Tele-Health Pulmonary Rehabilitation: Lessons from Alberta

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Tele-Health Pulmonary RehabilitationLessons
from Alberta
Mike Stickland, PhD CIHR New Investigator
Co-Director Centre for Lung Health Edmonton
General
Assistant Professor Pulmonary Division Faculty of
Medicine U of Alberta
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Conflict of Interest Disclosure

• Educational Grant
• Glaxo-Smith Klein
• Astrazeneca
• Speakers Honoriarium 
• Glaxo-Smith Klein

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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)

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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
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Canadian Situation
An urgent need exists to increase access to
Pulmonary Rehabilitation programs across
Canada (ODonnell et al., CTS Guidelines,
Can Resp J, 2007)
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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?

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Breathe Easy ProgramCentre for Lung Health
(Covenant Health)
6 8 week outpatient program for ambulatory
patients Chronic Respiratory Disease

• 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

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

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Components of Pulmonary Rehabilitation
Education
Exercise
Support
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Standard Outcomes

• All conducted before and after
• Cardiopulmonary exercise test
• Walk test
• Quality of life
• SF-36
• St-Georges Respiratory
• Questionnaire (SGRQ)

Conducted at 6 and 12 month follow-up
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TELE-HEALTH
Tele-Health involves the use of communications
and information technology to deliver health
services and information over large and small
distances. Clinical Educational Administrative
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Tele-Health Pulmonary Rehabilitation

• Remote sites required
• A local health care coordinator (typically RT)
• An exercise facility
• Telehealth capabilities

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Pre Program consult w/ Pulmonologist
Edmonton Site Telehealth
MD Consult In Person Via Tele-Health w/ RT _at_ 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
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Telehealth Pulmonary Rehab
15 Sites Total

• North
• Grande Prairie
• Peace River
• Athabasca
• Bonnyville
• Cold Lake
• Elk Point
• Barrhead
• Fort McMurray

Central Camrose Drayton Valley Killam
Vermillion Wainwright Edmonton Sherwood
Park Fort Saskatchewan Leduc
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Is Telehealth PR as effective as standard PR for
COPD?(non-inferiority trial)
Edmonton Site
Patients N147
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)
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Is Telehealth PR as effective as standard PR for
COPD?(non-inferiority trial)
Edmonton Site Telehealth
Patients N147 N147
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)
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Non-Inferiority Analysis
(Intention-to-treat)
Similar results seen w/ per-protocol analysis
Responses similar across GOLD category
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Non-Inferiority Analysis
(Intention-to-treat)
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6 Month Data
Pre vs. Post Pre vs. 6mo
(n45)
(n47)
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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

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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

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Thanks to
Co-investigators
CFLH Staff
Pulmonologists
Dr. F. MacDonald Dr. J. Archibald Dr. M. Bhutani
Dr. T. Bryan Dr. A. Liu Dr. S. Marcushamer Dr.
L. Melenka Dr. W. Ramesh Dr. D. Stollery Dr. E.
Wong
Dr. F. MacDonald T. Jourdain Dr. W. Rodgers Dr.
E. Wong

• M. Pratley
• R. Hamir
• T. Jourdain
• S. Olson
• L. Simmonds
• B. Gendron
• S. Martin
• B. Yee

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

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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

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Is Telehealth PR as effective as standard PR for
COPD?(non-inferiority trial)
Telehealth
Patients N147
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)
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Is Telehealth PR as effective as standard PR for
COPD?(non-inferiority trial)
Telehealth Edmonton Site
Patients N147 N147
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)
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Is Telehealth PR as effective as standard PR for
COPD?(non-inferiority trial)
Telehealth Edmonton Site
Patients N147 N147
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)