Preventing Rehospitalization in Lung Transplant Recipients Utilizing mHealth

Mission and Specific Aims: Lung transplantation has several important aims: 1) extend
survival; 2) relieve disability, and 3) improve health-related quality of life (HRQL) for
adults suffering from end-stage lung disease. Advances in medical therapies and changes in
the US organ allocation system in 2005 have prioritized lung transplant for sicker and older
patients. This achievement has come at substantial cost, including recent trends in
recipients towards increased disability, poorer HRQL, and increased longer-term mortality.

Reflecting these trends, lung transplant recipients have the highest risk of unexpected
readmission after the index admission among solid organ transplant patients, with published
rates of 38-43%. Over the course of the first post-transplant year, the investigators have
shown that 60% of lung transplant recipients have a readmission within 30 days of a hospital
discharge, of which 30% occur after initial discharge (as above) and 70% occur after a
subsequent readmission (2). Each readmission increases the risk for another unplanned
rehospitalization as well as long-term mortality, suggesting that this is a particularly
vulnerable population.

Over the last year, the investigators performed a single center cohort study to identify risk
factors for readmission after index lung transplant discharge. As part of this initiative,
the investigators have been evaluating the role of frailty as measured by the Short Physical
Performance Battery (SPPB) test. The SPPB is a three-component battery of lower extremity
performance, measures that includes gait speed, chair stands, and balance. The investigators
have previously demonstrated that frailty is a risk factor for delisting and death among wait
listed lung transplant recipients as well as a significant predictor of mortality within the
first year after transplant (Figure 1)(3). In a recent single center cohort study of 90 Penn
lung transplant recipients, the investigators demonstrated that patients who are frail at
index hospitalization discharge based on SPPB are 3.4 times more likely to have an unplanned
re-hospitalization within the next 30 days, regardless of whether they are discharged home or
to acute rehab. Interestingly, patients are not frail at the time of listing for transplant -
frailty develops during the hospital stay for lung transplantation suggesting that physical
frailty is dynamic over a short period of time and may be amenable to intervention. The
frequent re-admissions, in part due to significant frailty, lead to 1) increased healthcare
expenditures (the median professional and hospital payments at Penn for an unplanned
hospitalization following discharge was $13048, 2) severely impact the patient's quality of
life, and 3) lead to increased mortality.

The investigators have previously found that, among recipients who were frail at discharge
and who were enrolled in an intensive outpatient physical therapy program, the median
improvement in SPPB was 6 points and 85.7% became not frail (unpublished data). Although this
demonstrates that frailty can be reversed in the lung transplant population, the impact of
reduced frailty on subsequent readmission has not been evaluated. It remains unknown whether
there are other, less resource intensive, mechanisms for improving frailty. The
investigator's belief is that improving access to individualize exercise training plans that
are modified based on a patient's progress and needs will greatly improve transplant
recipient's level of physical fitness and independence, and decrease the risk of hospital
readmission. This will lead to an overall improvement in a patient's quality of life. This
study, therefore, targets a population of lung transplant recipients at highest risk for
readmission and further complications.

Specific Aim: Evaluate the impact of targeted physical therapy rehabilitation plans utilizing
a customizable app based interface on the subsequent readmission rates of lung transplant
patients at the highest rate of readmission. Patients who are 1) frail at the time of
discharge (SPPB≤8) or 2) have already been readmitted after their transplant hospitalization
are at the highest risk of subsequent readmission. The investigators hypothesize that
targeted, individualized rehabilitation plans will reduce the risk of subsequent readmission.

Inclusion Criteria:

- Lung transplant recipient

- SPPB score less than or equal to 9 OR a readmission within 30 days of lung transplant
discharge

Exclusion Criteria:

- SPPB >9