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The "contingent valuation" method is used to quantify the value of services not available in traditional markets, by assessing the monetary value an individual ascribes to the benefit provided by an intervention. The aim of this study was to determine preferences for home or center-based pulmonary rehabilitation for participants with chronic obstructive pulmonary disease (COPD) using the "willingness to pay" (WTP) approach, the most widely used technique to elicit strengths of individual preferences. This is a secondary analysis of a randomized controlled equivalence trial comparing center-based and home-based pulmonary rehabilitation. At their final session, participants were asked to nominate the maximum that they would be willing to pay to undertake home-based pulmonary rehabilitation in preference to a center-based program. Regression analyses were used to investigate relationships between participant features and WTP values. Data were available for 141/163 eligible study participants (mean age 69 [SD 10] years

Background: Physical activity levels are low in people with chronic obstructive pulmonary disease, and there is limited knowledge about how pulmonary rehabilitation transforms movement behaviors. This study analyzed data from a pulmonary rehabilitation trial and identified determinants of movement behaviors.Methods: Objectively assessed time in daily movement behaviors (sleep, sedentary, light-intensity physical activity, and moderate- to vigorous-intensity physical activity) from a randomized controlled trial (n = 73 participants) comparing home- and center-based pulmonary rehabilitation was analyzed using conventional and compositional analytical approaches. Regression analysis was used to assess relationships between movement behaviors, participant features, and response to the interventions.Results: Compositional analysis revealed no significant differences in movement profiles between the home- and center-based groups. At end rehabilitation, conventional analyses identified positive relationships between exercise capacity (6-min walk distance), light-intensity physical activity, and moderate- to vigorous-intensity physical activity time. Compositional analyses identified positive relationships between a 6-minute walk distance and moderate- to vigorous-intensity physical activity time, accompanied by negative relationships with sleep and sedentary time (relative to other time components) and novel relationships between body mass index and light-intensity physical activity/sedentary time.Conclusion: Compositional analyses following pulmonary rehabilitation identified unique associations between movement behaviors that were not evident in conventional analyses.

INTRODUCTION People with mild chronic obstructive pulmonary disease (COPD) experience exercise intolerance, dyspnoea and poor quality of life. However, the role of pulmonary rehabilitation (PR) in this group is unclear. OBJECTIVES This randomised controlled trial aimed to explore the effects of home-based PR in people with mild COPD. METHODS People with mild COPD (FEV1 /FVC 80%predicted) with a smoking history of ≥10 packet years were randomised to either 8 weeks of home-based PR (one home visit and seven once-weekly telephone calls) or standard care (weekly social telephone calls). Six minute walk distance (6MWD), and Modified Medical Research Council Dyspnoea Scale (mMRC) and Chronic Respiratory Disease Questionnaire (CRQ) scores were compared. RESULTS A total of 58 participants (34 males, mean age 68 (SD 9) years, FEV1 %predicted 90 (7), 6MWD 496 (105) m) were included with 31 participants randomised to home-based PR. Participants attended an average of 6.8 of the 8 scheduled sessions, ranging from 3 to 8 sessions. Both groups showed improvements in exercise capacity, symptoms and health-related quality of life (HRQoL) over time, however there was no difference in 6MWD at end-intervention (mean difference -3 m, 95% confidence interval (CI) -64 to 58) or 6 months (7 m, 95% CI -59 to 72). At 6 months home-based PR participants were more likely to have clinically important improvements in CRQ emotional function (50% of home PR vs 0% control, P

To compare levels of physical activity during center and home-based pulmonary rehabilitation (PR) in people with chronic obstructive pulmonary disease.Forty-five consecutive participants (23 male, n = 20, in the home-based group) with mean age of 68 ± 8 yr and forced expiratory volume in the first second of expiration (FEV1) 53 ± 18% predicted undertook physical activity monitoring using the SenseWear Armband during the final week of the interventions of center or home-based PR. Differences in time spent in total physical activity (≥1.5 METs), time spent in moderate to vigorous intensity physical activity (≥3 METs), and steps were compared.Home participants spent a median and interquartile range of 310 (199-328) min/d engaged in total physical activity (29% moderate to vigorous intensity physical activity) compared with 300 (204-370) min/d for the center group (28% moderate to vigorous intensity physical activity, P = .98). Daily step count did not differ between groups (home-based median 5232 [2067-7718] versus center-based median 4049 [1983-6040], P = .66). Of note, center-based participants took 38% more steps on days of program attendance compared with nonattendance days (mean difference: 761 steps/d; 95% CI, -56 to 1579, P = .06).For people with chronic obstructive pulmonary disease undertaking PR, no differences in physical activity levels between center and home-based programs were demonstrated. Understanding the impact of the indirect supervision and motivational interviewing technique utilized during home-based PR on levels of physical activity in people with chronic obstructive pulmonary disease may support clinical implementation of the model as an alternative option to traditional care.

Background The optimal method to collect accurate healthcare utilisation data in people with chronic obstructive pulmonary disease (COPD) is not well established. The aim of this study was to determine feasibility and compare self-report and administrative data sources to capture health care resource use in people with COPD for 12 months following pulmonary rehabilitation. Methods This is a secondary analysis of a randomised controlled equivalence trial comparing centre-based and home-based pulmonary rehabilitation. Healthcare utilisation data were collected for 12 months following pulmonary rehabilitation from self-report (monthly telephone questionnaires and diaries) and administrative sources (Medicare Benefits Schedule, medical records). Feasibility was assessed by the proportion of self-reports completed and accuracy was established using month-by-month and per participant comparison of self-reports with administrative data. Results Data were available for 145/163 eligible study participants (89%, mean age 69 (SD 9) years, mean forced expiratory volume in 1 s 51 (SD 19) % predicted; n = 83 male). For 1725 months where data collection was possible, 1160 (67%) telephone questionnaires and 331 (19%) diaries were completed. Accuracy of recall varied according to type of health care encounter and self-report method, being higher for telephone questionnaire report of emergency department presentation (Kappa 0.656, p p p p Conclusion For self-reported methods of healthcare utilisation in people with COPD following pulmonary rehabilitation, monthly telephone questionnaires were more frequently completed and more accurate than diaries. Compared to administrative records, self-reports of emergency department presentations and inpatient admissions were more accurate than for general practitioner and medical specialist appointments. Trial registration NCT01423227 at clinicaltrials.gov

Abnormal sleep duration is associated with poor health. Upwards of 50% of people with chronic obstructive pulmonary disease (COPD) report poor sleep quality. The effect of pulmonary rehabilitation on self-reported sleep quality is variable. The aim of this study was to assess the effect of pulmonary rehabilitation on objectively measured sleep quality (via actigraphy) in people with COPD. Sleep quality was assessed objectively using the SenseWear Armband (SWA, BodyMedia, Pittsburgh, PA), worn for ≥4 days before and immediately after completing an 8-week pulmonary rehabilitation program. Sleep characteristics were derived from accelerometer positional data and registration of sleep state by the SWA, determined from energy expenditure. Forty-eight participants (

Background Pulmonary rehabilitation is a cornerstone of care for COPD but uptake of traditional centre-based programmes is poor. We assessed whether home-based pulmonary rehabilitation, delivered using minimal resources, had equivalent outcomes to centre-based pulmonary rehabilitation. Methods A randomised controlled equivalence trial with 12 months follow-up. Participants with stable COPD were randomly assigned to receive 8 weeks of pulmonary rehabilitation by either the standard outpatient centre-based model, or a new home-based model including one home visit and seven once-weekly telephone calls from a physiotherapist. The primary outcome was change in 6 min walk distance (6MWD). Results We enrolled 166 participants to receive centre-based rehabilitation (n=86) or home-based rehabilitation (n=80). Intention-to-treat analysis confirmed non-inferiority of home-based rehabilitation for 6MWD at end-rehabilitation and the confidence interval (CI) did not rule out superiority (mean difference favouring home group 18.6 m, 95% CI −3.3 to 40.7). At 12 months the CI did not exclude inferiority (−5.1 m, −29.2 to 18.9). Between-group differences for dyspnoea-related quality of life did not rule out superiority of home-based rehabilitation at programme completion (1.6 points, −0.3 to 3.5) and groups were equivalent at 12 months (0.05 points, −2.0 to 2.1). The per-protocol analysis showed the same pattern of findings. Neither group maintained postrehabilitation gains at 12 months. Conclusions This home-based pulmonary rehabilitation model, delivered with minimal resources, produced short-term clinical outcomes that were equivalent to centre-based pulmonary rehabilitation. Neither model was effective in maintaining gains at 12 months. Home-based pulmonary rehabilitation could be considered for people with COPD who cannot access centre-based pulmonary rehabilitation. Trial registration number NCT01423227, clinicaltrials.gov.

Background and objective This study aimed to compare the cost-effectiveness and cost-utility of home and centre-based pulmonary rehabilitation for adults with stable chronic obstructive pulmonary disease (COPD). Methods Prospective economic analyses were undertaken from a health system perspective alongside a randomized controlled equivalence trial in which participants referred to pulmonary rehabilitation undertook a standard 8-week outpatient centre-based or a new home-based programme. Participants underwent clinical assessment prior to programme commencement, immediately following completion and 12 months following programme completion. They provided data for utility (quality-adjusted life years (QALY) determined using SF6D (utility scores for health states) calculated from 36-Item Short Form Health Survey version 2) and effectiveness (change in distance walked on 6-min walk test (Δ6MWD) following pulmonary rehabilitation ). Individual-level cost data for the 12 months following programme completion was sourced from healthcare administration and government databases. Results Between-group mean difference point estimates for cost (-$4497 (95% CI: -$12 250 to $3257), utility (0.025 (-0.038 to 0.086) QALY) and effectiveness (14 m (-11 to 39) Δ6MWD) favoured the home-based group. Cost-utility analyses demonstrated 63% of estimates falling in the dominant southeast quadrant and the probability that the new home-based model was cost-effective at a $0 threshold for willingness to pay was 78%. Results were robust to a range of sensitivity analyses. Programme completion was associated with significantly lower healthcare costs in the following 12 months. Conclusion Home-based pulmonary rehabilitation provides a cost-effective alternative model for people with COPD who cannot access traditional centre-based programmes.

Introduction: Evaluating adherence to home-based pulmonary rehabilitation (PR) could be challenging due to lack of direct supervision and the complex nature of the rehabilitation model. To measure adherence to home-based PR in the HomeBase trial, participants were encouraged to work towards a goal of at least 30 min of whole-body exercise on most days of the week and report their participation using a home exercise diary. Objective: This project aimed to evaluate the acceptability and validity of the home exercise diary. Methods: Diary return and completion rates assessed acceptability of the home exercise diary. Home participants underwent physical activity (PA) monitoring using the Sensewear armband during the final week of an 8-week PR. The correlation between self-documented and objective daily exercise minutes was calculated. Objective exercise minutes were defined as bouts of ≥10 min spent in ≥ moderate PA. Differences in self-documented weekly exercise minutes between sufficiently active (≥7000 daily steps) and inactive participants were computed. Results: Diaries were returned by 92% of programme completers. Of those who returned diaries, 72% have completed exercise documentation. Fifteen programme completers underwent PA monitoring [mean age 69 (9) (SD) years, FEV1 55 (19) %predicted]. A moderate correlation was observed between self-documented and objective mean daily exercise minutes (r = .59, P = .02). Active participants [n = 6, 10 253 (1521) daily steps] documented more exercise (111 min) during week eight compared with inactive participants [n = 9, 2705 (1772) daily steps, P = .002]. Conclusion: The self-documented home exercise diary is an acceptable and valid method to reflect exercise participation during home-based PR.

Objective: Pulmonary rehabilitation (PR) improves function, reduces symptoms and decreases healthcare usage in people with chronic obstructive pulmonary disease (COPD) following an acute exacerbation (AECOPD). However, rehabilitation uptake rates are low. This study aimed to address barriers to uptake and completion of PR following AECOPD. Methods: An action research approach was used to reflect on study feasibility, and to plan and implement an improved protocol. Phase I tested the feasibility of home-based PR started early after AECOPD. Phase II used qualitative interviews to identified potential barriers to program uptake. Phase III re-tested the program with changes to recruitment and assessment strategies. Results: Phase I: From 97 screened patients, 26 were eligible and 10 (38%) started home-based PR. Eight participants undertook ≥70% of PR sessions, achieving clinically meaningful improvement in 6-minute walk distance (mean (SD) change 76 (60) m) and chronic respiratory disease questionnaire total score (15 (21) units). Phase II: Potential barriers to uptake of home-based PR included access issues, confidence to exercise, and lack of information about PR benefits. Phase III: From 77 screened patients, 23 were eligible and 5 (22%) started the program. Discussion: Home-based PR improved clinical outcomes, but program eligibility and uptake remain challenging. Efforts should be made to ensure PR program eligibility criteria are broad enough to accommodate patient needs, and new ways of engaging patients are needed to improve PR uptake after AECOPD.

Objectives To examine the predictive validity, minimal important difference (MID) and responsiveness of the PRAISE tool. Design Retrospective data analysis from HomeBase trial of home vs centre-based pulmonary rehabilitation. Setting Tertiary health service. Participants One hundred and sixty-six participants with COPD (100 men) with mean age 69 (SD 9) years, FEV1% predicted 50% (19). Interventions Eight-week pulmonary rehabilitation program, conducted at the hospital or at home. Main outcome measures The 15-item PRAISE tool comprising 10 general and five pulmonary rehabilitation-specific self-efficacy questions. Predictive validity was examined by exploring the relationship between baseline PRAISE score and objective change in physical activity following pulmonary rehabilitation using the SenseWear Armband. The MID was evaluated using anchor-based and distribution-based methods. Responsiveness was assessed with effect sizes. Results A higher baseline PRAISE score (indicating better self-efficacy) was an independent predictor of reduced sedentary time following pulmonary rehabilitation (P = 0.03). A one point increase in PRAISE was associated with a decrease in sedentary time of 4 minutes/day (95% confidence interval −7.8 to −0.4 minutes/day). Anchor-based estimates of the MID were 0.5 to 1.5 points; however sensitivity and specificity were modest (area under the curve Conclusions The PRAISE tool has predictive validity and may be useful to identify those with high self-efficacy who are more likely to achieve important health behaviour changes with pulmonary rehabilitation. The small effect size suggests that the PRAISE tool was not responsive to changes following pulmonary rehabilitation. Trial registration number NCT01423227, clinicaltrials.gov .

Background Patients with chronic obstructive pulmonary disease (COPD) who are not severely hypoxaemic at rest may experience significant breathlessness on exertion, and ambulatory oxygen is often prescribed in this circumstance despite a lack of conclusive evidence for benefit. This study aimed to determine whether such patients benefit from domiciliary ambulatory oxygen and, if so, which factors may be associated with benefit. Methods This was a 12 week, parallel, double-blinded, randomised, placebo-controlled trial of cylinder air versus cylinder oxygen, provided at 6 l/min intranasally, for use during any activity provoking breathlessness. Patients underwent baseline measurements of arterial blood gases and lung function. Outcome measures assessed dyspnoea, health-related quality of life, mood disturbance, functional status and cylinder utilisation. Data were analysed on an intention-to-treat basis, p≤0.05. Results 143 subjects (44 female), mean±SD age 71.8±9.8 years, forced expiratory volume in 1 s (FEV 1 )1.16±0.51 lites, Pao 2 9.5±1.1 kPa (71.4±8.5 mm Hg) were randomised, including 50 patients with exertional desaturation to ≤88%. No significant differences in any outcome were found between groups receiving air or oxygen. Statistically significant but clinically small improvements in dyspnoea and depression were observed in the whole study group over the 12 weeks of the study. Conclusion In breathless patients with COPD who do not have severe resting hypoxaemia, domiciliary ambulatory oxygen confers no benefits in terms of dyspnoea, quality of life or function. Exertional desaturation is not predictive of outcome. Intranasal gas (either air or oxygen) may provide a placebo benefit. Clinical trial number ACTRN12605000457640.

PURPOSE: Precise, inexpensive tools for measuring physical activity levels are important for developing strategies to improve symptoms and enhance quality of life in chronic obstructive pulmonary disease (COPD). Self-report questionnaires and diaries have been used in many populations with variable results. The pedometer is widely recognized as a valid and reliable objective measurement tool, but it has not been well tested in COPD. This study aimed to determine the relationship between free-living physical activity recorded in a daily diary and that measured by using a pedometer in patients with COPD. METHODS: Participants with COPD (n = 80) recorded physical activity over 7 days. Cumulative pedometer readings and diary records of 4 activity categories for each 0.5 hour were compared. RESULTS: Participants (n = 76) with complete data sets were included in the analysis. The diary was more reliably completed. Mean pedometer reading per week was 23,129 (SD = 17,083) "step" counts (range, 1,725-66,454). Mean diary-recorded standing and walking time per week was 98.9 (SD = 10.4) hours (range, 73-119.5). The relationship between these measures was moderate and statistically significant (r = 0.37, P = .001). CONCLUSIONS: A daily diary record appears to offer more promise than the pedometer as a tool for measuring free-living physical activity in patients with COPD. Further research is required to assess the value of the 2 methods as discriminative, evaluative, and predictive tools in COPD populations.

Guidelines on informed consent intend to protect patients and promote ethical research conduct. To give informed consent, individuals should understand the purpose, process, risks, benefits, and alternatives to research (or a proposed clinical intervention) and make a free, voluntary decision about whether to participate. Many participants have incomplete understanding of various features of clinical trials. Issues associated with the length, format, and language of documents for written informed consent are common. Here, we analyse the written consent form, particularly in the context of clinical research, and the discussions that take place between clinician or investigator and patient. We review strategies to improve consent forms, particularly the use of plain language. Recommendations are made on discussions between investigator and patient to improve participant comprehension and satisfaction with the informed-consent process.

This scientific letter considers the rationale for the target oxygen saturation measured by pulse oximetry (SpO

The purpose of the Thoracic Society of Australia and New Zealand guidelines is to provide simple, practical evidence-based recommendations for the acute use of oxygen in adults in clinical practice. The intended users are all health professionals responsible for the administration and/or monitoring of oxygen therapy in the management of acute medical patients in the community and hospital settings (excluding perioperative and intensive care patients), those responsible for the training of such health professionals, and both public and private health care organizations that deliver oxygen therapy.

Background Pulmonary rehabilitation is widely advocated for people with chronic obstructive pulmonary disease (COPD) to improve exercise capacity, symptoms and quality of life, however only a minority of individuals with COPD are able to participate. Travel and transport are frequently cited as barriers to uptake of centre-based programs. Other models of pulmonary rehabilitation, including home-based programs, have been proposed in order to improve access to this important treatment. Previous studies of home-based pulmonary rehabilitation in COPD have demonstrated improvement in exercise capacity and quality of life, but not all elements of the program were conducted in the home environment. It is uncertain whether a pulmonary rehabilitation program delivered in its entirety at home is cost effective and equally capable of producing benefits in exercise capacity, symptoms and quality of life as a hospital-based program. The aim of this study is to compare the costs and benefits of home-based and hospital-based pulmonary rehabilitation for people with COPD. Methods/Design This randomised, controlled, equivalence trial conducted at two centres will recruit 166 individuals with spirometrically confirmed COPD. Participants will be randomly allocated to hospital-based or home-based pulmonary rehabilitation. Hospital programs will follow the traditional outpatient model consisting of twice weekly supervised exercise training and education for eight weeks. Home-based programs will involve one home visit followed by seven weekly telephone calls, using a motivational interviewing approach to enhance exercise participation and facilitate self management. The primary outcome is change in 6-minute walk distance immediately following intervention. Measurements of exercise capacity, physical activity, symptoms and quality of life will be taken at baseline, immediately following the intervention and at 12 months, by a blinded assessor. Completion rates will be compared between programs. Direct healthcare costs and indirect (patient-related) costs will be measured to compare the cost-effectiveness of each program. Discussion This trial will identify whether home-based pulmonary rehabilitation can deliver equivalent benefits to centre-based pulmonary rehabilitation in a cost effective manner. The results of this study will contribute new knowledge regarding alternative models of pulmonary rehabilitation and will inform pulmonary rehabilitation guidelines for COPD. Trial registration ClinicalTrials.gov: NCT01423227.

A link between irritable bowel syndrome (IBS) and psychiatric illness is well recognized. The authors set out to establish whether a group with a risk of poor outcome IBS could be identified at presentation to a general hospital clinic in a prospective series of 70 subjects. Potential risk factors showed no correlation with IBS outcome at 6-9 months. There was a high rate of persistent mental illness. Clinicians offering specialist care for IBS should consult with psychiatric services to provide assessment irrespective of IBS outcome if major psychopathology is not to be neglected.

Background and objective: Hyperoxia has been shown to reduce resting ventilation, hyperinflation and dyspnoea in patients with severely hypoxaemic COPD. This study assessed the effects of hyperoxia on these resting measures in patients with COPD of varying disease severity and characterized those patients who responded. Methods: Measurements of dyspnoea (Borg score), oxyhaemoglobin saturation (SpO2), inspiratory capacity (IC), minute ventilation, tidal volume, breathing and cardiac frequency were performed at rest in 51 patients with COPD while they breathed air and 44% oxygen, in a randomized double-blinded fashion. Results: Hyperoxia induced significant reductions in cardiac frequency and dyspnoea and a significant increase in SpO2. No significant change was noted in IC for the group overall, and there was substantial inter-subject variation in this measurement. No significant changes were found in ventilation, and there was no correlation between change in dyspnoea and change in IC. In patients with moderate to severe airflow obstruction (FEV1