Results Summary
What was the research about?
Patients with chronic obstructive pulmonary disease, or COPD, can have breathing problems and chronic cough. Being active may help people with COPD breathe more easily.
In this study, the research team wanted to learn if a physical activity program called Walk On! improved the health of patients with COPD when added to usual care. The program includes
- Education about physical activity and COPD
- A daily step-count goal and wearable step counter
- Four phone calls from a coach
- Check-in phone calls as needed over 11 months
- Monthly group visits for peer support
Usual care included services covered by a patient’s health insurance, but no additional support for physical activity.
The research team first compared all patients assigned to Walk On! with patients who received usual care alone. The team then compared the smaller group of patients who actively took part in Walk On! with patients receiving usual care alone.
What were the results?
During the study, patients assigned to Walk On! and patients who received usual care alone had similar rates of emergency room visits and hospital stays. They also had similar rates of death for any reason.
After 10 months, patients who were in the group that actively took part in Walk On! had a lower risk of a short hospital stay compared with patients who received usual care alone. These patients were also more likely to report getting some physical activity and as much physical activity as recommended. After six months, these patients reported improved quality of life related to physical health and less time sitting compared with those receiving only usual care. But these changes were no longer present after one year.
Who was in the study?
The study included 2,707 patients ages 40 or older who went to the hospital because of COPD in the past year. All received care at Kaiser Permanente in Southern California. Of the patients, 74 percent were white, 14 percent were African American, 5 percent were Asian, 1 percent were Hawaiian or Pacific Islander, and 5 percent were other or unknown race. The average age was 72, and 54 percent were women.
What did the research team do?
The research team assigned patients by chance to Walk On! plus usual care or usual care alone. The team reviewed patients’ health records to look at use of health care, reported activity levels, and number of deaths. Patients completed surveys on quality of life and physical activity when the study began and again 6 and 12 months later.
Patients with COPD, caregivers, COPD advocacy groups, clinicians, and health system leaders gave input during the study.
What were the limits of the study?
Only 24 percent of the patients invited to join Walk On! did so. Patients who took part in Walk On! may differ from those who didn’t. Patients in the study reported their own physical activity. It’s possible those reports weren’t always correct.
Future studies could look at other ways to support physical activity among patients with COPD.
How can people use the results?
Health systems can use the results when considering how to help patients with COPD increase their physical activity.
Professional Abstract
Objective
To compare the effectiveness of a physical activity coaching intervention added to usual care versus usual care alone on reducing healthcare utilization and death among patients at high risk for exacerbations of chronic obstructive pulmonary disease (COPD)
Study Design
| Design Element | Description |
|---|---|
| Design | Randomized controlled trial |
| Population | 2,707 patients ages 40 or older who had COPD-related acute care utilization—defined as at least one hospitalization, ED visit, or observation stay—in the past year |
| Interventions/ Comparators |
|
| Outcomes |
Primary: composite measure of all-cause acute care utilization and death Secondary: COPD-related acute and outpatient care utilization; cardio-metabolic markers (body mass index, blood pressure, blood glucose and lipid levels); self-reported physical activity, symptoms, quality of life, and health behavior |
| Timeframe | 1-year follow-up for primary outcome |
This randomized controlled trial examined whether adding a community-based physical activity coaching intervention called Walk On! to usual care reduces healthcare utilization and death among patients at high risk for COPD exacerbations.
Researchers randomly assigned patients to one of two groups, Walk On! plus usual care or usual care alone. Patients in the first group received an invitation to participate in Walk On!, a program that included
- Education on physical activity and managing COPD
- An individualized step-goal recommendation
- An activity sensor and training on its use
- Weekly phone-based coaching for four weeks
- Follow-up calls for the remaining 11 months
- Monthly group visits to build peer support
Usual care included services covered by patients’ health benefits, including referrals to pulmonary rehabilitation if needed.
The study included 2,707 patients who had received COPD-related acute care in the past year at Kaiser Permanente in Southern California. Of these, 74% were white, 14% were African American, 5% were Asian, 1% were Hawaiian or Pacific Islander, and 5% were other or unknown race. The average age was 72, and 54% were female.
Researchers reviewed patients’ electronic health records for acute care utilization, activity levels, and clinical outcomes. Patients completed surveys on patient-reported outcomes at baseline and again 6 and 12 months later. Researchers completed an intent-to treat analysis and then a secondary, a priori as-treated analysis for the smaller group of patients who actively participated in Walk On!
Patients living with COPD, caregivers, COPD advocacy groups, clinicians, and health system leadership provided input throughout the study.
Results
Over 12 months, patients assigned to the Walk On! plus usual care and the usual care alone groups did not differ significantly on the composite measure of all-cause acute care utilization and death or on these measures individually.
Over 10 months, compared with patients receiving usual care alone, patients in the subgroup that actively participated in Walk On! had a lower risk of having an observation stay (hazard ratio [HR]=0.72; 95% confidence interval [CI]: 0.53, 0.98; p=.04) and were more likely to report engaging in any physical activity (47% vs. 31%; p<0.001) and meeting recommended physical activity levels (21% vs. 13%; p<0.01). These patients also reported a greater increase in quality of life related to physical health (p=0.01) and a greater decrease in sedentary time (p=0.02) at 6 months, but not at 12 months. Other study outcomes did not differ significantly.
Limitations
Only 24% of patients randomized to participate in Walk On! took part in the program. Patients self-reported their activity rates, which may have introduced inaccuracies.
Conclusions and Relevance
In this study, adding Walk On! to usual care was not more effective than usual care alone at reducing acute care utilization and mortality for patients with COPD.
Future Research Needs
Future studies could examine other ways to encourage patients with COPD to be physically active.
Final Research Report
View this project's final research report.
Engagement Resources
Journal Citations
Results of This Project
Related Journal Citations
Peer-Review Summary
Peer review of PCORI-funded research helps make sure the report presents complete, balanced, and useful information about the research. It also assesses how the project addressed PCORI’s Methodology Standards. During peer review, experts read a draft report of the research and provide comments about the report. These experts may include a scientist focused on the research topic, a specialist in research methods, a patient or caregiver, and a healthcare professional. These reviewers cannot have conflicts of interest with the study.
The peer reviewers point out where the draft report may need revision. For example, they may suggest ways to improve descriptions of the conduct of the study or to clarify the connection between results and conclusions. Sometimes, awardees revise their draft reports twice or more to address all of the reviewers’ comments.
Peer reviewers commented and the researchers made changes or provided responses. Those comments and responses included the following:
- The reviewers expressed concern about the considerable amount of missing data, given the attrition of 75 percent of those participating in the coaching intervention. The researchers agreed that the level of participation was suboptimal and revised the results to better describe the level of participation. They also noted that patients could still receive the coaching intervention but not use the activity sensors or not upload activity data at 12 months. This may have led to an underestimate of patients’ physical activity, especially compared to self-reported physical activity. The researchers did, however, reflect on how missing data in activity monitoring and multiple comparisons may have overestimated the effectiveness of the coaching intervention.
- The reviewers cautioned the researchers to consider the heterogeneity in intervention delivery in their limitations section. The researchers acknowledged that there was variability in the type of activity monitor used and how patients used them, and that patients had the option of not attending some of the intervention sessions. They stated, however, that these aspects of the study illustrate the pragmatic nature of the study design, allowing patients to take advantage of the intervention based on their enthusiasm and preferences.
- The reviewers noted that there were clinical differences between patients who completed and did not complete the six-month data collection. The researchers acknowledged that patients who completed the six-month data collection tended to have fewer comorbid conditions but worse airflow obstruction. The same patients were also more likely to be white, partnered, and physically active at baseline. However, these differences were the same for both treatment groups so there does not appear to be a treatment-related reason for the difference.
- The reviewers questioned the value of self-reported measures of physical activity. The researchers agreed that self-reported physical activity data is less valuable than directly measured data but said it would be unrealistic to require objective measures of physical activity in such a large study sample. They also noted that restricting the study to only subjects who would wear a device would have created biases in the findings.