Background
Chronic obstructive pulmonary disease (COPD) is characterised by exertional dyspnoea, reduced exercise tolerance, marked disability and frequent hospitalisation. The current economic burden of COPD to the health system is considerable, with the majority of costs attributable to hospital use. International guidelines for managing COPD include referral to pulmonary rehabilitation, supported by compelling evidence that such programs deliver improvement in exercise capacity, reduction in breathlessness and improvement in health-related quality of life (HRQOL), irrespective of disease severity. Pulmonary rehabilitation is also associated with a reduced frequency of acute exacerbations and hospital admissions. Despite the strong evidence of its benefits, the proportion of people with COPD who receive pulmonary rehabilitation is very small, with estimates from developed countries suggesting that it is delivered to less than 5% of those who would benefit each year. Of those people with COPD who are referred to pulmonary rehabilitation, 8% to 50% will never attend, while non-completion rates range from 10% to 32%. The practical reasons for this lack of access include a shortage of programs, particularly in rural and regional centres, and an insufficient number of qualified health professionals. Patient-related barriers to attendance have also been identified, with travel and transport to centre-based programs being the most common obstacles to attendance in this disabled group.
In view of these barriers, the current model of a centre-based pulmonary rehabilitation program is not addressing the needs of many people with COPD who would benefit from this intervention. If new models are not found, uptake of these programs by patients with COPD will continue to be limited. Home-based, unsupervised pulmonary rehabilitation has been proposed as an alternative model which may enhance access and uptake while containing the rising costs of healthcare associated with COPD. Direct comparison of home and centre-based pulmonary rehabilitation has been explored in four studies. Home-based programs were found to be safe, with improvement in exercise tolerance and HRQOL and reduced symptoms demonstrated in both the home and hospital-based groups. However, only one study was a non-inferiority trial and important differences between supervised and unsupervised groups may not have been detected in other studies. Of greater importance is that no studies of self-monitored pulmonary rehabilitation have tested an entirely home-based intervention. In previous studies participants in the home training groups were required to attend the hospital for self-management education or weekly monitoring. These approaches fail to overcome the transport and mobility-related barriers to attendance.
Population ageing and the increasing health care burden associated with chronic disease provide an imperative to allocate our limited resources effectively. The variety of program models and staffing used for home-based rehabilitation in COPD suggests that costs could vary considerably. One home-based program incorporated frequent home visits from clinicians to supervise exercise, a model which has proved to be more costly than centre-based rehabilitation in patients with cardiac disease. Self-monitored exercise programs utilising telephone follow up have demonstrated clinical effectiveness, but not all components of pulmonary rehabilitation were delivered at home and no cost comparison to centre-based programs was undertaken. Analysis of the costs of delivery is a critical determinant of whether such a model of care is suitable for implementation in clinical practice.
Comprehensive economic evaluation includes both costs to the healthcare service and the patient. In addition, cost effectiveness analysis incorporates the evaluation of the impact of an intervention on the patient, to determine if benefits are accrued beyond standard healthcare gains. Such gains may be accessed through measurement of quality-adjusted life years (QALYs) which quantify the benefit gained due to an intervention by measuring the change in quality of life over time. In COPD, centre-based pulmonary rehabilitation (exercise training and education) has been demonstrated to be cost-effective with improvement in QALYs. However, no previous studies have assessed such outcomes for home-based pulmonary rehabilitation.
There is a need for new models of pulmonary rehabilitation which allow all program components to be delivered at home, with proven clinical outcomes and low costs. The aims of this study are to 1) compare completion rates of a home-based self-monitored pulmonary rehabilitation program with a hospital-based, outpatient program in people with COPD; 2) compare the clinical benefits of home-based pulmonary rehabilitation and hospital-based pulmonary rehabilitation and 3) compare the costs of home-based and hospital-based pulmonary rehabilitation. We hypothesise that the proportion of patients who complete pulmonary rehabilitation will be greater in the home-based intervention; the clinical effects on exercise capacity, symptoms and quality of life will be equivalent in both models; and the home-based program will be more cost-effective.