adherenceinthepatient with pulmonarydisease -...

SF_CTIONIV SPECIAL CONSIDERATIONS INPULMONARY R_HABILITATION

.... AdherenceinthePatientWith Pulmonary Disease

_ ._: Robert M. KaplanAndrew L. Ries

Professional Skills

Upon completion of this chapter; the reader will:

* P,ecognize the extent of nonadherence anaong patients with chronicobstructive puhnonar 3' disease (COPD)

• Be able to differentiate diff':rent adherence behaviors

* Summarize unique medicine adherence problems for patients withCOPD

• Define overadhcrence and rational nonadherence

• Describe steps to improve adherence with exercise tbr patients withCOPD

• Discuss behavioral interventions to improve adherence

• l',ecognize p,'oblcms of relapse among smokers

• IdentitY, interact resources to help patients stop smoking

Nearly all medical encounters end with advice and recommendations. Patients are advisedto fill a prescription, take a medication, stay on a prescribed diet, or give up cigarettes.Often medical advice is given by managed care organizations or nonprofit agencies suchas the American Lung Association. For example, the American Lung Association recom-mends that people with chronic bronchitis receive a vaccination against influenza andpneumococcal pneumonia. Nonadherence is the failure to follow such advice.

THEEXTENTOFTHEPROBLEM

Much literature suggests that failure to comply with medical advice is a major problemthat results in adverse consequences for consumers of health care. _-3Published figuressuggest that nonadherence rates vary between 15 and 93%, depending on the patientpopulation and the definition of adherence. Most studies suggest that at least a third ofpatients fail to adhere to treatment recommendations. 2 Nonadherence rates tend to bemuch higher among patients with chronic conditions. 4

347

348 Pulmonary Rehabilitation

PHYSICIANAWARENESSOFTHEPROBLEM

Although evidence consistently demonstrates that patient nonadherence is common, manyphysicians do not seem to appreciate the problem. DiMatteo and DiNicola s revieweda varletT of studies on practitioner awareness. They found that physicians most oftenoverestimated the extent to which their patients cooperated _th recommendations. Caronand Roth 6 found that 22 of 27 medical residents overestimated the degree to which theirpatients complied with a prescribed liquid antacid prescription. The same investigatorsfound that correlations between estimates made by senior faculty physicians and actualpatient adherence were near zero. Several studies (i.e., Norell 7) have suggested that physi-cians typically are inaccurate in their estimates of patient adherence and that they generalh.overestimate correspondence bem'een their orders and patient behavior. These problem'sraise serious doubts about the validity of physicians' predictions of future patient adherence.

ADHERENCEIN COPD

Despite major advances in diagnosis and medical therapeutics, man.v patients do not receiveoptimal benefit from standard medical care. Although some aspects of COPD are treatable,the medical regimen is extremely complex. Medical management of COPD requiresmultiple medications. However, treatment may also include respirator3.' chest physiotherapytechniques, exercise, and advice to quit smoking. Most patients are confronted withcomplex combinations of antibiotics, bronchodilators, anti-inflammatory drugs, and, insome cases, supplemental oxygen, tn the fbllowing sections, we consider adherence withdifferent components of the regimen for patients with COPD.

ADHERENCEWITHPHARMACOLOGICINTERVENTIONS

Using MEDLINE searches, we identified all papers on adherence with the COPD regimenback to 1980. In addition, we examined literature rcvicws published betbre 19802 `8Recentstudies are summarized in Table 19-1. Overall, the search rcvcalcd t_w studies that havedirecth' addressed adherence, especially regarding traditional medical rcgimcns, The studiesconsidered different treatments in diverse samples and uscd various definitions of andmeasurenaents tbr adherence. Untbrtunatcly, t_:w conclusions, if any, can be drawn fromthe current literature.

Published studies have considered adherence with regard to a vatieta, of differentregimens. Adherence with oxygen therapy in Scotland was reported by Morrison et al.9Among patients with COPD prescribed 24-hour oxygen, only 14% were in full adherence.The average use was 14.9 hours per day, and 44% used their oxygen less than 15 hoursper day. These patients also had poor adherence with other aspects of the regimen.Although all patients were requested to have acutc arterial blood gas measurements within12 months, onh' about half obtained the tests. In another study from the United Kingdom,it was shown that patients who are prescribed oxygen tbr less than 24 hours, in this case15 hours per day, obtained high levels of adherence with the prescription) °

Long-term adherence with inhaled medications was evaluated in the Lung HealthStudyJ _This was one of the first trials to evaluate inhaled bronchodilator medication usedregularly over time. The Lung Health Study was a large clinical trial (N = 3923) ofsmoking intervention and bronchodilator therapy for the early stages of COPD. Early inthe trial, self-report data suggested that nearly 70% of the patients adhered to the regimen.This rate dropped only slightly during the next 18 months. In addition to self reports,the investigators weighed the canisters containing the medications. Self-reports confirmed

Adherence in the Patient With Pulm(marv Disease 349

Table 19-1. Summary of Selected Recent Studies on Adherence

Citation Regimen Sample Measure Definition Adherence

Costello et Low-flow 99 hospital- DeliveR" of Number of 49% dislodged theal., 1995 s3 oxs'gen ized patients oxygen nasal can- oxwgen deliver)" de-

nulae dis- vice during theplaced dur- nig.ht; dislodginging night was more common

for Venturi facemasks than for nasalcannulae

Morrison et Long-term 519 COPD Hours of Use of o.,q,- 56% met definitioqal., 19950 oxTgen patients therapy per gen > 15 of adhere,ice; study

therapy (Scotland); day h/d had a high mortalityapproximately rateequal num-bers of malesand females;mean age, 85years

Nides et al., Metered 231 partici- Nebulizer Matching of Adherence was vari-1993 Is dose inhaler pants in the chronolog dose to pre- able; typically, ad-

Ltmg HeaLth that re- scription herence was highestStud), cords the before a follow-up

dateand visitand declinedtimeof afterthevisiteach medi-cation dose

Wise et al., Aerosolizcd 3923 male Self-reports Reduced 81% by self-report1998 X4 inhalers (el- and female and canister weight of and 66% by canister

ther pla- participants weights aerosol weightceboor in theLung canisteractive) Health Study

Rand et al., Metered 3923 male Self-reports Reduced M:tcr 2 y, self-re-1995 _ dose inhaler and female and canister weight of ported adherence

participants weights aerosol was 70%, with 48%in the Lung canister confirmedby canis-Health Stud.,,' tcr weight

Solomon et l'harmacist 98 ('OPD pa- Self-report Not defined No differences in ad-al., 1998t_ delivered ticnts ran- and service herenec;trend to-

care domh' as- use ward higher hospitalsignedto care useincontrolsbv clinicalpharmacy res-idents or tousual care

Kampcl- Long-tc?m 528 onoxy- Obscrva- Match to Only one-third ofreacheret oxygen gen therapy tions by protocol patients were ade-al., 1998 s_ therapy visited at medical stu- quatcly informed

home (in the dents and about treannent;Netherlands) self-reports most patients were

noncompliant

Corden and Home neb- 82 COPD pa- Self report Taking Adherence was poorRees, ulized tients using and St. <70% of in 56% of cases;199817 flaerapy nebulizers Georges prescribed poor adherence cor-

Respiratory dose related _gth lowQuestion- qualityof lift:nairc

(]()Pl), dmmic li[_Stl'tlclivcptlhllollal') disca_c.


b)' canister weights showed that 48% of the patients had good adherence at one year.Some nonadherence involved overuse of medication. Further analysis demonstrated thatthose who overuse medication are also likely to incorrectly report their true smoking status.

Personalita' measures tend not to be good predictors of adherence. A scale designedto assess medication adherence in COPD has been developed and reported by Powell, z'but it is not clear that it will be of great clinical value because it does not predict adherencewell. A varlet0.' of studies have investigated demographic characteristics associated withCOPD self-care behaviors. For example, the Lung Health Study 1_suggested that adherencewas associated with being married, older, and white and with having more severe disease.More adhercnt patients also had less shortness of breath and were hospitalized or confinedto bed less often. 1_Studies of adherence with nebulizer therapy from the IntermittentPositive-Pressure Breathing Stud), showed that about half of the patients were adherentand half were nonadherent. Predictors of adherence included white race, married, absti-nence t?om alcohol and cigarette use, and more severe shortness of breath. Furthermore,patients with more severe disease were also more likel.v to adhere to the therap.v. _3Fewtrials have evaluated interventions to improve adherence. Solomon et al. _4failed to demon-strate that instructions by clinical pharmacy residents significantly improved adherenceover usual care.

Some variables thought to predict adherence often fail to do so. For example, it iscommonly assumed that heavy drinkers will be less likely to follow the regimen than thosewho drink less. In the Lung Health Study, l_ alcohol consumption was used as a predictorof the ability to quit smoking. The results revealed that heax3' alcohol use (>25 drinks/wk) was not a significant predictor of relapse in smoking cessation. However, bingedrinking, defined as eight or more drinks per occasion once a month or more, wasassociated with greater relapse. 1_

Estimated or measured adherence values do not seem to converge on a specific rateor even a specific pattern. James et al. _"reported that only half of their patients took theirmedicine regularly. Corden and colleagues tr also fbund that about half of their patients(56%) failed to comply with home nebulizcr thcrapy. The Intermittent Positivc-PressureBreathing clinical trial, which used objective asscssments of actual time on intermittentpositive-pressure breathing therapy, found only half of the patients using the nebulizcrat least 25 minutcs per day. Intezwcntions bv clinical pharmacists seem to have relativelysmall cffccts on adherence. _4Adhcrcncc seems to be relatcd to health-related qualit T oflife. Patients with higher scores on the St. Gcorgc's Respirator)' Questionnaire have beenshown to be more likely to comply with nebulizer therapy, lr

Electronic medication monitors may be valuable methods for improving adherenceamong patients with COPD. One study evaluated 251 COPD patients participating in amultisite clinical t,'ial of nebulizer therapy with inhalers. Patients were divided into intem'en-tion and control groups. Using an electronic medication monitor known as the nebulizerchronolog, the intcr_'ention group received feedback on the accuracy of their medicationuse. Patients receiving f_:cdback were significantly more likely to adhere to the regimenand to use medications correctly than were those in thc control group. _s

The traditional view of adherencc/nonadhcrcncc, in which the patient either strictlytbllows or fhils to follow a treatment recommendation, may no longer be the optimaldirection of adherence research. The degree of adherence required for the desired outcome,bc it adhcrencc to a prescribed regimen or maximizing qualit T or life, varies from treatmcntto treatment and should be considered. To date, fcw studies have systematically evaluatedadherence with regard to the COPD regimen, and in these fcw cases, the focus has beenon drug and oxygen therapy. Furthcrmorc, o,alv a t_:xx"studies evaluating interventions toimprove COPD patients' ability to manage tiaeir disease have been reported. Severalcommentaries have ofl;zrcd strategies tbr enhancing adherence; however, none have beensystcmatically studied. Some individuals with asthma mistakenly stop using steroid inhalers,but continue bronchodilator inhalers, becausc thev do not notice any acute effect fromthe steroid inhaler.

Adherence in the Patient With Pulmonary Disease 351

Overadherence

Most of the literature on adherence behaviors focuses on the extent to which patientsunderuse medications. A less common, but perhaps equally important, problem invoh'esthe overuse of medication. Overadherence is a more common problem when medicationsprovide prompt synaptomatic relief. In the study by Chryssidis et al., 19for example, theuse of high doses of aerosol therapy often exceeded prescription rates. The mean percentageof prescribed dose actualh' used was 98.5% at 1 month follow-up and 110.8% at 2-monthfollow-up. Because each of these estimates were variable, it seems that some portion ofthe patients took considerably more medication than was prescribed, l" It is not surprisingthat patients with COPD, a highly symptomatic disorder, would overuse a medicationthat provides rapid symptomatic relief.

Some of the evidence for patient overadherence comes from innovative studies on theassessment of adherence. For example, in one clinical trial on antihypertensive medications,patients were asked to bring their medications with them for follow-up visits. Adherencerates were remarkably high--sometimes approaching 100%. However, considerable vari-ability existed among subjects, with those at higher adherence levels obtaining betterclinical results. Using innovative methods that attach microprocessors to pill blister packsor to the caps of standard pill bottles, 2°'2_it was possible to estimate not only how manyof the pills were removed from the packages but also specifically when the)' were removed.Studies using these methods suggest that patients often have lapses in adherence in periodsbet_veen visits or that medicine taking is erratic. Also, they may overuse medication orengage in " pill dumping" just before a clinic visit. These findings imply that medicationsmay not be used as prescribed. Often, patients overuse medications before a clinic visit.Erratic medication use may substantially bias estimates of dose-response in clinical trialsand provides an inaccurate measure of treatment side effects. 22.2a

Rational Nonadherence

Several compcting theories exist about why patients fail to comply with medical regimens.Explanations for why patients fail to adhere might be divided into three categories: thosethat fbcus on the patient, those that fbcus on the patient's environment, and those thatfocus on the interaction between the patient and the provider. Patient-oriented explana-tions suggest that certain personalities fail to adhere to medical treatments or that patientsintentionally reject therapy because of some flaw in their personality. 24These explanationshave Failed to gain empiric support. Some evidence suggests that patients misunderstandinstructions, 2_-'' but rclativch" little evidence suggests that patients intentionalh' try toharm themseh'cs by ignoring advice.

Environmcntal explanations suggest that elements in the patient's em'ironnaent, suchas famih' influences, remi,lders, or other environmental stimuli, influence adherence behav-ior.-" Evidence tbr this view of adherence is suggested by studies demonstrating thatreminders and simple environmental cues increase adhere1{ce. 28These simple remindersmight be notes attached to a refrigerator or electronic devices that beep when a dose ofmedication is indicated.

The third view of adherence emphasizes the role of the patient-provider relationship.Although the evidence cannot be reviewed in detail here, a substantial literature demon-strates that intbrmation exchanged between patients and providers is often poor. -'v.3°Thisview of adherence suggests that the remedy to the problem is to improve communicationbetween patients and their heahh care providers.

In considering the three views of noncompliant behavior, we find little evidencethat patient personality variables explain much of the variability in nonadherence, ai Theenvironmental view is valuable in identifying simple manipulations that may enhanceadherence behavior in some settings. However, the environmental view is not a comprehen-sive explanation that considers the patient's role in the choice to use or not use medications.


The patient-provider interaction view comes closest to dealing with the realities of theproblem. Substantial evidence suggests that patients often do not comprehend instructionsoffered to them by their providers, s Com'ersely, providers often have an inadequate pictureof the responses their patients have to treatment recommendations. In the followingsections we explore this issue in more detail.

Liang 32offered reasons why his chronically ill patients failed to take their medications.Common explanations were "I forgot," "too expensive," "felt dopey, .... felt constipated,"and "didn't work." Patients often have poor responses to medications, find that themedications are not providing the expected benefit, or cannot aflbrd to purchase themedications. These patients are taking several factors into consideration in their decisionto use or not use a product. Although the provider may condemn the patient as irrational,the patient may be ma'king what he or she considers to be an informed choice. Kaplanand Simon 3x suggested that patients are more likely to comply with treatment whenthey perceive a net health benefit. Nonadherence occurs when the perceived negativeconsequences outweigh expected benefits. In this decision process, patients may discountfuture benefits because of current side effects. A corollary of the theory is that treatmentsthat produce a short-term benefit may evoke better adherence than those that produce adelayed benefit, For example, treatments that provide immediate symptomatic relief, suchas inhalers, may be associated with higher adherence than those such as antihypertensivetherapies that exchange current inconvenience for furore benefit.

One major reason for nonadherence is that patients experience treatment side effects,and, therefore, increased medicine use results in increased discomfort. "_'_In one study, 36%of patients in a large tertian, care hospital had some iatrogenic disease. 3_''_sOlder individualsmay experience a sevenfold increase in adverse reactions compared with those aged 20 to29 years, seEvidence fi'om the United Kingdom indicates that as many as 10% of admissionsin geriatric units result from adverse reactions attributable to drug interactions. "_7Observednonadherence might reflect patient feedback about bad experiences with the regimen.Although patients may bc less direct about their decision not to adhere, obse_xations ofnonadherence may be a stimulus for discussion of treatment side et]_cts.

Several authors have argued that nonadherence can be rational._ Patients may adhereto a regimen but fail to obtain the desired benefit. If the probability of an expected benefitis low and undesirable side effects are experienced, nonadhcrence may enhance healthoutcome. For example, a patient with streptococcal pharyngitis who discontinues takingan antibiotic on the eighth day of a 10-day course might be regarded as a noncomplier.However, if the patient decides that the inconvenience and side effects associated withthe medication arc a greater concern than the low probability of developing rheumatic f_:ver,the decision may be regarded as rational. Nonadhe,'encc might also be regarded as rationalwhen the patient achieves the desired result despite nonadherence. Indeed, studies in manyareas do not show a systematic relationship between adherence and health outcome. TMManystudies in the adherence literature f_filto take health outcomes into consideration.

PracticalSuggestionson MedicationAdherence

Several practical suggestions emerge fi'om the review of"research on adherence to medicalregimens. These suggestions parallel discussions on the locus of the problem. First, alter-ations in the patient's environment may increase adherence behavior. Simple techniques,such as using mailed reminders, placing reminder magnets on refrigerators, or telephonecall reminders, have been successRfl in several studies. Some new products provide auditoq,cues as reminders. Patients might also purchase digital watches that beep according totheir medical regimen schedule.

Behavioral contracts have also been used with some success. These contracts specie'precise regimens and often require the patient to make some desired event or activitycontingent on medicine use. For example, the contract might make some highly probablebehavior, such as watching television, contingent on medicine use.

Adherence in the Patient With Pulmonan" Disease 353

A second approach to increasing medicine-taking adherence requires enhanced physi-cian-patient communication. A major focus of pulmonary rehabilitation programs is edu-cating patients and family members about their disease and treatments and enhancingtheir abilit 3, to communicate _4th their physicians. Several studies have shown that patientsoften have misconceptions about their illness and about the expected effi:cts of medica-tions, as Furthermore, patients often experience side effects of medication. Rarely is thisinformation fully communicated to the provider. Physicians should ask about all reactionsto medication, barriers to taking medication in the patient's environment, and shouldclarify the patient's view of why the medications may or may not be effective.

Finally, evidence suggests that inter,,entions designed to increase the patient's involve-ment might increase adherence and ultimately affect patient outcome. In one experiment,patients were coached on which questions to ask their provider before their encounter.in comparison with a group that received traditional patient education, those in thecoached group had actually achieved better health outcomes. Analysis of audiotapes ofthese physician-patient interactions demonstrated that those in the experimental groupwere tavice as effective as those in the control group in obtaining appropriate informationfrom their physician. "_v,4°The patient counseling sessions involved the use of a disease-specific algorithm and a set of diagnostic and therapeutic guidelines presented in thebranching logic format. The purpose of the session was to identi_, important componentsof medical decisions and to increase patient involvement at each decision point. Otheralgorithms have now been developed for several chronic disease conditions.

ADHERENCEWITHEXERCISE

An important component of most pulmonaq, rehabilitation programs has been the estab-lishment of a regular exercise regimen. Specific physical conditioning exercises, such aswalking, can be undertaken by the patient to help maintain lung function and improvethe remainder of the oxygen deliveq, system. 41In several published studies, the improve-ments in patients with COPD after rehabilitation training have been striking. 42Specifically,appropriate physical conditioning exercises can improve maximum oxygen consumptionand endurance, reduce heart rate, improve ventilator efficiency, and increase tolerancefor exercise.

Few studies have evaluated factors associated with long-term exercise maintenanceamong COPD patients. However, a rich literature in cardiac rehabilitation ma.v provideuseful suggestions. One literature review analyzed 24 studies that had reported 12 ormore months of follow-up. 4"_Long-term maintenance of exercise was associated withsupe/a'ision of the exercise, availability of equipment, more frequent contact with programstaff; the inclusion of a behavioral component, maintaining moderate as opposed to high-intensity activit3', and specific interventions to maintain the behavior. Some success hasbeen shown fbr difficult-to-reach paticnts. For example, Friedman and colleagues 44offereda rehabilitation program to the medically indigent. By individualizing instructions andproviding guidance tbr spccific conamunit3., activities such as mall walking, stair climbing,and use of neighborhood Facilities, they were able to obtain a self-reported adherence rateof 90%.

Exercise as a Component of Rehabilitation

A few controlled trials documented the benefits of exercise programs for patients withCOPD. 42 Cockcro_ et al. 4s randomly assigned 39 patients to a 6-week exercise programor to a no trcatment control group. Compared with the control group, patients in theexercise group experienced subjective benefits and increased the amount of distance theycould walk in 12 minutes. However, follow-up was only 2 months. McGavin and cowork-

354 Pulmona_" Rehabilitation

ers 46 randomly allocated 24 COPD patients to a 3-month unsupervised stair climbinghome exercise program or to a nonexercise control group. The 12 patients in the exercisegroup noted subjective improvements and an increased sense of well-being and decreasedbreathlessness. They also reported an objective increase in the 12-minute walk distanceand maximal level of exercise on a cycle ergometer. These changes did not occur in thecontrol group. However, follow-up was limited to 3 months. Ambrosino and coworkers 4=randomly assigned 23 patients to a 1-month medical and rehabilitative therapy group and28 patients to medical therapy alone without exercise training. The experimental groupimproved in exercise tolerance and respirator).' pattern, as evidenced by a decrease inrespiratoq' rate and an increase in tidal volume. Again, these changes were not presentin the control group.

One argument for the importance of exercise is that programs that do not have anexercise component are less effective. Sassi Dambron et ala s conducted a randomizedclinical trial to evaluate a modified pulmonaq, rehabilitation program focused on copingstrategies for shortness of breath, but without exercise training. Eighty-nine patients withCOPD were randomly assigned to the 6-week treatment or to a 6-week general healtheducation control group.

The treatment consisted of instruction and practice in techniques of progressive musclerelaxation, breathing retraining, pacing, self-talk, and panic control. Outcomes includedthe 6-minute walk test, quality of well-being, depression and anxiety scales, and six com-monly used dyspnca shortness of breath measures. No significant differences occurrcdbetween the treatment and control groups at the end of treatment or at 6-month tbllow-up. The authors concluded that although dyspnea management strategies are an importantcomponent of COPD management, the)' should be taught in combination with otheraspects of comprehensive pulmonaD, rehabilitation, namely, structured exercise training.

Another trial randomly assigned patients to one of three conditions: (a) waitinglist control; (b) education and stress management; or (c) exercise, education, and stressmanagement. Compared with the other t-wo groups, those whose program includedcxercise experienced reduced anxiety and improvements in endurance and cognitive func-tioning. 49

BehavioralInterventions

Behavioral interventions may bc helpti, I in achieving long-ternl changes in exercise behav-ior. Kaptcin s° reviewed randomized behavioral intervention studies involving paticnts withCOPD. He fbund 15 published studies, of which 13 suggested some benefit of inteta'en-tion. The outcome measurcs used in thcse studies vary considerabh'. Common outcome

measures assess qualit3." of life, knowledge, exercise duration, and mood.Atkins et al. sxreported the results of an experimental trial designed to evaluate behav-

ioral and cognitive-behavioral programs for increasing exercise among patients withCOPD. The patients underwent exercisc testing on a treadmill and wcrc given an exerciseprcscription. Then they were randomh' assigned to one of five cxperimcntal or controlgroups. The experimental groups wcrc designed to incrcasc participation in regular cxcr-cise. They included behavior modification, cognitive-behavior modification, and a cogni-tive modification condition.

The behavior modification treatment included goal setting, functional analysis ofreinforcers mediating walking, a behavioral contract, contingency management, and twosessions of relaxation training. In the cognitive treatment, subjects experienced didacticinteractions in which they learned to identity' negative sclf-statements and to replace themwith positive thoughts, to identilS." specific cues for promoting positive sclf-talk, and othersimilar strategies. The experimenter attempted to challenge irrational beliefs about walkingwhenever possible. The cognitive-behavioral group cxpcrienced many of the same positiveself-talk exercises. However, thcv also received training in contingency management andtwo relaxation sessions. The attention control group received attention but did not have


training specifically directed toward increasing adherence. During six sessions, they com-pleted a variety of questionnaires including the Minnesota Multiphasic Personality Inven-tory (MMPI), a life stress questionnaire, and the Trail Making Test from the Halstead-Reitan Batter)'. s: The results of these tests and their relationship to lung disease werediscussed during the sessions. A more detailed description of the treatments is given inAtkins et al.sj The first four sessions were held weekly during the month after the initialinterview. Sessions were held biweekly the second month. Three months after the initialassessment, patients were reevaluated on all measures in the clinic. Outcome measuresincluded a general quality, of life index, pulmonary function tasks, exercise tolerance tasks,and measures of self-efficacy.

Analysis of the data suggested that those in the cognitive behavior modification groupincreased their walking more than those in the other experimental or control groups. Allthree treatment groups walked more than those in the two control groups, s2These changeswere reflected in changes in exercise tolerance measured 1 month after the treatment.However, no significant changes were present in spirometric parameters. In the course of18 months, the experimental and control groups showed significant differences on aqualit3, of life index, s3These differences were used to calculate quality-adjusted life yearsand to demonstrate that the program was relatively cost-effective, s4

Two recently published randomized trials reported shorter-term benefits favoringpulmonary rehabilitation over conventional treatment. Goldstein and coworkers ss reportedsignificant improvement in exercise tolerance, dyspnea, and quality of life after 6 monthsin 45 patients receiving 8 weeks of inpatient pulmonary rehabilitation followed by 16weeks of supervised outpatient care compared with 44 patients who received convennonalcare from their own physicians. Wijkstra and coworkers s6reported significant improvementin exercise tolerance and quality of life in 28 patients who were randomly allocated to ahome pulmonary rehabilitation program for 12 weeks compared with 15 patients whoreceived no rehabilitation.

Although comprehensive rchabilitation is believed to improve functional and psy-chosocial outcomes in patients with COPD, studies have not typically followed up patientsfor longer than 6 months. This has been problematic because the effects of behavioralintervention are of:ten short lived. A treatment effect that lasts only 1 year, for example,may be of limited value because behavior modification does not cure the condition.Instead, there must be continuing behavior change.

In one of our studies, 119 patients with COPD were randomly assigned to eithercomprehensive pulmonary rehabilitation or an education control group. Pulmonary, reha-bilitation consisted of tavelve 4-hour sessions distributed over an 8-week period, w Thecontcnt of the sessions was education, physical and respirator), care, psychosocial support,and supera'ised excrcise. The education control group attended fbur 2-hour sessions thatwere scheduled twice per month but did not include any individual instruction or exercisetraining. Topics included medical aspects of COPD; pharmacy use; breathing techniques;and a variety ofintera'icws about smoking, life events, and social support. Lectures coveredpulmonary medicine, pharmacology, respirator), therapy, and nutrition. Outcomc measuresincluded lung function, maximum and endurance exercise tolerance, symptoms of per-ceivcd breathlessness, perceived fatigue, self-efficacy for walking, the Center for Epidemio-logical Studies Depression Scale and the Quality of Well-Being Scale.

Compared with the educational group, the pulmonary rehabilitation group showedgreater improvements on measures of exercise performance of both maximum level andendurance. In addition, the rehabilitation groups showed greater improvements for symp-toms of breathlessness and self efficacy. No diffi:rences were present betaveen groups formeasures of lung function, deprcssion, or general quality of life. However, both groupscxperienced equivalent reductions in quality of life. For exercise variables, benefits tendedto relapse toward baseline after 18 months of follow-up.

Several potential explanations exist fbr the failure to demonstrate long-term benefitsfrom comprehensive pulmonary, rehabilitation. One explanation is that behavioral inter_'en-

356 Pulmonary' Rehabilitation

tions, without long-term follow-up or maintenance sessions, such as rehabilitation, areinadequate to produce long-term change. Long-term maintenance of behavior changehas also been difficult to demonstrate in research on smoking cessation, ss weight toss, s9and exercise adherence2 ° The finding that patients experience behavior change duringtreatment that is not maintained after treatment is consistent across a variety of differentbehavioral interventions. 3 Discovering ways to maintain behavior change over extendedperiods of time remains a high priori W for research.

PracticalSuggestionsonExercisePromotionIn summary., patient adherence to exercise is perhaps the most difficult and least studiedcomponent of pulmonary rehabilitation. Exercise requires alteration in lifestyle, copingwith uncomfortable sensations, and changes in daily' schedules. To improve adherencewith an exercise program, we recommend the following:

1. Set realistic goals. Patients who set goals too high become discouraged.2. Perform a fimctional analysis. This involves identifying highly probable enjoyable

behaviors such as watching television, reading a novel, or having a cup of coffee.These activities will differ from patient to patient. Once identified, the highlyprobable behaviors can be used as reinforcers for the exercise activity. The patientmight be asked to sign a contract in which he or she agrees to make enjoyableactivities contingent on completion of an exercise session.

3. Use cognitive techniques. Identify negative things a patient may say to himself orherself during an exercise session. Then teach the patient to use realistic, butpositive, self-talk. For example, for a person who says to himself or herself "Thisis painful, I can't stand this," the positive coping self-'statements of"Although thisis painful, I know it will be good for me in the end" might be substituted.These statements must be rehearsed and practiced, Techniques for developingthese statements have been described elsewhere. '_l

ADHERENCEIN SMOKINGCESSATIONPROGRAMS

Because of the well-documented association bem'een smoking and COPD, successfulsmoking prevention programs arc expected to reduce the incidence of these diseases.Smoking cessation programs are also valuable. Considerable interest has focused on theeflkrcts ofsmoki,ag cessation fbr smokers with mild airway obstruction who may be at risktbr COPD. In addition to the role of smoking as a cause of COPD, active cigarettesmoking also affects the course of the illness. For example, cigarette smo "_ng is associatedwith mucous hypersecretion, acute respiratory' illnesses, altered airway reactivity, and in-creased risk of mortally' from other causes, including coronary heart disease. Some of therelations between smoking and problems in the airways have been reviewed elsewhere? IA varletT of studies have suggested that loss in lung function is associated with totalduration of cigarette use. 6-'Longitudinal studies indicate that pulmonaD' _hnction is pro-gressively lost with continued cigarette smoking. However, some evidence suggests thatlung function is partially' recoverable for those who cease cigarette smoking, particularl.vfor those who do so early in life. 6"_

Because of the potential benefits of smoking cessation, efforts to improve adherenceto smoking cessation programs are of great importance. Evidence has accumulated sug-gesting that the physician may play a critical role in helping patients to stop smoking andto maintain this behavioral c]aange. 64 Several experimental trials have trained physiciansto provide a smo "ldng cessation intervention. The components of the intervention include


approaches for taking a smoking history, personalizing the health risks, setting a quit date,prescribing nicotine chewing gum, and counseling techniques for follow-up. In one study,Ockene and associates 6s assigned physicians to receive training in behaviorally orientedcounseling techniques or to a control group in which patients were provided with onlybrief advice to stop smoking. Some of the interventions involved the use of nicotinegum, whereas others did not. The results suggested that the behavioral intervention,with or without the use of nicotine gum, resulted in greater reductions in cigaretteuse among patients. Furthermore, differences bet-ween these groups remained at &monthfollow-up. 6s

The Agency for Health Care Policy and Research (AHCPR) offered guidelines forsmoking cessation in primary care medicine. 66Despite the well-established health conse-quences of tobacco use, less than half of all physicians commonly advise their patients togive up cigarettes. _7 Among those who discuss smoking with their patients, few go muchfurther. For example, only about one in four physicians make an), effort beyond simplystating that the patient should quit smoking. 67One of the biggest challenges in gettingpatients to quit smoking is the recognition that relapse is common. Most smokers whostop wilt begin using cigarettes again within 3 months. Among smokers who have abstainedfor 48 hours, nearly 20% relapse within the first week and an additional 13% relapse duringthe second week. 6s About 23% remain smoke free for 6 months. Relapse rates amongthose who participate in formal programs are somewhat better than they are for self-quitters. 69 Recent studies suggest that those smokers who slip are most likely to relapse.For example, a smoker who takes an occasional cigarette is significantly more likeh' torelapse than one who does not slip. ls,6_-Tl

Perhaps the best predictor of relapse is low personal expectations for remaining smokefree. 6s'7:Using electronic daily diaries, Shiffman and colleagues 73,z4have determined factorsthat precipitate relapse. These studies suggest that lapses associated with self-reportedstress or good mood were more likely to progress to relapses than those associated witheating or drinking.

Practical Suggestions on Smoking Interventions

Much literature on smoking cessation techniques has been developed and is best summa-rized in the AHCPR Guideline. 7s Overall, self-help groups tend not to achieve betteroutcomes than control groups. 76,77We urge the use of self-help materials in combinationwith some counseling intervention. Telephone counseling seems to offer significant bene-fits. In addition, several toll-free 800 numbers are now available7 s Evidence suggests thatphysicians and othe," health care providers can otter brief smoking cessation counseling 7sand that these simple interventions enhance abstinence rates at 6 and 12 months. 79,s°Theaddition of nicotine replacement therapy has also been shown to increase long-termmaintenance. Pharmacotherapy may be more effective fbr men than for women, particularlywhen it is used in combination with smoking cessation counseling, s_

In an analysis of the potential for smoking cessation programs, the AHCPR consideredthe impact of applying their Smoking Cessation Clinical Practice Guidelines for the U.S.population. The guidelines identifi., 15 different smoking cessation guidelines, rangingfrom minimal counseling to intensive counseling. Each intervention is considered withand without concomitant use of nicotine replacement in the form of gum or patches. Theanalysis assumed that the inten,entions would be available to 75% of adult smokers, whichcorresponds to the proportion that made a previous quit attempt. The model assumesthat the program would yield 1.7 million new quitters, of whom 40% would have quiton their own and 60% may have been influenced in some way by the program to quit.Furthermore, the model assumed that 8.8% of smokers would quit with no intervention,10.7% would quit with minimal counseling, 12.1% would quit with brief counseling, and18.7% would quit with counseling lasting more than 10 minutes. Use of nicotine replace-


Table 19.2. Self-Help Smoking Cessation Programs Available to Physicians

Program .... Available From :::_ :_'" Website - _ :

Quit Smoking American Lung Association _,ww]ungusa.org " _Action Plan "( >_i'[

Adherence Tools for American Heart Association www.anaericanheart.org ,.,Professions

Quitdng Smoking American Cancer Society wx_v.cancer.org/tobacco/quitSmok.html

ment would boost these eftizcts further. The program would cost an estimated $6.3 billion,or about $32 per smoker. Cost per quality-adjusted life )'ear was estimated at 5;1915,

placing it well below most programs that have been analyzed, s:A variety of excellent materials arc available to help the patient through the cessa-

tion process. Some of these are described in Table 19-2. Some excellent self-help web-sites include http://wx_av.lungusa.org/tobacco, http://x_awv.nicotine-anonymous.org,http://xxavw.quimet.org, and http://clevcr.net/chrisco/nosmoke/cafe.html. To bemost cffi:ctive, these materials should be used in combination with some counseling inter-vention.

SUMMARY

The typical regimen for patients with COPD requires many different behaviors. Thesemight inchtde the use of sevcral different medications, exercise, oxygen, respirator T andphysiotherapy techniques, and other aspects of self care. Adhe,'ence to this regimen canbe challenging. In contrast to nea,'h' every other medical condition, relatively few publishedstudies evaluate the benefits of interventions to improve adherence among patients withCOPD. Furthermore, wc do not know the extent to which overuse of medication is

associated with poor outcomes for patients with COPD. Behavioral interwention mayenhance adherence with medicine taking, smoking cessation, and exercise. However,considerably more research is necessary to evaluate the long-term benefits of these interven-tions.

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