Total tobacco-attributable deaths including those due to chronic obstructive pulmonary disease (COPD), a leading cause of mortality and morbidity worldwide are projected to rise from 5.4 million in 2005 to 8.3 million in 2030.1–4 Prevalence and mortality rate are forecasted to increase due to the increasing number of smokers.2–6

Higher physical activity (PA) is associated with lower risk of mortality and cardiovascular events in individuals from low-, middle-, and high-income countries.7 Daily PA of patients with COPD is reduced in the early phases of disease as compared to healthy age-matched controls8 and worsen over time, with important clinical consequences.9 In these patients pulmonary rehabilitation improves symptoms, exercise capacity and health-related quality of life (HRQL),10,11 although the observed benefits do not consistently translate into enhanced PA levels.12 As a consequence guidelines for management of COPD suggest that pulmonary rehabilitation including exercise training should be provided to the vast majority of patients.1

In many countries, there are barriers to hospital based inpatient and outpatient supervised exercise training programs, such as a high number of patients, transportation, program costs, and geographical obstacles.13 A home program consisting of 3 weekly sessions for 8 weeks of aerobic leg cycling and strength exercises was a useful, equivalent alternative to outpatient rehabilitation for patients with COPD.14 Also tele-rehabilitation programs may be potentially useful to deliver and to maintain the benefits in difficult-to-reach areas.15,16

The daily steps and activity time were proven to be the most valid measurement of PA17,18 and their regular monitoring may benefit patients with COPD in achieving the effective daily PA.18 Pedometers have greatly advanced in recent years, providing daily step estimates,18 and smartphones with miniaturized accelerometre apps measuring PA are universal, widespread technologies which many patients with COPD may not use as they probably should.

We hypothesized that a home pedometer assisted program to incentivize PA might be an alternative to hospital based outpatient exercise training programs, especially in the context of regional asymmetries and difficult access to health facilities (as is the case of Indonesia with a 4.5% COPD prevalence,5 and a population of about 260 million – about 35 million living in Central Jawa, the others living on more than 17000 islands with limited access to health services19). The aim of this study was to evaluate the effect on exercise capacity, PA, dyspnea, and health status as well as costs of home pedometer assisted PA, as compared to a standard outpatient supervised exercise training program in patients with COPD.

Fig. 1 shows the Consolidated Standards of Reporting Tables (CONSORT) diagram of the study. Out of 40 patients recruited, 18 patients in each group completed the study. Two patients were excluded due to an exacerbation, one patient withdrew his consent, and one patient dropped out due to a motorcycle crash.

Figure 1.

CONSORT flow diagram.

(0.19MB).

Table 1 shows the demographic, anthropometric, physiological and clinical characteristics of the patients. The two groups were not different for any characteristic except for the older age in Group 1 patients.

A home pedometer assisted program to incentivize PA was cheaper than and as effective as a standard outpatient supervised exercise training program.

The baseline daily step count and 6MWT of our patients were lower than in other studies. In the study by Vorrink et al.,32 the mean daily step count and 6MWT in their intervention group were 5824 steps and 465m as compared to 2513 steps and 193m respectively, in our study. However the airway obstruction of our patients was more severe as shown by a mean FEV1 of 1.1 in our patients as compared to 1.7l in that study.32

Our results showed significant improvements in 6MWT and daily steps in both groups. However the mean improvement in 6MWT of Group 2 was slightly greater, albeit nonsignificantly, than in Group 1, whereas the change in daily steps was similar in both groups. This difference indicates the need to specifically assess both exercise capacity and PA, when evaluating the effects of pulmonary rehabilitation. Our results are similar to those of Mendoza et al.33: in that randomized study patients with COPD underwent either a standard program of PA encouragement alone, or a pedometer-based program. Their pedometer group gained significant improvements in PA (by 3080 daily steps) and CAT score (−3.5), similar to our results, and in 6MWT (by 12.4m), less than in our patients.33 An earlier study in Indonesian COPD patients31 showed after a 5-week program a mean 44m increase in 6MWT, a result similar to that observed in Group 1 of our study. The post-program improvement in exercise tolerance and in PA observed in our study translated into an improvement in health status as assessed by the CAT score and dyspnea as assessed by MRC in both groups. Previous studies found that MRC, due to its limited number of levels, was not sensitive enough to detect small changes after programs.34

In our study the perceived health status was assessed by the CAT score. A specific HRQL questionnaire such as the Saint George Respiratory Questionnaire (SGRQ) was not available at our Institution. Although CAT is correlated to SGRQ in terms of discriminating health status, there is evidence that the SGRQ shows a greater responsiveness in patients with COPD undergoing pulmonary rehabilitation.35

The main findings of our study suggest that independently of the setting, whether home pedometer assisted or standard outpatient program, our COPD patients gained similar mean improvements in assessed outcome measures, except the BODE index. However, from a clinical point of view, it is important to note that the proportion of patients reaching the MCID in all outcome measures was greater than 60% only in Group 2. Other studies have reported conflicting results. A 6-week online-supported pulmonary rehabilitation program was non-inferior to a conventional program in terms of effects on 6MWT, and symptom scores; furthermore it was safe and well tolerated.36 A home maintenance pulmonary rehabilitation program was equally as effective as an outpatient hospital, maintenance program in reducing the risk for acute COPD exacerbations and hospitalizations.16 Physical activity could be significantly increased in patients with COPD using a 12-week intervention including a step counter and a smartphone app.37 A home pulmonary rehabilitation program, delivered with minimal resources, produced short-term clinical outcomes similar to a center-based program.38

A recent simulation study39 has reported that pulmonary rehabilitation was cost-effective in every setting in the comprehensive management of patients with COPD. In the programs of our study as a whole the cost per patient of Group 1 was about half than that of Group 2. In the frame of Indonesian economy the mean 76.3 euros saving per patient obtained in Group 1, is not negligible. The cost analysis in our study involved direct costs and transportation as the only indirect cost. We were unable to calculate other indirect costs, such as time spent by relatives to transport patients to and from the hospital, or costs of exacerbations, hospital admissions or unscheduled visits. Previous studies reported a reduction in health service usage in rehabilitated outpatients. Griffiths et al.,40 reported that outpatient pulmonary rehabilitation produced cost per quality adjusted life years (QALYs) ratios within bounds considered to be cost effective. In a retrospective case-control study,41 a short-term, inpatient pulmonary rehabilitation program induced a short-term improvement in exercise tolerance, similar to a longer, outpatient program. The duration of program and the need for daily transportation significantly influenced the total costs of the outpatient pulmonary rehabilitation.41 In a RCT including an economic evaluation, outpatient pulmonary rehabilitation appeared highly cost-effective in comparison with a program incorporating a substantial period of inpatient care.30,42 Comparisons of cost-effectiveness between programs performed in different countries, institutions and health-care systems are difficult because of differences in case-mix, outcome measures, and the time-points when outcomes are measured. Therefore, the application of our results to other health-care systems must be considered with caution.

Our study has some limitations. We have compared home pedometer assisted PA with outpatient supervised exercise training. Stimulated PA and supervised exercise training are only two of the components of pulmonary rehabilitation which, according to the ATS/ERS statement,10 should also include other multidisciplinary interventions such as education, and behavior change. Whether a more comprehensive intervention also including other components as defined by that statement10 would have obtained different results, remain to be evaluated. We have also compared two groups performing a different number of exercise sessions. On the other hand our results may indicate also the effectiveness of our supervised hospital based outpatient program achieving the same benefits as an unsupervised program despite less exercise sessions. The use of pedometers by the home program might have introduced some bias to the study, as standard hospital based programs do not routinely offer this device. Patients and researchers were not blind to allocation. However, this bias probably would have favored results of Group 1 which in fact did not show any superiority over Group 2.

In conclusion with these limitations this preliminary RCT showed that, at least in our health-care system and for our patients with COPD, a home pedometer assisted program to incentivize PA may be a useful and cheaper alternative to outpatient supervised exercise training programs.

The authors have no conflicts of interest to declare.