Research in focus
Professor Anne Holland

Professor Anne Holland, the ARCH Chair at Alfred Health,
talks about Home Based Pulmonary Rehabilitation.

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"If you can’t breathe, nothing else matters"
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/ Categories: ARCH, Alfred Health

"If you can’t breathe, nothing else matters"

Home Based COPD Pulmonary Rehab success from ARCH partners.

Home Based Pulmonary Rehabilitation (PR) was shown to be as effective as clinic-based PR in research at Alfred Health and Austin Health led by Alfred Health ARCH chair, and Professor in Physiotherapy, Anne Holland. The research has had impact around the world, including being included in National Strategic Action Plan for Lung Conditions from the Australian Government. 

With initial funding from the Lung Foundation Australia, the research received an NMHRC grant and was trialed at Alfred Health and Austin Health and is being rolled out at both institutions. 

 

Professor Holland answered some questions about the research and its trajectory in a recent conversation.

Q: What's the issue? 

A: It’s around access to best care practices for people with COPD which is emphysema and chronic bronchitis. All the major guidelines around the world say that people with COPD should be offered pulmonary rehab because it improves their breathing, it improves their quality of life, improves their exercise capacity and it keeps them out of hospital. It's a really important treatment. 

The data from both Australia and around the world suggests that in developed countries less than 10% of the patients who could have benefited from pulmonary rehab ever undertake a programme. That figure hasn't really changed over the last 15, 20 years. The model that we have is not working and it's not giving the treatment to the people who need it.

As well as issues of capacity to deliver, especially in regional and rural areas, it tends to be an older group of patients. Asking them to get into a pulmonary rehab programme at a hospital or another kind of healthcare centre twice a week for eight weeks is actually a really big ask.

Q: How does the home based model work?

A: It’s really very different to the centre-based model. In the home-based model there is one visit from a physiotherapist to the patient's home to start them off and in that visit they supervise their first exercise session, they talk to them about their exercise goals and sit them down and write them in a diary. 
They go through anything that you can't do subsequently over the phone which is how the rest of it works. Things like inhaler technique, checking that it's working okay, they would do that in person.

Q: And how do the phone calls work? 

A: It's a once weekly telephone call which happens at the same time every week so it's very structured. We use a motivational interviewing approach which is key because it's around helping people to find their own motivation to engage in the programme, their own motivation to get fitter and stronger and be more active and to set goals that are meaningful and motivating for them.  Things like quitting smoking, managing chest infections, managing nutrition, those sorts of things.
 

Q:  And how did the home based PR compare? 

A: We were able to show in the trial that we got very similar results in our home-based programme than we would in the traditional centre-based programme. The big difference is that 90% of our home-based people got all the way through the programme compared to only about 50% of those in the hospital group. The reason why that was important was that it was the people who completed the programme who stayed out of hospital for longer in the following year.

Q: And how did the health partners find the trials? 

A: The partners at Alfred and Austin were really receptive. The partnership with these two with pulmonary rehab programmes is very long standing, this wasn't the first trial that we had done together. They were very enthusiastic about this one particularly because this is a problem that the clinicians see every day of their working life. They have people on their waiting lists for pulmonary rehab who they just can't get into the programme because the burden of coming in was just too much.

We were able to embed the centre-based programme just in our normal clinical pulmonary rehab programme so it was truly usual care with all the patients that we would normally put in those programmes. We recruited from the people who'd been referred to those programmes. We had a lot of the clinical staff involved in delivering the interventions. I got to do some of the initial trial calls as well, which was really rewarding.  We used clinicians from the hospital to help us to do the assessments. It was really an important partnership and that was the thing that really made the trial successful, that it was so embedded within the healthcare system where this intervention would normally be delivered.

Q: And where did the research go from there? 

A: At Alfred Health, which was one of our partner sites, they rolled this programme out into usual clinical practice straight off the back of the trial because they were so convinced of the benefits of the programme and they wanted to keep going with it. Home-based PR is now standard care at Alfred Health and it sits alongside the centre-based programme, so patients can have a choice of which of the programmes they engage in. At Austin Health they're in the process of implementing that now. Lung Foundation Australia have been able to get some funding to partner with the Murray Primary Health Network to implement this in regional Victoria. We've been working with sites out of Bendigo over the last 12 months to implement the programme. It is gradually getting take up across the country in clinical programmes where they really see the need for a different model of care that can extend the benefits of the programme. 

We’re really pleased that the Australia New Zealand Pulmonary Rehabilitation Guidelines, published about a year ago, include a recommendation to deliver home-based rehab for first time. Actually, that's probably the first guideline in the world that makes that recommendation. We've also seen the National Strategic Action Plan for Lung Conditions endorsed by the Health Minister. In there is a recommendation to expand the delivery of pulmonary rehab beyond the hospital setting into the community and home settings. That also provides a policy mandate to try and implement this more broadly into practice. 

There's been a great deal of variation in how the research has been received outside of Australia. In the UK, where they have a fairly similar health system to ours including experiencing all the problems with access, it's been incredibly well received. In Europe it's been a different story. A number of high profile pulmonary rehab investigators think that this is something that should not be broadly implemented. They say what we should be doing is advocating for better access to centre-based programmes. 

I think what that reflects is very different health systems and different funding. These tend to be smaller countries with better resourced healthcare systems with less problems around patient access than we're experiencing in Australia.

Q: And what about the costs of this method of treatment? 

A: We've done a full economic analysis and in terms of the direct costs of delivering it, it's about the same. Pulmonary rehabilitation is incredibly cheap to deliver, the whole programme cost about $300 per patient so virtually nothing when you think about pulmonary care. That's the same across both centre and home-based, they're both about $300. When we look at the full economic analysis which includes things like the cost of their healthcare over the following 12 months what we find is that because the people in the home-based programme tend to stay out of hospital more the cost is a bit lower in that group but they're not significantly different. 

I think the real benefit here is around improved access to care. What it's doing is it's getting more people into a treatment that we know is effective. The downstream benefits of that is a reduction in hospitalisation and that's where the cost saving comes from this.

More information: 

National strategic action plan (pdf) Download document here
Original paper on HomeBase pulmonary rehab https://thorax.bmj.com/content/72/1/57
Description of the model: http://homebaserehab.net/
Contact Professor Anne Holland http://arch.latrobe.edu.au/Metro-Health/Alfred-Health/Contact-Us

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