- Email: [email protected]
Developing Complementary Clinical Guidelines for Pulmonary Rehabilitation in COPD
3. White RH. The epidemiology of venous thromboembolism. Circulation. 2003;107(23 Suppl):I4-I8. 4. Geerts WH, Heit JA, Clagett GP, et al. Prevention of venous thromboembolism. Chest. 2001;119(1 Suppl):132S-175S. 5. Geerts WH, Bergqvist D, Pineo GF, et al; American College of Chest Physicians. Prevention of venous thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th edition). Chest. 2008;133(6 Suppl): 381S-453S. 6. Mismetti P, Laporte-Simitsidis S, Tardy B, et al. Prevention of venous thromboembolism in internal medicine with unfractionated or low-molecular-weight heparins: a metaanalysis of randomised clinical trials. Thromb Haemost. 2000; 83(1):14-19. 7. Decousus H , Tapson VF, Bergmann J-F, et al; for the IMPROVE Investigators. Factors at admission associated with bleeding risk in medical patients: findings from the IMPROVE Investigators. Chest. 2011;139(1):69-79. 8. Tapson VF, Decousus H, Pini M, et al; for the IMPROVE Investigators. Venous thromboembolism prophylaxis in acutely ill hospitalized medical patients: findings from the International Medical Prevention Registry on Venous Thromboembolism. Chest. 2007;132(3):936-945. 9. Monreal M, Kakkar AK, Caprini JA, et al; RIETE Investigators. The outcome after treatment of venous thromboembolism is different in surgical and acutely ill medical patients. Findings from the RIETE registry. J Thromb Haemost. 2004; 2(11):1892-1898. 10. Hirsh J, Guyatt G, Albers GW, Harrington R, Schünemann HJ; American College of Chest Physicians. Executive summary: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest. 2008;133(6 Suppl): 71S-109S. 11. Urbankova J, Quiroz R, Kucher N, Goldhaber SZ. Intermittent pneumatic compression and deep vein thrombosis prevention. A meta-analysis in postoperative patients. Thromb Haemost. 2005;94(6):1181-1185. 12. Kuijer PM, Hutten BA, Prins MH, Büller HR. Prediction of the risk of bleeding during anticoagulant treatment for venous thromboembolism. Arch Intern Med. 1999;159(5): 457-460. 13. Beyth RJ, Quinn LM, Landefeld CS. Prospective evaluation of an index for predicting the risk of major bleeding in outpatients treated with warfarin. Am J Med. 1998;105(2): 91-99. 14. Ruíz-Giménez N, Suárez C, González R, et al; RIETE Investigators. Predictive variables for major bleeding events in patients presenting with documented acute venous thromboembolism. Findings from the RIETE Registry. Thromb Haemost. 2008;100(1):26-31. 15. Tay KH, Lane DA, Lip GY. Bleeding risks with combination of oral anticoagulation plus antiplatelet therapy: is clopidogrel any safer than aspirin when combined with warfarin? Thromb Haemost. 2008;100(6):955-957. 16. Pisters R, Lane DA, Nieuwlaat R, de Vos CB, Crijns HJ, Lip GY. A novel user-friendly score (HAS-BLED) to assess 1-year risk of major bleeding in atrial fibrillation patients: The Euro Heart Survey. Chest. 2010;138(5):1093-1100. 17. Gage BF, Yan Y, Milligan PE, et al. Clinical classification schemes for predicting hemorrhage: results from the National Registry of Atrial Fibrillation (NRAF). Am Heart J. 2006;151(3): 713-719. 18. Shireman TI, Mahnken JD, Howard PA, Kresowik TF, Hou Q, Ellerbeck EF. Development of a contemporary bleeding risk model for elderly warfarin recipients. Chest. 2006;130(5): 1390-1396. www.chestpubs.org
Developing Complementary Clinical Guidelines for Pulmonary Rehabilitation in COPD Why Add More? a result of the steady progress in evidence from Aswell-designed controlled trials that have used valid,
interpretable, and meaningful outcome measures, rehabilitation of the patient with COPD has moved from being peripheral to patient care to a central component of his/her comprehensive management. This process has been helped by the growing awareness of the global magnitude of the impact of COPD on mortality, morbidity, health-care use, and health-related quality of life. It has also been helped by the increasing number and sophistication of clinical practice guidelines designed to assist health-care professionals in establishing and maintaining best practice pulmonary rehabilitation (PR) programs. There are several examples of excellent guidelines, including those of the American College of Chest Physicians (ACCP)/American Association of Cardiopulmonary Rehabilitation, the American Thoracic Society/European Respiratory Society, and the National Institute for Health and Clinical Excellence.1-3 As discussed at the recent Guideline International Network Conference, hosted by the ACCP and held August 2010 in Chicago, Illinois, guideline development involves a rigorous process of systematically searching publications that address various aspects in the area of interest and then, based on the findings, formulating meaningful recommendations that can be readily implemented. In some instances, document committees with a document editor have been employed to help standardize, monitor, and coordinate the development of official professional society documents. Inconsistencies in document development are minimized by the provision of explicit descriptions of the questions addressed, the process of evidence identification, the evaluation and grading of quality, and the design and final formatting of the guideline document. The committee may also assume responsibility for implementation strategies and for assessing the impact of the document after publication. Needless to say, the process is time consuming (if not tedious), but the outcome is a detailed evidence-informed critique of the current literature that can guide our understanding and practices of how best to manage patients. Why then should we add more to the excellent guidelines already developed? The recent Canadian Thoracic Society Clinical Practice Guideline, “Optimizing Pulmonary Rehabilitation in Chronic CHEST / 139 / 1 / JANUARY, 2011
Downloaded from chestjournal.chestpubs.org by Kimberly Henricks on January 4, 2011 © 2011 American College of Chest Physicians
13
Obstructive Pulmonary Disease–Practical Issues,”4 employed a slightly different approach that complements, rather than competes with, the existing guidelines. Instead of a comprehensive review of all available data pertaining to the entire field of PR, the working group focused on six important practical questions voiced by representative healthcare professionals who participate in rehabilitation programs. These questions were chosen to add an important clinical dimension to a rigorous standardized method of data gathering and evidence grading. Questions were constructed in accordance with a “PICO” process, taking into consideration the Problem, Intervention, Comparison and Outcomes within each question. This enabled the working group to construct an answerable question and to develop an appropriate search strategy that outlined the types of studies and databases to search, as well as the inclusion/exclusion criteria. Importantly, this also enabled the formulation of meaningful recommendations to specifically address these important, focused clinical questions. The practical questions, applied to rehabilitation of the patient with COPD, are summarized as follows: (1) Are non-hospital-based PR programs as effective as hospital-based programs? (2) Does adding resistance training to aerobic exercise improve outcomes in PR? (3) Does continuing PR beyond 6 to 8 weeks improve outcomes compared with standard-duration programs? (4) Are PR programs as effective in patients with mild to moderate COPD as in patients with severe to very severe COPD? (5) Are PR programs as effective in female patients as they are in male patients? and (6) Does PR initiated within 1 month of an acute exacerbation of COPD improve outcomes compared with standard care? The above practical questions remained despite the prior comprehensive guidelines. The recommendations developed by the working group follow a complete assessment of the evidence and provide guidance to support important issues likely to challenge rehabilitation practitioners, at a time when a confident conclusion of added clinical benefit must precede committing further (or maintaining current) health-care resources. This complementary approach is attractive because it is both efficient and can be expanded to address other practical issues as they evolve. Although addressed in more detail in the document, additional issues might include identifying optimal approaches to maintenance programming, determining the required intensity and method(s) of exercise training, understanding the incremental benefits of various program components and the value of exercise and
activity outside of PR, developing approaches to minimize and manage anxiety and depression, assessing adjunct training techniques, and appreciating the many barriers to adherence. Acknowledging the heterogeneity of phenotypic expression of COPD, it is not surprising that practical questions remained despite the use of existing guideline documents. The clinicians caring for these patients, with the goal of optimizing the outcomes of rehabilitation, have a difficult task. Their task can be supported by personalizing evidence-informed rehabilitation and allowing program- and location-specific clinical practice designed to maximize patient-centered clinical outcomes. Clinical practice guideline development, intended to complement rather than compete with existing guidelines, will help achieve that goal. It is both desirable and practical for guideline working groups to develop documents and formulate recommendations intended to harmonize with the work of others who share the same goal. It just makes sense, and our patients would be the first to agree. Roger Goldstein, MBChB, FCCP Toronto, ON, Canada Darcy Marciniuk, MD, FCCP Saskatoon, SK, Canada Affiliations: From the Respiratory Division (Dr Goldstein), West Park Healthcare Centre, University of Toronto; and the Division of Respirology, Critical Care and Sleep Medicine (Dr Marciniuk), University of Saskatchewan. Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article. Correspondence to: Roger Goldstein, MBChB, FCCP, Respiratory Division, West Park Healthcare Centre, University of Toronto, Toronto, ON, M6M 2J5, Canada; e-mail: [email protected] © 2011 American College of Chest Physicians. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/ site/misc/reprints.xhtml). DOI: 10.1378/chest.10-2280
References 1. Ries AL, Bauldoff GS, Carlin BW, et al. Pulmonary rehabilitation. Joint ACCP/AACVPR evidence-based clinical practice guidelines. Chest. 2007;131(5 Suppl):4S-42S. 2. Nici L, Donner C, Wouters E, et al. ATS/ERS Pulmonary Rehabilitation Writing Committee. American Thoracic Society/ European Respiratory Society statement on pulmonary rehabilitation. Am J Respir Crit Care Med. 2006;173(12): 1390-1413. 3. NICE COPD guidelines. 2010. http://guidance.nice.org.uk/ CG101. Accessed October 2010. 4. Marciniuk DD, Brooks D, Butcher S, et al; Canadian Thoracic Society COPD Committee Expert Working Group. Optimizing pulmonary rehabilitation in chronic obstructive pulmonary disease—practical issues: a Canadian Thoracic Society Clinical Practice Guideline. Can Respir J. 2010;17(4):159-168.
14
Editorials
Downloaded from chestjournal.chestpubs.org by Kimberly Henricks on January 4, 2011 © 2011 American College of Chest Physicians
Developing Complementary Clinical Guidelines for Pulmonary Rehabilitation in COPD Why Add More? a result of the steady progress in evidence from Aswell-designed controlled trials that have used valid,
interpretable, and meaningful outcome measures, rehabilitation of the patient with COPD has moved from being peripheral to patient care to a central component of his/her comprehensive management. This process has been helped by the growing awareness of the global magnitude of the impact of COPD on mortality, morbidity, health-care use, and health-related quality of life. It has also been helped by the increasing number and sophistication of clinical practice guidelines designed to assist health-care professionals in establishing and maintaining best practice pulmonary rehabilitation (PR) programs. There are several examples of excellent guidelines, including those of the American College of Chest Physicians (ACCP)/American Association of Cardiopulmonary Rehabilitation, the American Thoracic Society/European Respiratory Society, and the National Institute for Health and Clinical Excellence.1-3 As discussed at the recent Guideline International Network Conference, hosted by the ACCP and held August 2010 in Chicago, Illinois, guideline development involves a rigorous process of systematically searching publications that address various aspects in the area of interest and then, based on the findings, formulating meaningful recommendations that can be readily implemented. In some instances, document committees with a document editor have been employed to help standardize, monitor, and coordinate the development of official professional society documents. Inconsistencies in document development are minimized by the provision of explicit descriptions of the questions addressed, the process of evidence identification, the evaluation and grading of quality, and the design and final formatting of the guideline document. The committee may also assume responsibility for implementation strategies and for assessing the impact of the document after publication. Needless to say, the process is time consuming (if not tedious), but the outcome is a detailed evidence-informed critique of the current literature that can guide our understanding and practices of how best to manage patients. Why then should we add more to the excellent guidelines already developed? The recent Canadian Thoracic Society Clinical Practice Guideline, “Optimizing Pulmonary Rehabilitation in Chronic CHEST / 139 / 1 / JANUARY, 2011
Downloaded from chestjournal.chestpubs.org by Kimberly Henricks on January 4, 2011 © 2011 American College of Chest Physicians
13
Obstructive Pulmonary Disease–Practical Issues,”4 employed a slightly different approach that complements, rather than competes with, the existing guidelines. Instead of a comprehensive review of all available data pertaining to the entire field of PR, the working group focused on six important practical questions voiced by representative healthcare professionals who participate in rehabilitation programs. These questions were chosen to add an important clinical dimension to a rigorous standardized method of data gathering and evidence grading. Questions were constructed in accordance with a “PICO” process, taking into consideration the Problem, Intervention, Comparison and Outcomes within each question. This enabled the working group to construct an answerable question and to develop an appropriate search strategy that outlined the types of studies and databases to search, as well as the inclusion/exclusion criteria. Importantly, this also enabled the formulation of meaningful recommendations to specifically address these important, focused clinical questions. The practical questions, applied to rehabilitation of the patient with COPD, are summarized as follows: (1) Are non-hospital-based PR programs as effective as hospital-based programs? (2) Does adding resistance training to aerobic exercise improve outcomes in PR? (3) Does continuing PR beyond 6 to 8 weeks improve outcomes compared with standard-duration programs? (4) Are PR programs as effective in patients with mild to moderate COPD as in patients with severe to very severe COPD? (5) Are PR programs as effective in female patients as they are in male patients? and (6) Does PR initiated within 1 month of an acute exacerbation of COPD improve outcomes compared with standard care? The above practical questions remained despite the prior comprehensive guidelines. The recommendations developed by the working group follow a complete assessment of the evidence and provide guidance to support important issues likely to challenge rehabilitation practitioners, at a time when a confident conclusion of added clinical benefit must precede committing further (or maintaining current) health-care resources. This complementary approach is attractive because it is both efficient and can be expanded to address other practical issues as they evolve. Although addressed in more detail in the document, additional issues might include identifying optimal approaches to maintenance programming, determining the required intensity and method(s) of exercise training, understanding the incremental benefits of various program components and the value of exercise and
activity outside of PR, developing approaches to minimize and manage anxiety and depression, assessing adjunct training techniques, and appreciating the many barriers to adherence. Acknowledging the heterogeneity of phenotypic expression of COPD, it is not surprising that practical questions remained despite the use of existing guideline documents. The clinicians caring for these patients, with the goal of optimizing the outcomes of rehabilitation, have a difficult task. Their task can be supported by personalizing evidence-informed rehabilitation and allowing program- and location-specific clinical practice designed to maximize patient-centered clinical outcomes. Clinical practice guideline development, intended to complement rather than compete with existing guidelines, will help achieve that goal. It is both desirable and practical for guideline working groups to develop documents and formulate recommendations intended to harmonize with the work of others who share the same goal. It just makes sense, and our patients would be the first to agree. Roger Goldstein, MBChB, FCCP Toronto, ON, Canada Darcy Marciniuk, MD, FCCP Saskatoon, SK, Canada Affiliations: From the Respiratory Division (Dr Goldstein), West Park Healthcare Centre, University of Toronto; and the Division of Respirology, Critical Care and Sleep Medicine (Dr Marciniuk), University of Saskatchewan. Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article. Correspondence to: Roger Goldstein, MBChB, FCCP, Respiratory Division, West Park Healthcare Centre, University of Toronto, Toronto, ON, M6M 2J5, Canada; e-mail: [email protected] © 2011 American College of Chest Physicians. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/ site/misc/reprints.xhtml). DOI: 10.1378/chest.10-2280
References 1. Ries AL, Bauldoff GS, Carlin BW, et al. Pulmonary rehabilitation. Joint ACCP/AACVPR evidence-based clinical practice guidelines. Chest. 2007;131(5 Suppl):4S-42S. 2. Nici L, Donner C, Wouters E, et al. ATS/ERS Pulmonary Rehabilitation Writing Committee. American Thoracic Society/ European Respiratory Society statement on pulmonary rehabilitation. Am J Respir Crit Care Med. 2006;173(12): 1390-1413. 3. NICE COPD guidelines. 2010. http://guidance.nice.org.uk/ CG101. Accessed October 2010. 4. Marciniuk DD, Brooks D, Butcher S, et al; Canadian Thoracic Society COPD Committee Expert Working Group. Optimizing pulmonary rehabilitation in chronic obstructive pulmonary disease—practical issues: a Canadian Thoracic Society Clinical Practice Guideline. Can Respir J. 2010;17(4):159-168.
14
Editorials
Downloaded from chestjournal.chestpubs.org by Kimberly Henricks on January 4, 2011 © 2011 American College of Chest Physicians