Testing whether a referral to a telehealth program helps African-American and Hispanic adults with COPD transition from hospital to home / Negin Hajizadeh.

Format:

Book

Author/Creator:

Hajizadeh, Negin, author.

Language:

English

Subjects (All):

Outcome assessment (Medical care).

Outcome assessment (Medical care)--Methodology.

Physical Description:

1 online resource

Place of Publication:

Washington, DC : Patient-Centered Outcomes Research Institute (PCORI), 2021.

Summary:

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is a leading cause of hospitalization in the United States. African American and Hispanic patients bear a high burden of illness and death due to COPD, with a prevalence similar to that of White patients but with poorer disease control. Both groups are disproportionately affected by social and economic inequalities that affect their access to care and are twice as likely to visit the emergency department for COPD-associated conditions than are non-Hispanic White individuals. Reasons for this high disease burden are complex and include higher rates of smoking, reduced health access (especially to pulmonary rehabilitation [PR]), and lower socioeconomic status. Early referral to PR after admission for COPD improves quality of life (QOL) and decreases hospital readmissions. Unfortunately, referral and uptake rates are poor among all persons with COPD and even worse for those from racial/ethnic minority groups. Telehealth-delivered PR (TelePR) for COPD is equivalent to standard clinic-based (ie, outpatient) PR (SPR), in terms of QOL and exercise capacity, and superior in terms of patient adherence in individuals with COPD, most of whom were White in nonrandomized studies. A referral to TelePR may lead to improved outcomes because TelePR has the potential to overcome many barriers that are more pronounced in populations of patients with an increased risk of health disparities and health care disparities. OBJECTIVES: We aimed to (1) adapt a culturally tailored TelePR intervention for Hispanic and African American patients with low income who have moderate to severe COPD and assess the acceptability and usability of TelePR; and (2) conduct a randomized controlled trial (RCT) comparing outcomes after referral to TelePR vs SPR among Hispanic and African American patients discharged from the hospital for acute exacerbation of COPD. METHODS: For aim 1, we used a community-based participatory research (CBPR) process to adapt the TelePR intervention to facilitate acceptability and usability. For aim 2, we conducted a 2-arm, single-blinded RCT to assess whether a referral to TelePR vs SPR (here, an outpatient PR clinic) resulted in decreased 6-month COPD-related hospital readmissions (primary outcome) among Hispanic and African American patients. For this study, designed as a superiority study, the inclusion criteria were being aged >18 years, being diagnosed with moderate COPD, being African American or Hispanic, having Spanish or English fluency, being able to follow basic exercise instruction and use a stationary bike, and weighing <300 lb (<136 kg). Both arms received a referral to PR for 8 weeks, social worker follow-up, and surveys administered at baseline, 8 weeks, 6 months, and 12 months. The PR sessions were conducted twice a week for 90 minutes each (16 sessions total). Participants in TelePR received an ergonomic bike, Wi-Fi modem, tablet computer, and vital-signs monitoring equipment; with this equipment, the respiratory therapist could remotely monitor up to 3 patients simultaneously, including obtaining real-time vital signs, while promoting socialization among participants during sessions. Quantitative data were analyzed using 2-sample t tests or nonparametric Wilcoxon tests for continuous data and ?2/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. RESULTS: TelePR was adapted with feedback from 7 community advisory board member meetings, 2 focus groups, and iterative usability testing. Of 725 patients who were approached, 209 with COPD enrolled in the study and 85 (n = 57 in the TelePR arm; n = 28 in the SPR arm) completed at least 1 PR session. The mean age of those in the TelePR arm was 66.89 years (SD, 10.80); 60.36% were female; the mean Charlson Comorbidity Index (CCI) score was 5.03 (SD, 2.29); and the mean forced expiratory volume in the first second of expiration (FEV1) was 51% (SD, 0.27). In the SPR arm, the mean (SD) values were aged 65.96 years (10.68); 58.16%, female; CCI score 5.17(2.58); and FEV1 48% (0.19). TelePR did not decrease the composite outcome of 6-month COPD-readmission or mortality rate (OR 1.58; 95% CI, 0.77-3.22; P = .21). For prespecified secondary outcomes, there was a significant reduction in fatigue (PROMIS(r) scale) from baseline to 8 weeks among the TelePR participants compared with the SPR participants (mean difference [SD], -1.34 [4.22]; P = .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 (according to the COPD Assessment Test and Modified Medical Research Council scale), knowledge about COPD management (Bristol COPD Knowledge Questionnaire), fatigue, and functional capacity. Among the patients who had 1 initial visit, adherence rates were similar (TelePR arm, 59% of sessions; SPR arm, 63%). During the preintervention, we used a CBPR approach to identify necessary adaptations to TelePR, in particular for Hispanic and African American individuals with COPD. Qualitative analysis during postintervention revealed that adherence by patients in either arm was influenced by several socioeconomic factors as well as patient-level beliefs about treatment efficacy of PR. TelePR was feasible to implement, as evidenced by the ability to deliver all equipment to participants' homes and to conduct remote PR sessions for almost all participants who started the TelePR program. In addition, there were high rates of patient satisfaction with TelePR. CONCLUSIONS: Of the 209 patients who were referred to TelePR, only 85 were able to attend at least one 1 session. The most common reason for not completing the referral was the need to complete medical clearance appointments. A referral to TelePR did not decrease 6-month COPD-hospital readmissions, compared with a referral to SPR. However, TelePR was feasible to implement among African American and Hispanic patients with moderate to severe COPD, despite this population's multiple comorbidities and severe illness. LIMITATIONS: The most significant limitations of this study were the small sample size of patients who participated in at least 1 PR session and a consequent underpowered analysis for the primary outcome. Poor uptake of PR was largely due to comorbid illness and barriers to obtaining medical clearances, which often competed with comorbidity-related medical appointments and were challenging to schedule and motivate attendance at, despite the provision of transportation.

Contents:

ABSTRACT

BACKGROUND

PATIENT AND STAKEHOLDER ENGAGEMENT

METHODS

RESULTS

DISCUSSION

CONCLUSIONS

REFERENCES

RELATED PUBLICATIONS

ACKNOWLEDGMENTS

APPENDICES.

Notes:

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