Pulmonary Rehabilitation Guidelines for Australia and New ......Sue Jenkins Catherine Hill Vanessa McDonald Peter Frith Paul Caferella Kirsten Phillips Juliet Brown. A collaboration

AcollaborationbetweenLungFoundationAustraliaandtheThoracicSocietyofAustralia&NewZealand

PulmonaryRehabilitationGuidelinesforAustraliaandNewZealand

JenniferAlison


Alisonetal,Respirology 2017; 22(4):800–819


COPD• NewZealand– 14%adultsover40yearshaveCOPD(Telfar B2015)– Cost:$NZ5.6billion($484millionindirecthealthsystemexpenditure)(Telfar B2015)

–Māori:4.4xhigherhospitalisation2.2xhigherdeaths(MilneRJ2015)


PulmonaryRehabilitation• KeycomponentofCOPDmanagement(YangI2016,COPD-X)• symptoms- breathlessnessandfatigue• exercisecapacity• qualityoflife(McCarthy2015)

• hospitalreadmissions(Puhan 2016)• lengthofstay


Whydoweneedguidelines?• Statement (ATS/ERS)aboutwhatshouldbeincludedbutnotan

evidence-basedguideline(SpruitAJRCCM2013)

• Evidence-basedguidelinespublishedinothercountries:– BritishThoracicSociety(Bolton2014)– CanadianThoracicSociety(Marciniuk 2010)

• WhatwehadalreadydevelopedinAustralia- apracticalresources– PulmonaryRehabilitationToolkitwww.pulmonaryrehab.com.au

• Supportfutureinitiatives– MBSitemnumber(currentlyunderreview)


• Healthcarecontextaffectsdelivery

Whydoweneedguidelines?

AustraliaandEuropeareasizecomparison


AimToprovideevidence-basedrecommendationsforthepracticeofpulmonaryrehabilitation(PR)specifictoAustralianandNewZealandhealthcarecontexts


Methods• GuidelinePanel:28healthprofessionals(11leadexperts)• 9PICOquestionsconsideredasmostimportantinANZcontext.• Systematicreviewmethodologyforallquestions(unlessrecentSR)

– Meta-analysesforAust/NZcontextwherepossible

• Searchstrategies(librariansUSYDandLaTrobe)– DefinitionofPRtoguidesearches:Anyin-patient,out-patient,community-basedorhome-basedrehabilitationprogrammeofatleastfourweeks’durationthatincludedexercisetherapywithorwithoutanyformofeducationand/orpsychologicalsupportdeliveredtopatientswithexerciselimitationattributabletoCOPD (McCarthy2015)


Inclusionofstudies• RCTs,systematicreviewsofPR• Hadtoreportatleastonepre-specifiedoutcomeofinterest– Exercisecapacity– HRQoL– Healthcareutilisation– Anxietyanddepression– Mortality


Movingfromevidencetorecommendation– GRADE

• Eachrecommendationrated(basedonGRADEcriteria)for:– Qualityofevidence:strong,moderateorlow

• Strengthofrecommendation– strongorweak- considered4factors:– Trade-offsbetweendesirableandundesirableoutcomes– Confidenceinestimatesofeffect(qualityofevidence)– Valuesandpreferencesofpatients– Resourceimplications

(AndrewsJ,2013)


Implicationfor: StrongRecommendation WeakRecommendation ‘Inresearch’

recommendationPatients Almostallindividualsinthis

situationwouldwanttherecommendedintervention,andonlyasmallproportionwouldnot.

Mostindividualsinthissituationwouldwanttherecommendedintervention,butasubstantialnumberwouldnot.

Clinicians Almostallindividualsshouldreceivetheintervention.Adherencetothisrecommendationaccordingtotheguidelinecouldbeusedasaqualitycriterionorperformanceindicator.Formaldecisionaidsarenotlikelytobeneededtohelpindividualsmakedecisionsconsistentwiththeirvaluesandpreferences.

Recognise thatdifferentchoiceswillbeappropriateforindividualpatientsandcliniciansmusthelpeachpatientarriveatamanagementdecisionconsistentwithhisorhervaluesandpreferences.Decisionaidsmaybeusefulinhelpingindividualstomakedecisionsconsistentwiththeirvaluesandpreferences.

Insufficientevidencetorecommendtheinterventionandmoreresearchcouldclarifytheeffectsoftheinterventionandwouldbeworthwhile.

(AndrewsJ2013)


PICOQUESTIONSANDRECOMMENDATIONS


PICOquestion Recommendation: PRshouldbeprovidedfor… Strength

IspulmonaryrehabilitationeffectivecomparedwithusualcareinpeoplewithCOPD?a)McCarthy2015,Cochraneb)Puhan 2016,Cochrane

a) peoplewithstable chronicobstructivepulmonarydisease(COPD)

b) peopleafteranexacerbation ofCOPD,withintwoweeksofhospitaldischarge

• Exercisecapacity, HRQoL,readmissions

Strong

Weak

Doespulmonaryrehabilitationaffecthealthcareutilisation?

peoplewithmoderate-to-severeCOPD(stableorfollowingdischargefromhospital)todecreasehospitalisations• Hospitalisation, LOS

Strong

Inpeoplewithmilddiseaseseverity,ispulmonaryrehabilitationmoreeffectivethanusualcare?

mildCOPD(basedonsymptoms)(mMRC ≤1)• Exercisecapacity,HRQoL

Weak

Hospitalisation


• DespitebenefitsofPR• <5-10%ofmod-severeCOPDparticipateinPR

(AIHW2013)

• Barriersinclude:– transport(KeatingA2011)


PICOquestion Recommendation:PRshouldbeprovidedfor…… Strength

Isahome-basedorcommunitypulmonaryrehabilitationprogramaseffectiveasahospital-basedpulmonaryrehabilitationprogram?

people withCOPDas:a) home-basedasanalternativetousualcareb) home-basedasanalternativetohospital-basedc) community-basedasanalternativetousual

care• Exercisecapacity, HRQoL

WeakWeakWeak

Doesastructurededucationprogramenhancethebenefitsofpulmonaryrehabilitation?

allpeoplewithCOPD,irrespectiveoftheavailabilityofastructuredmultidisciplinarygroupeducationprogram.• Exercisecapacity,HRQoL,HCU

Weak

IspulmonaryrehabilitationeffectiveinchronicrespiratorydiseasesotherthanCOPD?

a) Bronchiectasis(PR+ACTs)(Lee2016-SystRev)b) ILD (Dowman 2014Cochrane )c) PH (Morris2016Cochrane)• Exercisecapacity,HRQoL,breathlessness

WeakWeakWeak

Structurededucation

Setting

HospitalOPD Home Community


PICOQUESTIONSNORECOMMENDATIONS


PICOquestion Recommendation: Strength

Areprogramsoflongerdurationmoreeffectivethanthestandardeight-weekprograms?

Norecommendation- lackofevidence

• Exercisecapacity,HRQoL

Doesongoingsupervisedexerciseatalowerfrequencythantheinitialpulmonaryrehabilitationprogram,maintainexercisecapacityandqualityoflifeto12months?

Optimalmodelofmaintenanceexerciseprogramsnotclear• Exercisecapacity,HRQoLSupervisedmaintenance- monthly,orless -insufficienttomaintainthegainsofPRandshouldnotbeoffered• Exercisecapacity,HRQoL

Inresearch

Weak

Dopatientswhoexperienceoxygendesaturationduringexercisehavegreaterimprovementsifoxygensupplementationisprovidedduringtraining?

UncertaintyaroundeffectofO2supplementationduringtraining inCOPDwhodesaturate duringexercise- furtherresearchneeded• Exercisecapacity,breathlessness,

anxiety/depression

Inresearch

Maintainingthegains

Oxygenduringexercise


What’snewintheguidelines?• Recommendationforhome- andcommunity-basedPR• RecommendationforPRinpeoplewithmildCOPD(symptoms)• Clearstatementthatmonthlymaintenanceprogramsarenot

useful• PermissiontodeliverPRwithoutastructurededucationprogram• RecommendationforPRinpeoplewithbronchiectasis,ILDand

pulmonaryhypertension,intherightsetting


Whatdotheguidelinesmeanforpatients,cliniciansandpolicymakers?

• InpeoplewithCOPD,compellingevidenceformeaningfulbenefitsfromPRprovidesastrongmandatetoimproveaccess,referralanduptake

• Todeliveronthiswillrequiremultiplestrategies:– Patientshavebetterunderstandingofroleandlikelybenefits– Cliniciansknowhowtorefer,anddosomoreoften– Programsmorereadilyavailableandaccessible– Qualitystandardsagainstwhichwecanevaluateeffectiveness


ForAustraliaandNewZealandcontext

• Weakrecommendationsfornewmodelsofpulmonaryrehab(eg home-based,community-based)havepotentialtoimproveaccessforpeoplelivingawayfrommajorcentres


ForAustraliaandNewZealandcontext

• IndigenousAustralianandNewZealandcommunitieshavedisproportionatedisadvantagefromCOPD– Importanttoimprovepulmonaryrehabaccess– Greatereffortsrequiredtoensuresafeculturalenvironmentsfordeliveryofpulmonaryrehab

– InNZ,attendanceenhancedby• pulmonaryrehabprovidedforMāoribyMāoriorganisations• informationandcommunicationinacommonMāorilanguage(Levack

VM2016)


Limitationsoftheguidelines

• OnlyaddressedaselectednumberofPICOquestions• OtherimportantquestionsforpulmonaryrehabinAust andNZmay

nothavebeenanswered• Someexamples:

– Roleofselfmanagementtraining– Componentsofexercisetraining– Roleofnutritionalsupplementation– Inclusionofpeoplewithasthma,lungcancer,cysticfibrosis– Repeatingpulmonaryrehab


Conclusions– newPRguidelines

• StrongrecommendationthatpeoplewithCOPDundertakepulmonaryrehabtoimproveexercisecapacity,HRQoL andavoidhospitalisation– Nosurprise,butmandatesrenewedeffortstoimproveaccessand

uptake• Weakrecommendationsfornewmodelsofpulmonaryrehab,andrehab

innewpopulations– Maypromptchangestothepulmonaryrehabilitationmodel

• WatchthisspacefornewdevelopmentsaroundqualitystandardsandMBSitemnumber


AcknowledgementsPRGuidelinePanel(28),LFA,Librarians

ExpertAdvisoryPanel:ChristineJenkins,ChristineMcDonald,IanYang,KerryHancockTSANZ,ReviewersAustraliaandNewZealand

JennyAlison AnneHolland ZoeMcKeough KylieJohnston RenaeMcNamara LissaSpencer

SueJenkins CatherineHill VanessaMcDonald PeterFrith PaulCaferella KirstenPhillips JulietBrown


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Pulmonary Rehabilitation Guidelines for Australia and New ......Sue Jenkins Catherine Hill Vanessa McDonald Peter Frith Paul Caferella Kirsten Phillips Juliet Brown. A collaboration