Preventing Rehospitalization in Lung Transplant Recipients Utilizing mHealth
Condition: Lung Transplant; Complications
Study type: Interventional

Summary: 
      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
      health-related quality of life, and increased longer-term mortality. Additionally, lung
      transplant recipients have the highest risk of unexpected readmission after the index
      admission, with published rates of 40-43%. Frailty at the time of discharge is one of the
      leading factors for readmission. The investigator's belief is that improving access to
      individualized exercise training plans that are modified based on a patient's progress and
      needs will greatly improve a 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.
    

Detailed description: 
      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.
    

Intervention name(s): Aidcube digital app-based platform
Intervention type(s): Other
Intervention description(s): Use of customizable, patient-specific mHealth home rehabilitation plan
Intervention model: Single Group Assignment
Intervention model description: Pre-post intervention study design
Masking: None (Open Label)
Primary purpose: Treatment
Keywords: Lung Transplantation; Frailty; Readmisson; Physical Therapy; Personalized