COPD Access to Pulmonary Rehabilitation Intervention

Conventional pulmonary rehabilitation (PR) programs are highly effective and the standard of
care in patients with chronic obstructive pulmonary disease (COPD). PR faces two significant
problems: (1) most patients with COPD who would benefit from PR cannot access it, and 2)
there is no effective long-term strategy to maintain physical activity (PA) and benefits
after completing PR. The investigators propose a randomized controlled trial (RCT) to test
the efficacy of a technology-mediated intervention to increase PA in persons with COPD who
cannot access conventional, hospital-based PR. The investigators also propose a
non-randomized study to explore the ability of the PA intervention to maintain PA and
exercise adherence, extending the benefits of PR, in persons with COPD who complete a
conventional PR program. COPD is the third leading cause of death in the United States; an
estimated 16 million Americans have COPD. Despite maximal medical therapy, patients with COPD
characteristically experience breathlessness, which leads to a downward spiral of sedentary
behavior, physical inactivity, deconditioning, and functional disability. Low physical
activity is associated with poor outcomes in COPD--increased risk of acute exacerbations,
hospitalizations, and death, independent of lung function. The Global Initiative for Chronic
Obstructive Lung Disease (GOLD) guidelines recommend regular PA for all patients with COPD.
Conventional, supervised PR programs clearly reduce breathlessness, and improve
health-related quality of life (HRQL) and exercise capacity. However, PR programs face
significant challenges of access and adherence. The investigators developed Every Step Counts
(ESC), a technology-mediated intervention based on the Behavioral Theory of Self-Regulation,
to target sedentary behavior, promote PA, and alleviate deconditioning. ESC couples a website
with a pedometer to directly monitor step counts. The website provides individualized
step-count goals, iterative feedback, education on disease self-management, motivation, and
an online community of social support. In two randomized studies in Veterans with COPD, the
investigators demonstrated ESC's safety, feasibility, and efficacy to increase PA. Accessible
via the internet and available at any time from home, ESC could be an ideal low-cost platform
to address the limitations of conventional PR. The investigators hypothesize that ESC may be
an efficacious strategy to promote PA in the many patients who cannot attend a PR program,
and may be an option to maintain engagement in PA after patients complete a conventional PR
program.

Primary Aim 1: Determine the efficacy of a web-based intervention, ESC, to increase PA
(measured directly with an accelerometer and a questionnaire that assesses intensity),
compared to usual care, in persons with COPD who are referred to conventional PR but who
cannot access it.

Secondary Aim 2: Estimate the effect of the ESC intervention on (a) exercise adherence, (b)
exercise self-efficacy, (c) HRQL, (d) dyspnea, (e) anxiety and depression, (f) exercise
capacity, and (g) risk of acute exacerbations and COPD-related hospitalizations, compared to
usual care.

Exploratory Aim 3: Assess the ability of ESC to maintain PA and exercise adherence, and
extend the benefits of PR, in participants with COPD who have completed conventional PR.

Inclusion Criteria:

- Male and female subjects, greater than or equal to 40 years of age

- Clinical diagnosis of COPD defined as either a ratio of FEV1 to forced vital capacity
(FVC) < 0.70 or chest CT evidence of emphysema or prior documentation of FEV1/FVC
ratio of < 0.7 and clinical evidence of COPD

- defined as 10 pack-year cigarette smoking history

- dyspnea

- or on bronchodilators

- Have declined participation in a conventional pulmonary rehabilitation program

- Medical clearance from healthcare provider to participate in an exercise program

- Have access to a computer with Internet connection, a USB port or Bluetooth
capability, and Windows XP/Vista/7/8/10 or higher, or Mac OSX 10.5 or higher operating
system, or willing to come to VA Medical Center to use study computers

- Pedometer and accelerometer with >90% accuracy compared to manual counts on short
clinic walk

- Competent to provide informed consent

- Willingness to make return visits and be available by telephone for duration of study

Exclusion Criteria:

- COPD exacerbation in the previous 1 month

- Inability to ambulate with or without assistance

- Hypoxemia during six-minute walk test (6MWT)

- i.e. oxygen saturation <85% using supplemental oxygen

- Inability to complete questionnaires

- Inability to collect at least 7 of 10 days of baseline step counts

- Participation in a pulmonary rehabilitation program at time of screening or within the
previous 3 months

- Participation in another exercise-related research study at time of screening

- Plans to participate in an exercise-related research study in the next 3 months

- Average baseline step counts of greater than or equal to 10,000 steps per week