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Supervised maintenance programmes following pulmonary rehabilitation compared to usual care for chronic obstructive pulmonary disease.
Cochrane Database Syst Rev. 2021 08 17; 8:CD013569.CD

Abstract

BACKGROUND

Pulmonary rehabilitation benefits patients with chronic obstructive pulmonary disease (COPD), but gains are not maintained over time. Maintenance pulmonary rehabilitation has been defined as ongoing supervised exercise at a lower frequency than the initial pulmonary rehabilitation programme. It is not yet known whether a maintenance programme can preserve the benefits of pulmonary rehabilitation over time. Studies of maintenance programmes following pulmonary rehabilitation are heterogeneous, especially regarding supervision frequency. Furthermore, new maintenance models (remote and home-based) are emerging.

OBJECTIVES

To determine whether supervised pulmonary rehabilitation maintenance programmes improve health-related quality of life (HRQoL), exercise performance, and health care utilisation in COPD patients compared with usual care. Secondly, to examine in subgroup analyses the impact of supervision frequency and model (remote or in-person) during the supervised maintenance programme.

SEARCH METHODS

We searched the Cochrane Airways Trials Register, CENTRAL, MEDLINE, Embase, PEDro, and two additional trial registries platforms up to 31 March 2020, without restriction by language or type of publication. We screened the reference lists of all primary studies for additional references. We also hand-searched conference abstracts and grey literature through the Cochrane Airways Trials Register and CENTRAL.

SELECTION CRITERIA

We included only randomised trials comparing pulmonary rehabilitation maintenance for COPD with attention control or usual care. The primary outcomes were HRQoL, exercise capacity and hospitalisation; the secondary outcomes were exacerbation rate, mortality, direct costs of care, and adverse events.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles and abstracts, extracted data, and assessed the risk of bias. Results data that were similar enough to be pooled were meta-analysed using a random-effects model, and those that could not be pooled were reported in narrative form. Subgroup analyses were undertaken for frequency of supervision (programmes offered monthly or less frequently, versus more frequently) and those using remote supervision (e.g. telerehabilitation versus face-to-face supervision). We used the GRADE approach to assess the certainty of evidence.

MAIN RESULTS

We included 21 studies (39 reports) with 1799 COPD patients. Participants ranged in age from 52 years to 88 years. Disease severity ranged from 24% to 88% of the predicted forced expiratory volume in one second. Programme duration ranged from four weeks to 36 months. In-person supervision was provided in 12 studies, and remote supervision was provided in six studies (telephone or web platform). Four studies provided a combination of in-person and remote supervision. Most studies had a high risk of performance bias due to lack of blinding of participants, and high risk of detection, attrition, and reporting bias. Low- to moderate-certainty evidence showed that supervised maintenance programmes may improve health-related quality of life at six to 12 months following pulmonary rehabilitation compared to usual care (Chronic Respiratory Questionnaire total score mean difference (MD) 0.54 points, 95% confidence interval (CI) 0.04 to 1.03, 258 participants, four studies), with a mean difference that exceeded the minimal important difference of 0.5 points for this outcome. It is possible that supervised maintenance could improve six-minute walk distance, but this is uncertain (MD 26 metres (m), 95% CI -1.04 to 52.84, 639 participants, 10 studies). There was little to no difference between the maintenance programme and the usual care group in exacerbations or all-cause hospitalizations, or the chance of death (odds ratio (OR) for mortality 0.73, 95% CI 0.36 to 1.51, 755 participants, six studies). Insufficient data were available to understand the impact of the frequency of supervision, or of remote versus in-person supervision. No adverse events were reported.

AUTHORS' CONCLUSIONS

This review suggests that supervised maintenance programmes for COPD patients after pulmonary rehabilitation are not associated with increased adverse events, may improve health-related quality of life, and could possibly improve exercise capacity at six to 12 months. Effects on exacerbations, hospitalisation and mortality are similar to those of usual care. However, the strength of evidence was limited because most included studies had a high risk of bias and small sample size. The optimal supervision frequency and models for supervised maintenance programmes are still unclear.

Authors+Show Affiliations

Department of Cardiorespiratory Physiotherapy and Skeletal Muscle, Federal University of Juiz de Fora, Juiz de Fora, Brazil.Graduate Program in Rehabilitation Sciences, Nove de Julho University, São Paulo, Brazil.Cochrane Airways, Population Health Research Institute, St George's, University of London, London, UK.Physiotherapy, Alfred Health, Melbourne, Australia. Institute for Breathing and Sleep, Melbourne, Australia. Department of Allergy, Clinical Immunology and Respiratory Medicine, Monash University, Melbourne, Australia.

Pub Type(s)

Journal Article
Research Support, Non-U.S. Gov't
Review

Language

eng

PubMed ID

34404111

Citation

Malaguti, Carla, et al. "Supervised Maintenance Programmes Following Pulmonary Rehabilitation Compared to Usual Care for Chronic Obstructive Pulmonary Disease." The Cochrane Database of Systematic Reviews, vol. 8, 2021, p. CD013569.
Malaguti C, Dal Corso S, Janjua S, et al. Supervised maintenance programmes following pulmonary rehabilitation compared to usual care for chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2021;8:CD013569.
Malaguti, C., Dal Corso, S., Janjua, S., & Holland, A. E. (2021). Supervised maintenance programmes following pulmonary rehabilitation compared to usual care for chronic obstructive pulmonary disease. The Cochrane Database of Systematic Reviews, 8, CD013569. https://doi.org/10.1002/14651858.CD013569.pub2
Malaguti C, et al. Supervised Maintenance Programmes Following Pulmonary Rehabilitation Compared to Usual Care for Chronic Obstructive Pulmonary Disease. Cochrane Database Syst Rev. 2021 08 17;8:CD013569. PubMed PMID: 34404111.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Supervised maintenance programmes following pulmonary rehabilitation compared to usual care for chronic obstructive pulmonary disease. AU - Malaguti,Carla, AU - Dal Corso,Simone, AU - Janjua,Sadia, AU - Holland,Anne E, Y1 - 2021/08/17/ PY - 2022/08/17/pmc-release PY - 2021/8/17/entrez PY - 2021/8/18/pubmed PY - 2021/9/16/medline SP - CD013569 EP - CD013569 JF - The Cochrane database of systematic reviews JO - Cochrane Database Syst Rev VL - 8 N2 - BACKGROUND: Pulmonary rehabilitation benefits patients with chronic obstructive pulmonary disease (COPD), but gains are not maintained over time. Maintenance pulmonary rehabilitation has been defined as ongoing supervised exercise at a lower frequency than the initial pulmonary rehabilitation programme. It is not yet known whether a maintenance programme can preserve the benefits of pulmonary rehabilitation over time. Studies of maintenance programmes following pulmonary rehabilitation are heterogeneous, especially regarding supervision frequency. Furthermore, new maintenance models (remote and home-based) are emerging. OBJECTIVES: To determine whether supervised pulmonary rehabilitation maintenance programmes improve health-related quality of life (HRQoL), exercise performance, and health care utilisation in COPD patients compared with usual care. Secondly, to examine in subgroup analyses the impact of supervision frequency and model (remote or in-person) during the supervised maintenance programme. SEARCH METHODS: We searched the Cochrane Airways Trials Register, CENTRAL, MEDLINE, Embase, PEDro, and two additional trial registries platforms up to 31 March 2020, without restriction by language or type of publication. We screened the reference lists of all primary studies for additional references. We also hand-searched conference abstracts and grey literature through the Cochrane Airways Trials Register and CENTRAL. SELECTION CRITERIA: We included only randomised trials comparing pulmonary rehabilitation maintenance for COPD with attention control or usual care. The primary outcomes were HRQoL, exercise capacity and hospitalisation; the secondary outcomes were exacerbation rate, mortality, direct costs of care, and adverse events. DATA COLLECTION AND ANALYSIS: Two review authors independently screened titles and abstracts, extracted data, and assessed the risk of bias. Results data that were similar enough to be pooled were meta-analysed using a random-effects model, and those that could not be pooled were reported in narrative form. Subgroup analyses were undertaken for frequency of supervision (programmes offered monthly or less frequently, versus more frequently) and those using remote supervision (e.g. telerehabilitation versus face-to-face supervision). We used the GRADE approach to assess the certainty of evidence. MAIN RESULTS: We included 21 studies (39 reports) with 1799 COPD patients. Participants ranged in age from 52 years to 88 years. Disease severity ranged from 24% to 88% of the predicted forced expiratory volume in one second. Programme duration ranged from four weeks to 36 months. In-person supervision was provided in 12 studies, and remote supervision was provided in six studies (telephone or web platform). Four studies provided a combination of in-person and remote supervision. Most studies had a high risk of performance bias due to lack of blinding of participants, and high risk of detection, attrition, and reporting bias. Low- to moderate-certainty evidence showed that supervised maintenance programmes may improve health-related quality of life at six to 12 months following pulmonary rehabilitation compared to usual care (Chronic Respiratory Questionnaire total score mean difference (MD) 0.54 points, 95% confidence interval (CI) 0.04 to 1.03, 258 participants, four studies), with a mean difference that exceeded the minimal important difference of 0.5 points for this outcome. It is possible that supervised maintenance could improve six-minute walk distance, but this is uncertain (MD 26 metres (m), 95% CI -1.04 to 52.84, 639 participants, 10 studies). There was little to no difference between the maintenance programme and the usual care group in exacerbations or all-cause hospitalizations, or the chance of death (odds ratio (OR) for mortality 0.73, 95% CI 0.36 to 1.51, 755 participants, six studies). Insufficient data were available to understand the impact of the frequency of supervision, or of remote versus in-person supervision. No adverse events were reported. AUTHORS' CONCLUSIONS: This review suggests that supervised maintenance programmes for COPD patients after pulmonary rehabilitation are not associated with increased adverse events, may improve health-related quality of life, and could possibly improve exercise capacity at six to 12 months. Effects on exacerbations, hospitalisation and mortality are similar to those of usual care. However, the strength of evidence was limited because most included studies had a high risk of bias and small sample size. The optimal supervision frequency and models for supervised maintenance programmes are still unclear. SN - 1469-493X UR - https://www.unboundmedicine.com/medline/citation/34404111/Supervised_maintenance_programmes_following_pulmonary_rehabilitation_compared_to_usual_care_for_chronic_obstructive_pulmonary_disease_ L2 - https://doi.org/10.1002/14651858.CD013569.pub2 DB - PRIME DP - Unbound Medicine ER -