Elsevier

The Lancet

Volume 355, Issue 9201, 29 January 2000, Pages 362-368
The Lancet

Articles
Results at 1 year of outpatient multidisciplinary pulmonary rehabilitation: a randomised controlled trial

https://doi.org/10.1016/S0140-6736(99)07042-7Get rights and content

Summary

Background

Pulmonary rehabilitation seems to be an effective intervention in patients with chronic obstructive pulmonary disease. We undertook a randomised controlled trial to assess the effect of outpatient pulmonary rehabilitation on use of health care and patients' wellbeing over 1 year.

Methods

200 patients with disabling chronic lung disease (the majority with chronic obstructive pulmonary disease) were randomly assigned a 6-week multidisciplinary rehabilitation programme (18 visits) or standard medical management. Use of health services was assessed from hospital and general-practice records. Analysis was by intention to treat.

Findings

There was no difference between the rehabilitation (n=99) and control (n=101) groups in the number of patients admitted to hospital (40 vs 41) but the number of days these patients spent in hospital differed significantly (mean 10·4 [SD 9·7] vs 21·0 [20·7], p=0·022). The rehabilitation group had more primary-care consultations at the general practitioner's premises than did the control group (8·6 [6·8] vs 7·3 [8·3], p=0·033) but fewer primary-care home visits (1·5 [2·8] vs 2·8 [4·6], p=0·037). Compared with control, the rehabilitation group also showed greater improvements in walking ability and in general and disease-specific health status.

Interpretation

For patients chronically disabled by obstructive pulmonary disease, an intensive, multidisciplinary, outpatient programme of rehabilitation is an effective intervention, in the short term and the long term, that decreases use of health services.

Introduction

Chronic obstructive pulmonary disease and other chronic pulmonary disorders cause disability and handicap to patients, whose care becomes an increasing burden to the health services as well as the patients' families. Although medication may provide limited subjective benefit, many patients remain symptomatic with impaired quality of life.

The role of rehabilitation programmes for improving health in these patients has been recognised,1, 2, 3 and guidelines for rehabilitation4, 5 have been published. A meta-analysis of exercise-based respiratory rehabilitation in patients with chronic obstructive pulmonary disease6 reviewed 14 randomised controlled trials of rehabilitation versus care without rehabilitation, and confirmed statistically and clinically significant short-term benefits for rehabilitation. The studies reviewed in the meta-analysis were done in various settings in the hospital and the community, and lasted 4 weeks to 6 months. Another large randomised controlled trial7 has shown a long-term benefit for an 8-week outpatient programme in terms of walking ability and a sense of self efficacy for walking and breathlessness. However, there was no effect on general health status or use of health services. Subsequently, two randomised controlled trials have shown benefit for a 3-month community programme8 and a 3-month outpatient programme,9 in terms of exercise tolerance, disease-specific (but not general) health status, and activity of daily living scores.

A pulmonary rehabilitation programme was set up at our hospital, which functions both as a teaching hospital and district general hospital. We designed the introduction of this programme as a randomised controlled trial and compared standard care with outpatient, multidisciplinary, pulmonary rehabilitation. We investigated the short-term and long-term effects of the intervention. We present data on the outcomes of health service use, walking tolerance, and health status. A health economic analysis will be reported elsewhere.

Section snippets

Patients

Consultants in local hospitals and local general practitioners were invited to refer patients to the pulmonary rehabilitaton unit for assessment and entry into the study (figure). They were asked to refer patients who, in their judgment, had chronic obstructive bronchitis, emphysema, or chronic poorly reversible asthma or bronchiectasis. Patients were accepted into the study if their forced expiratory volume in 1 s (FEV1), measured at a time of clinical stability, was less than 60% of predicted

Results

The diagnoses of the participants are given in table 1. Because the subset of patients with non-obstructive pulmonary disease was so small and their inclusion in the analysis did not affect the outcome of the study, we present data with all patients included in the analysis.

At some time points information was not available for health status or walk testing, and these patients were excluded from analyses at those time points. Returns from primary care were complete for 199 of the 200 patients

Discussion

The rehabilitation programme we studied had many components designed to have an effect on physical impairments, disability, and handicap in a broad way. The benefits in use of health services and functional and health status cannot, therefore, be ascribed to any of the individual components in isolation. However, one intention of the programme was to change patient's behaviour and attitude to their disability and handicap.

Our primary intention was to look at the patients' use of health care

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