Ch 7: Patient-Centered Evidence-Based Outcomes in Pulmonary Rehabilitation

Purpose of the Chapter

This chapter focuses on critical aspects of patient-centered evidence-based outcomes in pulmonary rehabilitation, laying the groundwork for understanding how to evaluate and improve patient care. The main objectives include:

• Identifying key outcome areas for pulmonary patients.
• Developing suitable outcome goals.
• Recognizing the necessity of outcome measures in rehabilitation.
• Determining the appropriate assessments and interpreting their results.

Outcome Areas in Pulmonary Rehabilitation

Pulmonary rehabilitation (PR) evaluates outcomes in two primary domains:

1. Patient-centered clinical outcomes
2. Performance measures
   Both areas are vital for establishing PR protocols and securing certification from the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR). Patient-centered outcomes encompass three critical areas:

• Exercise capacity
• Symptoms (e.g., dyspnea and fatigue)
• Health-related quality of life
  Depending on individual patient needs and available program resources, assessments of functional performance may also be included.

Timing and Analyzing Outcomes

Effective outcome assessment necessitates measurements taken at two distinct time points:

• Baseline: before initiating pulmonary rehabilitation.
• Post-rehabilitation: immediately following completion of the program.
  Measurements can also be taken at intervals following rehabilitation (e.g., 3, 6, or 12 months after). For AACVPR certification, a comparison of pre- and post-rehabilitation outcomes is required, irrespective of program length. Specific statistical methods, such as paired t-tests or nonparametric tests, can analyze the aggregated data.

Functional Performance and Home-Based Activity

The primary goal of enhancing a patient's strength and endurance through exercise is to foster engagement in daily activities. Key considerations include:

• Assessing outcomes such as the distance achieved during exercise.
• Building strength, endurance, confidence, and self-efficacy in patients.
  To monitor these aspects, devices like pedometers and activity monitors may be utilized, along with functional status questionnaires, such as:
• PFSDQ (Pulmonary Function Status and Dyspnea Questionnaire)
• PFSDQM (Modified Pure Function Status and Dyspnea Questionnaire)
• PFSS (Pulmonary Function Status Scale)
  These tools assess changes in patients' activities of daily living (ADLs), particularly in relation to dyspnea and fatigue.

Psychological Outcomes

Common psychological symptoms among chronic respiratory disease patients include anxiety and depression, requiring appropriate assessment through screening questionnaires. Instruments like PRIME-MD help identify patients needing further psychological evaluation but do not establish formal diagnoses.
Understanding psychological states is crucial for tailoring rehabilitation programs effectively.

Patient Adherence

Evaluating patient adherence to rehabilitation programs is critical, considering factors that influence attendance and dropout rates:

• Travel distance
• Transportation availability
• Weather conditions
• Exacerbation of disease symptoms
  Tracking dropout reasons and attendance can elucidate patterns that assist in improving program design and adherence.

Knowledge and Self-Efficacy

Education is a fundamental aspect of pulmonary rehabilitation, enhancing disease management and health care utilization. To prove educational effectiveness, measures such as:

• Change in knowledge through regular tests
• Return demonstrations
  Notably, few standardized measures exist for self-efficacy; the COPD self-efficacy scale is commonly applied.

Weight Modification Changes

Weight changes during pulmonary rehabilitation can be indicative of various health dynamics:

• Weight loss may be targeted or problematic (linked to malnutrition and muscle loss).
• Conversely, weight gain may be a purposeful goal for maintaining health.
  Monitoring body weight, body mass index (BMI), or other composition measures before and after the program can yield valuable outcome data.

Health Care Utilization

Exacerbations often complicate chronic respiratory conditions, leading to increased symptoms and decreased functional abilities. Pulmonary rehabilitation is often recommended for patients experiencing frequent exacerbations, with outcomes to assess including:

• Rate of unplanned medical visits
• Hospitalization frequency and duration
  Understanding these factors underlines the importance of timely referrals to pulmonary rehabilitation.

Mortality

The impact of pulmonary rehabilitation on mortality rates remains inconclusive, particularly given the small sample size of current studies. Notably, prior studies highlight higher dyspnea levels and impairments in exercise capacity, functional status, and overall quality of life as indicators of increased mortality.

Patient Satisfaction

Surveys assessing patient satisfaction provide crucial feedback for refining pulmonary rehabilitation programs. Key areas of inquiry include:

• Satisfaction with program structure
• Perceived benefits of the rehabilitation process
• Willingness to recommend the program to others
  Parsing through satisfaction data can highlight necessary adjustments to meet participant needs better.

Summary of Outcome Assessments

In summation, comprehensive outcome assessments across various patient-centered domains—dyspnea, exercise capacity, and health-related quality of life—are imperative in pulmonary rehabilitation. While time constraints may limit thoroughness in assessment, practical evaluations can utilize:

• The 6-minute walk test for exercise capacity
• The Borg or VAS scale for dyspnea and health status
• CRQ (Chronic Respiratory Questionnaire) for quality of life and emotional function