2.106 | 0.148 | |
| MVV | 43 (35,70) | 41 (28,63) | 1.652 | 0.836 | |
| Post-intervention | FVC | 76 (63,90) | 71 (55,84) | 0.669 | 0.090 |
| FEV1 | 52 (34,66) | 43 (26,58) | 1.160 | 0.035 | |
| FEV1/FVC | 51 (41,61) | 49 (38,61) | 1.968 | 0.573 | |
| MVV | 53 (35,65) | 40 (29,60) | 1.412 | 0.046 | |
FEV1: forced expiratory volume in 1s, FVC: forced vital capacity, MVV: maximal voluntary ventilation.
RHDS and QDTS scores
The total and dimensional scores of the RHDS and QDTS followed a normal distribution. Statistical analysis showed no significant differences in total or subscale scores between the two groups before intervention (P>0.05) (Table 5).
Table 5.
Comparison of RHDS and QDTS scores between the two groups within 48 hours of admission
| Scale | Dimension | Kano group (n=50) | Control group (n=50) | t | P |
|---|---|---|---|---|---|
| RHDS | Personal status | 27.22±1.08 | 27.27±1.07 | 0.239 | 0.752 |
| Adaptive capacity | 15.45±1.85 | 15.99±1.70 | 0.181 | 0.632 | |
| Expected support | 17.98±1.75 | 16.69±1.16 | 0.622 | 0.846 | |
| Total scores | 60.66±1.59 | 59.96±1.32 | 0.804 | 0.531 | |
| QDTS | Content needed | 40.06±2.17 | 40.52±2.52 | -0.220 | 0.529 |
| Content actually obtained | 26.37±2.65 | 26.07±1.99 | 0.522 | 0.654 | |
| Teaching skills and effectiveness | 71.41±2.57 | 70.89±2.41 | 0.779 | 0.466 | |
| Total scores | 98.18±2.65 | 97.83±2.42 | 0.487 | 0.268 |
RHDS: Readiness for Hospital Discharge Scale, QDTS: Quality of Discharge Teaching Scale.
After the intervention, the total RHDS score was significantly higher in the Kano group than that in the control group (92.47±1.84 vs. 83.02±1.67, P<0.05). Similarly, the total QDTS score of the Kano group (89.92±2.45) was significantly higher than that of the control group (87.03±2.69) (P<0.05) (Table 6).
Table 6.
Comparison of RHDS and QDTS scores between the two groups before discharge
| Scale | Dimension | Kano group (n=50) | Control group (n=50) | t | P |
|---|---|---|---|---|---|
| RHDS | Personal status | 36.56±1.64 | 34.44±1.79 | 5.239 | <0.001 |
| Adaptive capacity | 22.74±1.56 | 19.68±1.32 | 5.452 | <0.001 | |
| Expected support | 33.26±2.09 | 28.95±1.88 | 8.651 | <0.001 | |
| Total scores | 92.47±1.84 | 83.02±1.67 | 16.463 | <0.001 | |
| QDTS | Content needed | 40.52±2.07 | 40.44±2.72 | 0.166 | 0.869 |
| Content actually obtained | 41.58±2.09 | 35.87±1.65 | 1.522 | 0.013 | |
| Teaching skills and effectiveness | 89.92±2.45 | 87.03±2.69 | 5.735 | <0.001 | |
| Total scores | 136.02±2.98 | 132.42±2.83 | 7.462 | <0.001 |
RHDS: Readiness for Hospital Discharge Scale, QDTS: Quality of Discharge Teaching Scale.
The needed and obtained content scores
Both groups were compared regarding the “content needed for discharge” and “content actually obtained” dimensions. The differences between the two dimensions followed a normal distribution. In the control group, the score for content actually obtained was significantly lower than that for content needed for discharge (35.87±1.65 vs. 40.52±2.72, P<0.05). Conversely, in the Kano group, the score for content actually obtained exceeded that for content needed for discharge (41.58±2.09 vs. 40.52±2.07, P<0.05) (Figure 2).
Figure 2.
Comparison of scores of content needed and content actually obtained between the two groups before discharge. A: Control group. B: Kano group.
Comparison of CAT scores
At admission, CAT scores were comparable (P>0.05). By discharge, the Kano group showed significantly lower CAT scores than the control group (P<0.05). Within-group comparisons also showed significant score reductions in both groups (P<0.05) (Table 7).
Table 7.
Comparison of CAT scores
| Kano group (n=50) | Control group (n=50) | t | P | |
|---|---|---|---|---|
| Admission | 21.12±2.08 | 21.29±2.13 | 0.404 | 0.687 |
| Discharge | 16.42±1.97 | 18.87±2.15 | 5.941 | <0.001 |
| t1 | 11.601 | 5.654 | ||
| P1 | <0.001 | <0.001 |
CAT: COPD assessment test.
Discussion
Previous studies have shown that discharge preparation services help ensure continuity of care after hospital discharge, reduce the risk of re-hospitalization or premature discharge, and improve patients and family satisfaction with health-care services [23]. This study demonstrated that COPD patients who received pulmonary rehabilitation interventions based on the Kano model achieved significantly higher RHDS and QDTS scores, as well as improved FEV1 and MVV values compared with the control group.
Pulmonary function tests provide objective measures of airflow limitation and are considered the ‘gold standard’ for the diagnosis of COPD. They are widely used to evaluate disease severity, monitor disease progression, and assess prognosis and therapeutic response. Specifically, FVC reflects airway resistance, while FEV1% is often used to determine the severity of airflow limitation. A post-bronchodilator FEV1/FVC ratio <70% indicates persistent airflow obstruction [24]. MVV primarily reflects the overall ventilatory reserve capacity of the lungs. Previous research indicates that combining empowerment-based continuous care with pulmonary rehabilitation can improve lung function and alleviate anxiety and depression in COPD patients [25]. In this study, post-intervention FEV1 was significantly higher in the Kano group than in the control group, consistent with the findings of Andrello et al. [26]. The observed improvement in FEV1 may be explained by two key mechanisms. First, airway inflammation is a hallmark pathological feature of COPD. Elevated inflammatory cytokines exacerbate the inflammatory responses, contributing to progressive decline in lung function [27]. Previous studies have demonstrated a negative correlation between inflammatory markers and lung function indices, including FEV1 and FEV1/FVC [28]. Respiratory training alleviates dyspnea and enhances ventilation efficiency. Techniques such as pursed-lip breathing increase airway pressure, prevent premature small airway collapse, promote alveolar gas exchange, and reduce lung hyperinflation. These mechanisms may explain the improvement in FEV1 observed in the present study. However, the absence of a significant change in FEV1/FVC further supports the understanding that airflow limitation in COPD remains largely irreversible [29]. The magnitude of MVV reflects respiratory muscle strength and airway resistance. Long-term inhalation therapy can alleviate dyspnea and partially reduce airway resistance, thereby improving MVV in COPD patients. Previous studies have demonstrated that MVV is closely correlated with the prognosis of COPD, and both MVV and FEV1 possess strong predictive value for functional exercise capacity and patient-reported outcomes [26]. Additionally, the CAT score was used to further evaluate the impact of the intervention on patients’ health-related quality of life. A significantly greater reduction in CAT scores was observed in the Kano group prior to discharge, indicating that the Kano-based intervention effectively alleviated subjective symptoms and enhanced overall quality of life. As a widely recognized tool in COPD management, the CAT scale captures multidimensional improvements in cough, dyspnea, physical activity, and energy levels, thereby reflecting the multidimensional benefits of rehabilitation. The observed improvements in MVV and CAT scores may be related to enhanced respiratory muscle function and reduced airway resistance through pulmonary rehabilitation and long-term medication use [30]. These interventions can strengthen ventilatory reserve, alleviate dyspnea, and promote better adherence to treatment. In addition, individualized discharge guidance based on the Kano model may increase patients’ self-efficacy and participation in rehabilitation, which in turn contributes to both objective and subjective improvements in lung function and quality of life [31].
The concept of discharge readiness was first defined as the extent to which a patient perceives themselves as prepared to transition from hospital to home and to adapt to changes in health status [32]. Evaluating discharge readiness before a patient leaves the hospital enables healthcare professionals to understand the patient’s perceptions and psychological state, allowing further adjustments to the discharge care plan to better meet the patient’s needs. This process is crucial for a successful transition from hospital to home [33]. A Previous research conducted abroad has shown that disease adaptability, that is, the patient’s acceptance of illness, is significantly related to age; as age increases, both adaptability and acceptance tend to decline [34].
Elderly patients often experience multiple comorbidities and age-related physiological decline, which, coupled with limited disease-related knowledge-such as medication management-results in poor adaptability after discharge [35]. In this study, the total RHDS score and all subscale scores in the intervention group were significantly higher than those in the control group at discharge, indicating that the Kano model-based pulmonary rehabilitation intervention effectively improved discharge readiness among elderly COPD patients. These findings are consistent with those reported by Wu et al. [36]. Within-group comparison of the “content actually obtained” and “content needed for discharge” dimensions revealed that, in the control group, the difference between these scores was negative, suggesting that discharge education did not meet patients’ needs. In contrast, the difference was positive in the intervention group, indicating that patients in this group received discharge guidance that adequately met their informational and educational needs. Furthermore, both the discharge teaching skills scores and overall QDTS scores were higher in the intervention group than in the control group, demonstrating that the Kano model-based discharge preparation intervention improved the quality of discharge guidance for elderly COPD patients. These findings are consistent with previous research showing that individualized and structured discharge planning significantly enhances patient readiness and continuity of care, particularly among elderly patients with chronic diseases [37].
It is noteworthy that this study has several limitations. First, only short-term outcomes at discharge were evaluated, and long-term follow-up data were lacking. Therefore, the sustained effects of the intervention could not be fully determined, which limits the conclusiveness of our findings regarding its long-term benefits. Future studies with larger sample sizes, more rigorous designs, and extended follow-up periods are needed to further validate the stability and durability of the observed results. Second, COPD is a chronic condition characterized by a long disease course, and frequent exacerbations requiring repeated hospitalizations. Although we recorded whether patients were first-time admissions and ensured compatible baseline characteristics between groups, no further stratifications or subgroup analysis was performed for patients with repeated hospitalizations, which may have introduced potential bias. Third, this study did not directly compare the Kano model-based intervention with other established discharge preparation strategies for COPD, which limits the ability to determine its relative superiority. Future studies should incorporate comparative analyses to clarify its advantages and cost-effectiveness in clinical practice.
Conclusion
Kano model-based pulmonary rehabilitation interventions significantly improve lung function and discharge readiness in patients with COPD compared with conventional care. These findings suggest that the Kano model holds promising potential for broader application in discharge preparation services for COPD management.
Disclosure of conflict of interest
None.
References
- 1.World Health Organization. The top 10 causes of death. World Health Organ. 2024 [Google Scholar]
- 2.Liu X, Zhang H, Yang Z, Ran Y, Qiu Y, Wang L, Zeng L, Li X, Zhi C, Lu J. Quantifying the length of stay and economic impact of albuterol and levalbuterol in hospitalized patients with chronic obstructive pulmonary disease: a retrospective cohort study. Cureus. 2024;16:e59039. doi: 10.7759/cureus.59039. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Wang C, Xu J, Yang L, Xu Y, Zhang X, Bai C, Kang J, Ran P, Shen H, Wen F, Huang K, Yao W, Sun T, Shan G, Yang T, Lin Y, Wu S, Zhu J, Wang R, Shi Z, Zhao J, Ye X, Song Y, Wang Q, Zhou Y, Ding L, Yang T, Chen Y, Guo Y, Xiao F, Lu Y, Peng X, Zhang B, Xiao D, Chen CS, Wang Z, Zhang H, Bu X, Zhang X, An L, Zhang S, Cao Z, Zhan Q, Yang Y, Cao B, Dai H, Liang L, He J China Pulmonary Health Study Group. Prevalence and risk factors of chronic obstructive pulmonary disease in China (the China Pulmonary Health [CPH] study): a national cross-sectional study. Lancet. 2018;391:1706–1717. doi: 10.1016/S0140-6736(18)30841-9. [DOI] [PubMed] [Google Scholar]
- 4.Chen Q, Fan Y, Huang K, Li W, Geldsetzer P, Bärnighausen T, Yang T, Wang C, Chen S. Cost-effectiveness of population-based screening for chronic obstructive pulmonary disease in China: a simulation modeling study. Lancet Reg Health West Pac. 2024;46:101065. doi: 10.1016/j.lanwpc.2024.101065. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Vidigal MTC, Borges GH, Rabelo DH, de Andrade Vieira W, Nascimento GG, Lima RR, Costa MM, Herval ÁM, Paranhos LR. Cost-effectiveness of home care compared to hospital care in patients with chronic obstructive pulmonary disease (COPD): a systematic review. Front Med. 2024;11:1405840. doi: 10.3389/fmed.2024.1405840. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Fang L, Gao P, Bao H, Tang X, Wang B, Feng Y, Cong S, Juan J, Fan J, Lu K, Wang N, Hu Y, Wang L. Chronic obstructive pulmonary disease in China: a nationwide prevalence study. Lancet Respir Med. 2018;6:421–430. doi: 10.1016/S2213-2600(18)30103-6. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Zhu B, Wang Y, Ming J, Chen W, Zhang L. Disease burden of COPD in China: a systematic review. Int J Chron Obstruct Pulmon Dis. 2018;13:1353–1364. doi: 10.2147/COPD.S161555. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Zhou M, Wang H, Zeng X, Yin P, Zhu J, Chen W, Li X, Wang L, Wang L, Liu Y, Liu J, Zhang M, Qi J, Yu S, Afshin A, Gakidou E, Glenn S, Krish VS, Miller-Petrie MK, Mountjoy-Venning WC, Mullany EC, Redford SB, Liu H, Naghavi M, Hay SI, Wang L, Murray CJL, Liang X. Mortality, morbidity, and risk factors in China and its provinces, 1990-2017: a systematic analysis for the global burden of disease study 2017. Lancet. 2019;394:1145–1158. doi: 10.1016/S0140-6736(19)30427-1. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Kichloo A, Aljadah M, Vipparla N, Wani F. Optimal glucocorticoid dose and the effects on mortality, length of stay, and readmission rates in patients diagnosed with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) J Investig Med. 2019;67:1161–1164. doi: 10.1136/jim-2019-001105. [DOI] [PubMed] [Google Scholar]
- 10.Shah T, Press VG, Huisingh-Scheetz M, White SR. COPD Readmissions: addressing COPD in the Era of Value-based Health Care. Chest. 2016;150:916–926. doi: 10.1016/j.chest.2016.05.002. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Liu H, Song J, Wang Z, Wu S, Qiu S, Chen B, Rao Z, Jing X. Investigation of nutrition status and analysis of 180-day readmission factors in elderly hospitalized patients with COPD. Aging Clin Exp Res. 2024;36:155. doi: 10.1007/s40520-024-02820-9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Chen Q, Wu X, Huang Y, Chen L. Internet of things-based home respiratory muscle training for patients with chronic obstructive pulmonary disease: a randomized clinical trial. Int J Chron Obstruct Pulmon Dis. 2024;19:1093–1103. doi: 10.2147/COPD.S454804. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Zheng M, Meng C, Zhang Q, Yan X, Li N. Optimal evidence summary for discharge preparation in elderly chemotherapy patients. J Multidiscip Healthc. 2024;17:4587–4600. doi: 10.2147/JMDH.S485665. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Wouters EF, Posthuma R, Koopman M, Liu WY, Sillen MJ, Hajian B, Sastry M, Spruit MA, Franssen FM. An update on pulmonary rehabilitation techniques for patients with chronic obstructive pulmonary disease. Expert Rev Respir Med. 2020;14:149–161. doi: 10.1080/17476348.2020.1700796. [DOI] [PubMed] [Google Scholar]
- 15.Rochester CL, Alison JA, Carlin B, Jenkins AR, Cox NS, Bauldoff G, Bhatt SP, Bourbeau J, Burtin C, Camp PG, Cascino TM, Dorney Koppel GA, Garvey C, Goldstein R, Harris D, Houchen-Wolloff L, Limberg T, Lindenauer PK, Moy ML, Ryerson CJ, Singh SJ, Steiner M, Tappan RS, Yohannes AM, Holland AE. Pulmonary rehabilitation for adults with chronic respiratory disease: an official American thoracic society clinical practice guideline. Am J Respir Crit Care Med. 2023;208:e7–e26. doi: 10.1164/rccm.202306-1066ST. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.He W, Wang J, Feng Z, Li J, Xie Y. Effects of exercise-based pulmonary rehabilitation on severe/very severe COPD: a systematic review and meta-analysis. Ther Adv Respir Dis. 2023;17:17534666231162250. doi: 10.1177/17534666231162250. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Wang Z, Tang X, Li L, Zhou H, Zhu Y, Chen L, Su T, Liu M, Pang X, Yi X, Liu L, Liu J, Liu M. Spiritual care needs and their attributes among Chinese inpatients with advanced breast cancer based on the Kano model: a descriptive cross-sectional study. BMC Palliat Care. 2024;23:50. doi: 10.1186/s12904-024-01377-8. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Yao X, Li J, He J, Zhang Q, Yu Y, He Y, Wu J, Tang W, Ye C. A Kano model-based demand analysis and perceived barriers of pulmonary rehabilitation interventions for patients with chronic obstructive pulmonary disease in China. PLoS One. 2023;18:e0290828. doi: 10.1371/journal.pone.0290828. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Fenwick AM. An interdisciplinary tool for assessing patients’ readiness for discharge in the rehabilitation setting. J Adv Nurs. 1979;4:9–21. doi: 10.1111/j.1365-2648.1979.tb02984.x. [DOI] [PubMed] [Google Scholar]
- 20.Weiss ME, Piacentine LB, Lokken L, Ancona J, Archer J, Gresser S, Holmes SB, Toman S, Toy A, Vega-Stromberg T. Perceived readiness for hospital discharge in adult medical-surgical patients. Clin Nurse Spec CNS. 2007;21:31–42. doi: 10.1097/00002800-200701000-00008. [DOI] [PubMed] [Google Scholar]
- 21.Wang B, Wang H, Yang C. Reliability and validity of the Chinese version of the quality of discharge teaching scale. Chin J Nurs. 2016;51:752. [Google Scholar]
- 22.Ceyhan Y, Tekinsoy Kartin P. The effects of breathing exercises and inhaler training in patients with COPD on the severity of dyspnea and life quality: a randomized controlled trial. Trials. 2022;23:707. doi: 10.1186/s13063-022-06603-3. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Chouliara N, Cameron T, Byrne A, Fisher R. Getting the message across; a realist study of the role of communication and information exchange processes in delivering stroke Early Supported Discharge services in England. PLoS One. 2024;19:e0298140. doi: 10.1371/journal.pone.0298140. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Bhatt SP, Balte PP, Schwartz JE, Cassano PA, Couper D, Jacobs DR, Kalhan R, O’Connor GT, Yende S, Sanders JL, Umans JG, Dransfield MT, Chaves PH, White WB, Oelsner EC. Discriminative accuracy of FEV1: FVC thresholds for COPD-related hospitalization and mortality. JAMA. 2019;321:2438–2447. doi: 10.1001/jama.2019.7233. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25.Wang Q, Tang H, Zhang M. The clinical nursing effect of empowerment-based continuing nursing combined with pulmonary rehabilitation for chronic obstructive pulmonary disease. BMC Pulm Med. 2025;25:315. doi: 10.1186/s12890-025-03683-0. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26.Andrello AC, Donaria L, de Castro LA, Belo LF, Schneider LP, Machado FV, Ribeiro M, Probst VS, Hernandes NA, Pitta F. Maximum voluntary ventilation and its relationship with clinical outcomes in subjects with COPD. Respir Care. 2021;66:79–86. doi: 10.4187/respcare.07855. [DOI] [PubMed] [Google Scholar]
- 27.Morales-González F, Lira-Lucio JA, Falfán-Valencia R, Márquez-García JE, Abarca-Rojano E, Ramírez-Venegas A, Sansores RH, García-Gómez L, Hernández-Pérez A, Pérez-Rubio G. Characterization of the lung microbiome and inflammatory cytokine levels in women exposed to environmental risk factors: a pilot study. Immun Inflamm Dis. 2023;11:e825. doi: 10.1002/iid3.825. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 28.Li Q, Liu Y, Wang X, Xie C, Mei X, Cao W, Guan W, Lin X, Xie X, Zhou C, Yi E. The influence of CLEC5A on early macrophage-mediated inflammation in COPD progression. Cell Mol Life Sci. 2024;81:330. doi: 10.1007/s00018-024-05375-0. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 29.Riaz H, Amjad A, Mustafa N, Amon, Asif AA, Tahiri MA, Asim HAB. Impact of diaphragmatic breathing with purse lip breathing versus pursed-lip breathing alone on dyspnea and exercise capacity among copd patients. Insights-J Health Rehabil. 2024;2:488–495. [Google Scholar]
- 30.Silva RN, Goulart C da L, de Oliveira CR, Mendes RG, Arena R, Myers J, Borghi-Silva A. Respiratory muscle strength can improve the prognostic assessment in COPD. Sci Rep. 2024;14:12360. doi: 10.1038/s41598-024-54264-w. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 31.Santos CD, Santos AJ, Santos M, Rodrigues F, Bárbara C. Pulmonary rehabilitation adapted index of self-efficacy (PRAISE) validated to Portuguese respiratory patients. Pulmonology. 2019;25:334–339. doi: 10.1016/j.pulmoe.2019.06.003. [DOI] [PubMed] [Google Scholar]
- 32.Chuatrakoon B, Uthaikhup S, Ngai SP, Liwsrisakun C, Pothirat C, Sungkarat S. The effectiveness of home-based balance and pulmonary rehabilitation program in individuals with chronic obstructive pulmonary disease: a randomized controlled trial. Eur J Phys Rehabil Med. 2022;58:478–486. doi: 10.23736/S1973-9087.22.07383-X. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 33.Feldbusch H, Schmidt M, Steeb EM, Paschek N, Nemesch M, Sartory Y, Brenner R, Nöst S. Theoretical concepts and instruments for measuring hospital discharge readiness: a scoping review. Heliyon. 2024;10:e26554. doi: 10.1016/j.heliyon.2024.e26554. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 34.Hydzik P, Kolarczyk E, Kustrzycki W, Kubielas G, Kałużna-Oleksy M, Szczepanowski R, Uchmanowicz B. Readiness for discharge from hospital after myocardial infarction: a cross-sectional study. Int J Environ Res Public Health. 2021;18:6937. doi: 10.3390/ijerph18136937. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 35.Kaya S, Sain Guven G, Aydan S, Kar A, Teleş M, Yıldız A, Koca GŞ, Kartal N, Korku C, Ürek D, Demir İB, Toka O. Patients’ readiness for discharge: predictors and effects on unplanned readmissions, emergency department visits and death. J Nurs Manag. 2018;26:707–716. doi: 10.1111/jonm.12605. [DOI] [PubMed] [Google Scholar]
- 36.Wu DL, Luo CL, Du X, Li PP, Jiang M, Liu T, Sun Y. Current status and influencing factors of readiness for discharge of elderly patients with chronic obstructive pulmonary disease. Patient Prefer Adherence. 2023;17:1323–1333. doi: 10.2147/PPA.S410725. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 37.Shan M, Xu Y, Xi G, Ding Y. Effects of interventions on the readiness for hospital discharge in elderly patients with chronic heart failure: a randomized controlled trial. BMC Nurs. 2025;24:1058. doi: 10.1186/s12912-025-03715-4. [DOI] [PMC free article] [PubMed] [Google Scholar]