Application of the RE-AIM framework to evaluate the implementation of telehealth pulmonary rehabilitation in a randomized controlled trial among African-American and Hispanic patients with advanced stage Chronic Obstructive Pulmonary Disease

BMC Health Services Research

Research

Eugenia Boye-Codjoe¹  Richard Medina¹  Keyla Ordonez¹  Danielle Rodriguez¹  Donna Tsang¹  Sonia Jacome¹  Meng Zhang²  Sameer Khanijo²  Negin Hajizadeh²  Jennifer Polo³  Melissa J. Basile⁴  Myia Williams⁴  Renee Pekmezaris⁵  Parvez Mir⁶ 

[1] Northwell Health, Great Neck, NY, USA;Northwell Health, Great Neck, NY, USA;Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA;Northwell Health, Great Neck, NY, USA;Institute of Health System Science, Northwell Health, 600 Community Drive, Suite 403, 11030, Manhasset, NY, USA;Northwell Health, Great Neck, NY, USA;Institute of Health System Science, Northwell Health, 600 Community Drive, Suite 403, 11030, Manhasset, NY, USA;Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA;Northwell Health, Great Neck, NY, USA;Institute of Health System Science, Northwell Health, 600 Community Drive, Suite 403, 11030, Manhasset, NY, USA;Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA;Department of Occupational Medicine, Epidemiology, and Prevention, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Great Neck, NY, USA;Wyckoff Heights Medical Center, Brooklyn, NY, USA;

关键词: Chronic obstructive pulmonary disease;    Implementation;    Pulmonary rehabilitation;    Quality of life;    Telehealth;   

DOI  :  10.1186/s12913-023-09492-7

 received in 2022-12-05, accepted in 2023-05-03,  发布年份 2023

来源: Springer

【 摘 要 】

BackgroundPulmonary rehabilitation (PR) decreases rehospitalization for people with COPD. However, less than 2% receive PR, partly due to lack of referral and sparsity of PR facilities. This disparity is particularly pronounced in African American and Hispanic persons with COPD. Telehealth-provided PR could increase access and improve health outcomes.MethodsWe applied the RE-AIM framework in a post-hoc analysis of our mixed methods RCT comparing referral to Telehealth-delivered PR (TelePR) versus standard PR (SPR) for African American and Hispanic COPD patients hospitalized for COPD exacerbation. Both arms received a referral to PR for 8 weeks, social worker follow-up, and surveys administered at baseline, 8 weeks, 6, and 12 months. PR sessions were conducted twice a week for 90 min each (16 sessions total). Quantitative data were analyzed using 2-sample t tests or nonparametric Wilcoxon tests for continuous data and χ2/Fisher exact tests for categorical data. Logistic regression–estimated odds ratios (ORs) were used for the intention-to-treat primary outcome. Qualitative interviews were conducted at the end of the study to assess adherence and satisfaction and were analyzed using inductive and deductive methods. The goal was to understand Reach (whether the target population was able to be enrolled), Effectiveness (primary outcome was a composite of 6-month COPD rehospitalization and death), Adoption (proportion of people willing to initiate the program), Implementation (whether the program was able to be executed as intended, and Maintenance (whether the program was continued).ResultsTwo hundred nine people enrolled out of a 276-recruitment goal. Only 85 completed at least one PR session 57/111 (51%) TelePR; 28/98 (28%) SPR. Referral to TelePR compared to SPR did not decrease the composite outcome of 6-month COPD-readmission rate/death (OR1.35;95%CI 0.69,2.66). There was significant reduction in fatigue (PROMIS® scale) from baseline to 8-weeks in TelePR compared to SPR (MD-1.34; ± SD4.22; p = 0.02). Participants who received TelePR experienced improvements from baseline in several outcomes (ie, before and after 8 weeks of PR) in the following: COPD symptoms, knowledge about COPD management, fatigue, and functional capacity. Among the patients who had 1 initial visit, adherence rates were similar (TelePR arm, 59% of sessions; SPR arm, 63%). No intervention-related adverse events occurred. Barriers to PR adoption included difficulty or reluctance to complete medical clearances and beliefs about PR efficacy. Notably, only 9 participants sustained exercise after program completion. Maintenance of the program was not possible due to low insurance reimbursement and sparsity of Respiratory Therapists.ConclusionsTelePR can reach COPD patients with health disparities and can be successfully implemented. The small sample size and large confidence intervals prevent conclusion about the relative effectiveness of participating in TelePR compared to SPR. However, improved outcomes were seen for those in TelePR as well as in SPR. Increasing adoption of PR and TelePR requires consideration of comorbidity burden, and perception of PR utility, and must facilitate medical clearances. Given the sparsity of SPR locations, TelePR can overcome at least the barrier of access. However, given the challenges to the uptake and completion of PR - many of the additional barriers in PR (both in TelePR and SPR) need to be addressed. Awareness of these real-world challenges will not only inform implementation of TelePR for clinicians seeking to adopt this platform but will also inform study designers and reviewers regarding the feasibility of approaches to patient recruitment and retention.

【 授权许可】

CC BY   
© The Author(s) 2023

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