Tele-Health Pulmonary Rehabilitation: Lessons from Alberta Mike Stickland, PhD CIHR New Investigator...

Tele-Health Pulmonary Rehabilitation:Lessons from Alberta

Mike Stickland, PhD

CIHR New Investigator

Assistant Professor

Pulmonary Division

Faculty of Medicine

U of Alberta

Co-Director

Centre for

Lung Health

Edmonton General

Conflict of Interest Disclosure

Educational Grant:• Glaxo-Smith Klein• Astrazeneca

Speakers Honoriarium • Glaxo-Smith Klein

Canadian Situation

• A recent national survey revealed that only 98 programs exist in Canada (Brooks et al. Can Resp J, 2007)

• These programs combined have the capacity to serve only 1.2% of the COPD population in Canada

(Brooks et al. Can Resp J, 2007)

Grande Prairie (pop.50000)

- 400 km / 250 m

Peace River (pop.7000 )

- 480 km / 300 m

Fort McMurray (pop.88000 )

- 400 km / 250 m

High Level (pop.4000)

- 775 km / 480 m

Canadian Situation

‘An urgent need exists to increase access to Pulmonary Rehabilitation programs across Canada’

(O’Donnell et al., CTS Guidelines, Can Resp J, 2007)

Purpose

• To develop a pulmonary rehabilitation program using Tele-Health technology to provide PR services in rural Alberta

• Is rehab delivered via Tele-Health as effective as standard out-patient rehab?

Patient Referral:• Physician Referral• Full lung function test• Chest X-ray• ABG (if on O2)• Any additional cardiac info appreciated

•All pts seen by pulmonologist at enrollment

6 – 8 week outpatient program for ambulatory patients

Chronic Respiratory Disease

Breathe Easy ProgramCentre for Lung Health (Covenant Health)

Rehab Classes• 31 classes• M/W/F or Tue/Thur • Daytime & evening classes• ~ 500 pts enrolled / year

Components of Pulmonary Rehabilitation

Education Exercise Support

Standard Outcomes

All conducted before and after:• Cardiopulmonary exercise test• Walk test*• Quality of life

– SF-36*– St-George’s Respiratory

Questionnaire (SGRQ)** Conducted at 6 and 12 month follow-up

Tele-Health involves the use of communications and information technology to deliver health services and information over large and small distances.

ClinicalEducationalAdministrative

TELE-HEALTH

Remote sites required:

• A local health care coordinator (typically RT)

• An exercise facility

• Telehealth capabilities

Tele-Health Pulmonary Rehabilitation

Pre Program consult w/ Pulmonologist

Edmonton Site Telehealth

MD Consult In Person Via Tele-Health

w/ RT @ remote site

Chest X-ray Yes Yes

Lung Function Full Pulmonary Function Test

Minimum Spirometry

Exercise Test Cardiopulmonary Exercise Test

6min walk w/ SpO2

and resting EKG

Telehealth Pulmonary Rehab

North:Grande Prairie Peace River Athabasca Bonnyville Cold LakeElk PointBarrheadFort McMurray

Central:Camrose Drayton Valley Killam VermillionWainwright

Edmonton:Sherwood ParkFort SaskatchewanLeduc

15 Sites Total:

Is Telehealth PR as effective as standard PR for COPD?

(non-inferiority trial)

Edmonton Site

Patients N=147

Age 69 ± 10

% Female 50%

FEV1 (% predicted) 49.1 ± 18

Quality of Life (SGRQ, %) 46.0 ± 17

12-minute walk (m) 627 ± 238

Drop-outs 17

(Stickland, Jourdain, Wong, Rodgers, Jendzjowsky, MacDonald In Press)

Is Telehealth PR as effective as standard PR for COPD?

(non-inferiority trial)

Edmonton Site Telehealth

Patients N=147 N=147

Age 69 ± 10 69 ± 9

% Female 50% 53%

FEV1 (% predicted) 49.1 ± 18 48.1 ± 25

Quality of Life (SGRQ, %) 46.0 ± 17 50.9 ± 16 *

12-minute walk (m) 627 ± 238 507 ± 241 *

Drop-outs 17 20

(Stickland, Jourdain, Wong, Rodgers, Jendzjowsky, MacDonald In Press)

Change in SGRQ (%)

-6 -4 -2 0 2 4 6

MCID MCID

Main Program

Telehealth

Main - Tele

Non-Inferiority Analysis

Similar results seen w/ per-protocol analysis

(Intention-to-treat)

Responses similar across GOLD category

Change in Walk Distance (m)

-150 -100 -50 0 50 100 150

Main Program

Telehealth

Main - TelehealthΔ

Non-Inferiority Analysis

(Intention-to-treat)

Change in SGRQ (%)

-6 -4 -2 0 2 4 6

MCID MCID

Main Program

Telehealth

Main - TelehealthΔ

6 Month DataPre vs. Post

Pre vs. 6mo(n=45)

(n=47)

Key Findings

• Tele-Health PR as effective as standard pulmonary rehabilitation– Similar responses seen across GOLD stage– Safe, no difference in drop-outs / adverse events– Does not need to be complicated

• Excellent way to provide pulmonary services/support to rural regions

Lessons Learned

• Need for key central coordinator– Standardize referral data for MDs– Ensure scheduling & delivery– IT support– Ensure proper discharge reporting– Track Health outcomes

• Flexibility for Education delivery– Varying Tele-Health equipment– Limited telehealth facilities– Ability to podcast education sessions

Thanks to:

M. Pratley

R. Hamir

T. Jourdain

S. Olson

L. Simmonds

B. Gendron

S. Martin

B. Yee

CFLH Staff: Pulmonologists:Dr. F. MacDonaldDr. J. ArchibaldDr. M. Bhutani Dr. T. BryanDr. A. LiuDr. S. MarcushamerDr. L. MelenkaDr. W. RameshDr. D. StolleryDr. E. Wong

Dr. F. MacDonaldT. JourdainDr. W. RodgersDr. E. Wong

Co-investigators

Funding for this project was obtained from the Alberta Health Services Telehealth Clinical Grant Fund & Covenant Health Research Foundation.

Tele-Health Pulmonary Rehab

• Pre Program consult w/ Pulmonologist via Tele-Health

• The following test results are reviewed at the initial consult:• 6 minute walk with oximetry • Pulmonary Function Test (minimum spirometry)• Baseline Electrocardiogram• Chest X-Ray

• Education given via Tele-Health • Patients exercise at local site under supervision

Tele-Health Pulmonary Rehab

• Pre Program consult w/ Pulmonologist via Tele-Health

• The following test results are reviewed at the initial consult:• 6 minute walk with oximetry • Pulmonary Function Test (minimum spirometry)• Baseline Electrocardiogram• Chest X-Ray

• Education given via Tele-Health • Patients exercise at local site under supervision

Is Telehealth PR as effective as standard PR for COPD?

(non-inferiority trial)

Telehealth

Patients N=147

Age 69 ± 9

% Female 53%

FEV1 (% predicted) 48.1 ± 25

Quality of Life (SGRQ, %) 50.9 ± 16 *

12-minute walk (m) 507 ± 241 *

Drop-outs 20

(Stickland, Jourdain, Wong, Rodgers, Jendzjowsky, MacDonald In Press)

Is Telehealth PR as effective as standard PR for COPD?

(non-inferiority trial)

Telehealth Edmonton Site

Patients N=147 N=147

Age 69 ± 9 69 ± 10

% Female 53% 50%

FEV1 (% predicted) 48.1 ± 25 49.1 ± 18

Quality of Life (SGRQ, %) 50.9 ± 16 * 46.0 ± 17

12-minute walk (m) 507 ± 241 * 627 ± 238

Drop-outs 20 17

(Stickland, Jourdain, Wong, Rodgers, Jendzjowsky, MacDonald In Press)

Is Telehealth PR as effective as standard PR for COPD?

(non-inferiority trial)

Telehealth Edmonton Site

Patients N=147 N=147

Age 69 ± 9 69 ± 10

% Female 53% 50%

FEV1 (% predicted) 48.1 ± 25 49.1 ± 18

Quality of Life (SGRQ, %) 50.9 ± 16 * 46.0 ± 17

12-minute walk (m) 507 ± 241 * 627 ± 238

Drop-outs 20 17

(Stickland, Jourdain, Wong, Rodgers, Jendzjowsky, MacDonald In Press)