Reply to Janaudis-Ferreira <i>et al.</i>: One Step at a Time: A Phased Approach to Behavioral Treatment Development in Pulmonary Rehabilitation
Authors: Ruth E. Barker, Sarah E. Jones, Winston Banya, Sharon Fleming, Samantha S. C. Kon, Stuart F. Clarke, Claire M. Nolan, Suhani Patel, Jessica A. Walsh, Matthew Maddocks, Morag Farquhar, Derek Bell, Jadwiga A. Wedzicha, William D.-C. Man
Journal: American Journal of Respiratory and Critical Care Medicine (2020)

Despite evidence and consensus across international guidelines (2) that patients who have experienced an acute exacerbation of chronic obstructive pulmonary disease (AECOPD) should participate in pulmonary rehabilitation (PR) within 4 weeks after hospital discharge, the uptake of this treatment remains low (3).This is of concern, as PR has been shown to improve dyspnea, quality of life, and exercise capacity, and reduces hospital readmissions among patients with AECOPD (2).The authors rightly indicate that to date, very few studies have investigated the effects of interventions that aim to increase uptake of PR after an AECOPD (4).None of the existing published studies used a randomized controlled trial (RCT) design.Barker and colleagues conducted an RCT to investigate the effects of an intervention, an educational video about PR, as an adjunct to usual care (1).Their primary outcome was uptake of PR within 28 days of hospital discharge.They concluded that a video delivered at hospital discharge did not improve uptake of PR.Although their RCT was well conducted, it does not appear that the authors applied behavioral theory to guide the key messages included in the video, nor was there a progressive and systematic framework guiding the development of their behavior-change intervention as suggested by the Obesity-related Behavioral Intervention Trials (ORBIT) model ( 5).The ORBIT model encourages investigators to complete a series of studies to define and refine the intervention (phase I) and to preliminarily test it (phase II) before conducting efficacy (phase III) and effectiveness (phase IV) trials, akin to the usual practice of pharmaceutical studies.These suggested steps for behavioral intervention development ensure that the treatment package includes essential components offered in an efficient way and, importantly, helps to ensure a clinically significant effect on the behavioral risk factor (5).Although this process can be long and laborious, it is a critical step to prevent a potential waste of resources-for example, by conducting a large RCT for a treatment that cannot impact the target clinical outcomes (5).It seems that Barker and colleagues designed their RCT before they determined whether their video intervention included the essential components (e.g., a motivational communication style and the optimal frequency, duration, and timing of contacts to show the video).The video was only shown once at hospital discharge, a time that can be very overwhelming for patients and family members, and thus is not the best time to make such a decision (6).Indeed, 6 out of the 15 participants interviewed did not recall even watching the video at hospital discharge.Furthermore, at the outset of the RCT, the potential effect on behavioral risk factors (such as knowledge about PR, and self-efficacy/readiness for commencing PR) was not known, as no preliminary testing of these important mediate outcomes was performed.Finally, the rationale for their secondary outcomes is not clear.It is unlikely that an educational video shown once at hospital discharge would have an impact on PR completion rates and adherence, physical performance, or health-related quality of life.The present study by Barker and colleagues addresses a very important question and was well conducted for an RCT.However, if the authors had used a theoretical framework such as the ORBIT model, they would have had the opportunity to strengthen their behavioral intervention and make it as effective as possible before conducting an RCT.It is important to emphasize the value of using a systematic, phased approach to develop a behavioral treatment before testing it in rigorous effectiveness trials.