1. Tele-Health Pulmonary Rehabilitation: Lessons from Alberta Mike Stickland, PhD CIHR New Investigator Assistant Professor Pulmonary Division Faculty of Medicine U of Alberta Co-Director Centre for Lung Health Edmonton General

2. Conflict of Interest Disclosure Educational Grant: Glaxo-Smith Klein Astrazeneca Speakers Honoriarium Glaxo-Smith Klein

3. Canadian Situation A recent national survey revealed that only 98 programs exist in Canada (Brooks et al. Can Resp J, 2007) These programs combined have the capacity to serve only 1.2% of the COPD population in Canada (Brooks et al. Can Resp J, 2007)

4. Grande Prairie (pop.50000) - 400 km / 250 m Peace River (pop.7000 ) - 480 km / 300 m Fort McMurray (pop.88000 ) - 400 km / 250 m High Level (pop.4000) - 775 km / 480 m

6. Canadian Situation ‘An urgent need exists to increase access to Pulmonary Rehabilitation programs across Canada’ (O’Donnell et al., CTS Guidelines, Can Resp J, 2007)

7. Purpose To develop a pulmonary rehabilitation program using Tele-Health technology to provide PR services in rural Alberta Is rehab delivered via Tele-Health as effective as standard out-patient rehab?

8. Patient Referral: Physician Referral Full lung function test Chest X-ray ABG (if on O 2 ) Any additional cardiac info appreciated All pts seen by pulmonologist at enrollment 6 – 8 week outpatient program for ambulatory patients Chronic Respiratory Disease Breathe Easy Program Centre for Lung Health (Covenant Health) Rehab Classes 31 classes M/W/F or Tue/Thur Daytime & evening classes ~ 500 pts enrolled / year

9. Components of Pulmonary Rehabilitation EducationExerciseSupport

10. Standard Outcomes All conducted before and after: Cardiopulmonary exercise test Walk test* Quality of life –SF-36* –St-George’s Respiratory Questionnaire (SGRQ)* * Conducted at 6 and 12 month follow-up

11. Tele-Health involves the use of communications and information technology to deliver health services and information over large and small distances. Clinical Educational Administrative TELE-HEALTH

12. Remote sites required: A local health care coordinator (typically RT) An exercise facility Telehealth capabilities Tele-Health Pulmonary Rehabilitation

13. Pre Program consult w/ Pulmonologist Edmonton SiteTelehealth MD ConsultIn PersonVia Tele-Health w/ RT @ remote site Chest X-rayYes Lung FunctionFull Pulmonary Function Test Minimum Spirometry Exercise TestCardiopulmonary Exercise Test 6min walk w/ SpO 2 and resting EKG

14. Telehealth Pulmonary Rehab North: Grande Prairie Peace River Athabasca Bonnyville Cold Lake Elk Point Barrhead Fort McMurray Central: Camrose Drayton Valley Killam Vermillion Wainwright Edmonton: Sherwood Park Fort Saskatchewan Leduc 15 Sites Total:

15. Is Telehealth PR as effective as standard PR for COPD? (non-inferiority trial) Edmonton Site PatientsN=147 Age69 ± 10 % Female50% FEV1 (% predicted)49.1 ± 18 Quality of Life (SGRQ, %)46.0 ± 17 12-minute walk (m)627 ± 238 Drop-outs17 (Stickland, Jourdain, Wong, Rodgers, Jendzjowsky, MacDonald In Press)

16. Is Telehealth PR as effective as standard PR for COPD? (non-inferiority trial) Edmonton SiteTelehealth PatientsN=147 Age69 ± 1069 ± 9 % Female50%53% FEV1 (% predicted)49.1 ± 1848.1 ± 25 Quality of Life (SGRQ, %)46.0 ± 1750.9 ± 16 * 12-minute walk (m)627 ± 238507 ± 241 * Drop-outs1720 (Stickland, Jourdain, Wong, Rodgers, Jendzjowsky, MacDonald In Press)

17. Non-Inferiority Analysis Similar results seen w/ per-protocol analysis (Intention-to-treat) Responses similar across GOLD category

18. Non-Inferiority Analysis (Intention-to-treat)

19. 6 Month Data Pre vs. Post Pre vs. 6mo (n=45) (n=47)

20. Key Findings Tele-Health PR as effective as standard pulmonary rehabilitation –Similar responses seen across GOLD stage –Safe, no difference in drop-outs / adverse events –Does not need to be complicated Excellent way to provide pulmonary services/support to rural regions

21. Lessons Learned Need for key central coordinator –Standardize referral data for MDs –Ensure scheduling & delivery –IT support –Ensure proper discharge reporting –Track Health outcomes Flexibility for Education delivery –Varying Tele-Health equipment –Limited telehealth facilities –Ability to podcast education sessions

22. Thanks to: M. Pratley R. Hamir T. Jourdain S. Olson L. Simmonds B. Gendron S. Martin B. Yee CFLH Staff: Pulmonologists: Dr. F. MacDonald Dr. J. Archibald Dr. M. Bhutani Dr. T. Bryan Dr. A. Liu Dr. S. Marcushamer Dr. L. Melenka Dr. W. Ramesh Dr. D. Stollery Dr. E. Wong Dr. F. MacDonald T. Jourdain Dr. W. Rodgers Dr. E. Wong Co-investigators Funding for this project was obtained from the Alberta Health Services Telehealth Clinical Grant Fund & Covenant Health Research Foundation.

24. Tele-Health Pulmonary Rehab Pre Program consult w/ Pulmonologist via Tele-Health The following test results are reviewed at the initial consult: 6 minute walk with oximetry Pulmonary Function Test (minimum spirometry) Baseline Electrocardiogram Chest X-Ray Education given via Tele-Health Patients exercise at local site under supervision

25. Tele-Health Pulmonary Rehab Pre Program consult w/ Pulmonologist via Tele-Health The following test results are reviewed at the initial consult: 6 minute walk with oximetry Pulmonary Function Test (minimum spirometry) Baseline Electrocardiogram Chest X-Ray Education given via Tele-Health Patients exercise at local site under supervision

26. Is Telehealth PR as effective as standard PR for COPD? (non-inferiority trial) Telehealth PatientsN=147 Age69 ± 9 % Female53% FEV1 (% predicted)48.1 ± 25 Quality of Life (SGRQ, %)50.9 ± 16 * 12-minute walk (m)507 ± 241 * Drop-outs20 (Stickland, Jourdain, Wong, Rodgers, Jendzjowsky, MacDonald In Press)

27. Is Telehealth PR as effective as standard PR for COPD? (non-inferiority trial) TelehealthEdmonton Site PatientsN=147 Age69 ± 969 ± 10 % Female53%50% FEV1 (% predicted)48.1 ± 2549.1 ± 18 Quality of Life (SGRQ, %)50.9 ± 16 *46.0 ± 17 12-minute walk (m)507 ± 241 *627 ± 238 Drop-outs2017 (Stickland, Jourdain, Wong, Rodgers, Jendzjowsky, MacDonald In Press)

28. Is Telehealth PR as effective as standard PR for COPD? (non-inferiority trial) TelehealthEdmonton Site PatientsN=147 Age69 ± 969 ± 10 % Female53%50% FEV1 (% predicted)48.1 ± 2549.1 ± 18 Quality of Life (SGRQ, %)50.9 ± 16 *46.0 ± 17 12-minute walk (m)507 ± 241 *627 ± 238 Drop-outs2017 (Stickland, Jourdain, Wong, Rodgers, Jendzjowsky, MacDonald In Press)