Background
Chronic respiratory diseases, including chronic obstructive pulmonary disease (COPD), interstitial lung diseases (ILD), bronchiectasis and chronic asthma, contribute 7% to the global burden of disease [
1]. Chronic respiratory diseases are the third leading cause of death worldwide, and account for 10% of all disability adjusted life years lost due to disability alone [
2]. This level of disability is second only to that of cardiovascular disease, including stroke [
2]. People with chronic respiratory disease experience repeated need for hospitalisation, reduced quality of life and life expectancy, poor exercise tolerance and physical functioning, and increased incidence of anxiety and depression [
3]
.
Pulmonary rehabilitation is a proven, effective strategy to achieve clinically important gains in exercise and functional capacity, symptoms and quality of life [
4] across a variety of chronic respiratory diseases, including COPD [
5], bronchiectasis [
6], ILD [
7] and asthma [
8]. Participation in pulmonary rehabilitation also reduces hospitalisation due to acute exacerbations of respiratory disease [
9] as well as overall healthcare utilisation [
10]. Pulmonary rehabilitation is a recommended treatment strategy for individuals with a chronic respiratory disease in clinical guidelines across the world [
4].
Despite compelling evidence for the benefit of pulmonary rehabilitation, only a very small percentage of eligible people ever attend a program [
11]. There are well established barriers to uptake and participation in traditional centre-based pulmonary rehabilitation programs, both in the hospital and in the community, relating to referral practices, travel, transport, disability and lack of program staffing [
12,
13]. Such barriers disproportionately compromise access to programs for patients in rural and regional locations [
14]. In light of such obstacles, alternative modes of delivering pulmonary rehabilitation, in addition to traditional centre-based programs, are required to improve both equity of access and patient-related outcomes for people with chronic respiratory diseases and have been identified as a research priority [
15].
Home-based models of pulmonary rehabilitation have been proposed to increase the availability and accessibility of pulmonary rehabilitation services to patients [
16‐
20]. Recent work has demonstrated that home-based pulmonary rehabilitation achieves equivalent clinical outcomes to centre-based pulmonary rehabilitation [
20]. However, a disadvantage of such programs is the lack of supervised exercise training. Advances in Internet technology and accessibility have made it possible for people to receive specialist medical care and therapeutic interventions straight to their home. Telerehabilitation is the use of information and communication technologies to provide clinical rehabilitation services from a distance [
21]. Using the Internet, rehabilitation can be delivered directly to the patient’s location, regardless of physical proximity to a rehabilitation centre. Whilst telerehabilitation technology has existed for many years, the clinical efficacy of this model is not clear.
Preliminary studies have described the use of telerehabilitation in COPD, using a variety of program models. These studies suggest that telerehabilitation in COPD is safe, with no adverse events reported [
22‐
28]. However, most existing trials have a number of important limitations, including: the requirement for participants to attend a health facility in order to access the telerehabilition service [
22]; the use of bespoke, proprietary or poorly defined equipment to deliver telerehabilitation and monitor vital signs [
23‐
25,
27]; failing to include supervised exercise training in the telerehabilitation model [
23,
24,
27], and limiting the scope of application to individuals with COPD. These factors limit the clinical utility of previous telerehabilitation programs through restricted access [
12], and omission of an essential component of pulmonary rehabilitation [
4]. We have previously demonstrated the feasibility of a telerehabilitation model that delivers all the essential components of pulmonary rehabilitation into the home of people with COPD [
28]. By using readily available equipment such as an exercise bike and a tablet computer it is possible for people to undertake a supervised exercise training program in their own home. However, to date, a comparison of the outcomes and costs of telerehabilitation to centre-based pulmonary rehabilitation has only been undertaken in the maintenance period post-rehabilitation [
29]. A telerehabilitation model that allows all the essential components of pulmonary rehabilitation, specifically supervised exercise training and self-management education, to be delivered at home, using readily available equipment, with proven clinical outcomes and comparable costs, has the potential to dramatically change the uptake and accessibility of pulmonary rehabilitation for all patients with a chronic respiratory disease.
Analysing the cost of telerehabilitation is critical to determine the economic viability of implementing such a model into clinical practice. To date, there is a lack of evidence to support the cost-effectiveness of telerehabilitation, despite apparent clinical benefits in a range of health conditions [
21]. A comprehensive assessment of the economic value of telerehabilitation needs to include both costs to the healthcare system, including the initial costs of equipment and its transport [
30], together with costs to the patient [
31]. Telerehabilitation has the potential to overcome many known barriers to pulmonary rehabilitation participation and, if cost-effective, could be a relevant treatment alternative across all chronic respiratory diseases where rehabilitation is an accepted therapeutic intervention.
This paper describes the protocol for the Rehabilitation Exercise At Home (REAcH) trial – a study of telerehabilitation in chronic respiratory disease. The aims of the study are to compare the: 1) clinical outcomes of telerehabilitation and traditional centre-based pulmonary rehabilitation for people with a chronic respiratory disease; 2) costs of telerehabilitation and centre-based pulmonary rehabilitation. We hypothesise that the clinical effects on symptoms, exercise capacity, and health-related quality of life (HRQoL) will be equivalent between pulmonary rehabilitation models; that the proportion of participants who complete pulmonary rehabilitation will be greater in the telerehabilitation group; and, that telerehabilitation, delivered using our low-cost model, will provide a cost-effective alternative to centre-based pulmonary rehabilitation (from a societal perspective) for people with chronic respiratory disease.
Discussion
Pulmonary rehabilitation is a key recommended component of the non-pharmacological management of individuals with chronic respiratory disease [
4], yet limited access to programs prevents the widespread application of its benefits. This study will compare both the clinical- and cost-effectiveness of delivering pulmonary rehabilitation via telerehabilitation, using readily available consumer devices and equipment, to a traditional centre-based program.
The telerehabilitation model under investigation directly addresses access barriers for both individual patients and the health system. By delivering pulmonary rehabilitation directly into the homes of people with chronic respiratory disease issues of transport, travel, their associated costs and weather could be negated [
13,
62]. By improving ease of access, more individuals may have the opportunity to develop an informed and positive perception of the benefits of pulmonary rehabilitation. Reduced healthcare utilisation has also been reported following completion of pulmonary rehabilitation [
63], and thus implementation of telerehabilitation programs has the potential to positively impact on healthcare expenditure.
Unlike previous studies [
23‐
25,
27] the telerehabilitation model under investigation uses equipment that is familiar to clinicians and patients, requires little technical support, is scalable, and has the potential to be easily implemented into clinical practice. Telerehabilitation can be delivered any time and from any place, further extending access to patients who live away from metropolitan centres. By providing supervised exercise training in this way, pulmonary rehabilitation could be accessed in locations where specialist services would ordinarily be unavailable [
64]. The remote supervision of exercise training in this telerehabilitation model is a key feature frequently unavailable in models of pulmonary rehabilitation not based in a healthcare setting. In a recent study of home-based pulmonary rehabilitation, 80% of individuals who did not wish to take part in the study declined because they wanted to attend the supervised pulmonary rehabilitation group [
20]. By providing supervised exercise remotely, individuals who would otherwise be reluctant to exercise without the support of a healthcare professional may be more inclined to participate.
The purpose of this study conforms with policy statements to encourage the investigation of alternative models of pulmonary rehabilitation delivery in order to enhance implementation, access and delivery of pulmonary rehabilitation [
15]. If this study demonstrates that telerehabilitation has equivalent clinical outcomes to centre-based pulmonary rehabilitation, and is cost-effective, this model has the potential to significantly increase service availability and accessibility through increased options for pulmonary rehabilitation delivery.
Trial status
Recruitment commenced in August 2016 and is continuing.