Author: Yeung, Tsz Ling Meredith
Title: Evaluation of pulmonary rehabilitation at the Singapore General Hospital
Degree: DHSc
Year: 2012
Subject: Lungs -- Diseases, Obstructive -- Patients -- Rehabilitation -- Singapore.
Lungs -- Diseases -- Patients -- Rehabilitation -- Singapore.
Hong Kong Polytechnic University -- Dissertations
Department: Faculty of Health and Social Sciences
Pages: xxvi, 226 leaves : ill. ; 30 cm.
Language: English
Abstract: Background: Pulmonary rehabilitation program (PRP) has been advocated as a way to provide comprehensive care and improve the functional status of patients with chronic respiratory diseases. It is a mean to control and alleviate symptoms, and to optimize functional capacity to augment the conventional standard therapy. Positive evidence in support of both short-term and long-term benefits of PRPs conducted in the outpatient, inpatient and home-based settings is available. Whether the benefits of a PRP are truly meaningful to the patient could be influenced by different cultural backgrounds. This leads to the emerging research on estimation of "minimal clinically important difference"(MCID) in PRP. PRPs are only available at the Singapore General Hospital (SGH) in Singapore, however the effectiveness of PRPs conducted in SGH has never been evaluated and information on associated MCID of PRP in Singaporeans is not available. The overall aim of this study was therefore to evaluate the program effectiveness of the PRP conducted in the SGH; and with specific objectives to (1) compare the program effectiveness in the two different settings (outpatient and inpatient), (2) evaluate the MCID of six-minute walk distance, (3) evaluate the MCID of chronic respiratory disease questionnaires, and (4) determine the demographic, psychosocial and physical factors that could influence the intermediate PRP outcomes. Method: Records of 198 participants were retrieved for data analysis to compare the program effectiveness between the outpatient and inpatient settings. All participants completed a total of 18-sessions of 2-hours PRP. The outpatient group participated PRP two to three sessions per week, for a total of six to nine weeks; while the inpatient group participated for two sessions per day for ten consecutive working days. The content of the program are identical. The demographic data of patients and outcome measures between groups were compared using independent t-test. Subgroups of participants completed the PRP between 2005 to 2010 were included in the estimation of MCID for outcome measures. These subgroup participants were asked to rate the effect of rehabilitation they received using the Global Rating of Change scale via a telephone-interview. Anchor-based method using the receiver operating characteristics curves and distribution-based method using the Standard Error Measurement were conducted for the estimation of MCID for six-minute walk distance (6MWD). Similar anchor-based method was conducted for the estimation of MCID for chronic respiratory disease questionnaire. With the established MCID for 6MWD determined, responders with greater than the determined MCID were identified as having received a successful PRP, then the proportion of "successful" respondents in each setting was calculated. From univariate and multiple logistic regression analyses, factors associated with improvement were established. The Stata/IC 10.0 for Windows (TX 77845, USA) was used for all data analyses.
Result: Analysis of available data demonstrated significant improvement in 6MWD and chronic respiratory disease questionnaire scores between the pre- and post PRP analysis for both outpatients and inpatients. Five years mortality rates between the outpatient and inpatient groups were 46.2% and 45.6% respectively. The anchor-based MCID estimation for 6MWD was 17.4m, while the distribution-based method reported to be 18.6m. Hence, the smallest clinically important change estimation was concluded to be 18.6m. The anchor-based MCID estimation for chronic respiratory disease questionnaire were reported as 0.20 for dyspnoea, 0.25 for fatigue, 0.43 for emotional function, 0.25 for mastery and 0.25 for total score. Further analysis also showed that the patient's baseline 6MWD was the only significant factor associated with post PRP improvement, suggesting that for every increase in 10m in the baseline distance, the odds of clinically important improvement decreases by 20%. Conclusion: The positive results provided from this retrospective review of the PRP offered in SGH confirmed the value of the program. The high-frequency-short-duration inpatient program offered good alternative for participants who cannot take part in the outpatient program. The MCID estimation of 6MWD established in Singaporeans receiving PRP was 18.6m. Information obtained from this study is now ready for submission to administrators of Singapore Health, which could facilitate government support of pulmonary rehabilitation programs to be conducted in other hospitals in Singapore. Lastly, further studies are warranted to investigate long term effect of PRP in patients with chronic respiratory diseases.
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Access: restricted access

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