PR in VR

Wednesday, April 7, 2021

Many services have been forced to move to a virtual or remote platform, in order to continue to operate during the pandemic.


Dr Mukesh Singh, GP & Staffordshire STP’s Respiratory Lead told us about the pilot of a virtual Pulmonary Rehabilitation ( PRinVR) service he is leading in Staffordshire and Stoke on Trent.


(in the photo, the PR in VR Team, from top left: Dr Farhan Amin, Dr Mukesh Singh, Dr Ruth Chambers, Sarah Evans, Claire Stamp, Jane Murray, Sophie Ward

This is an example of how COVID-19 normalised the use of new ways to deliver care. Months before the pandemic reached the UK, and in truth, probably even before the first signs of the pandemic in China were reported by the international media, we put forward a funding proposal for a remote-based pulmonary rehabilitation service.

We found out that 95% of our COPD patients who were referred to PR, waited more than 28 days before they could start. NICE guidance suggests commencing PR within 28 days from discharge after an exacerbation or new diagnosis with MRC grade 3 or above, and the benefits from participation reduce with longer waits for the service. The health of untreated patients gets worse over the time with an increased risk of readmission to hospital and related mortality within 12 months.

It was early 2019, and we were concerned about people that would benefit from PR in our community in Staffordshire, but that was either not available for a plethora of reasons they wouldn’t attend their sessions. The reasons were diverse, including long waiting time, claustrophobia, mobility or transport issues, fear of infection on public transport or clashes with other commitments.

We just wanted to improve access to PR and reduce the health care utilisation in terms of GP visits and the number of non-elective COPD admissions to hospital. PR in VR has potential to reduce the time between referral and commencement of treatment to 7-21 days for 80% of referrals.

The science is clear, we know that pulmonary rehabilitation is the most cost-effective intervention to reduce acute COPD exacerbations and related hospital admissions. It motivates patients to be generally more active in their daily life and reduces the psychological burden of anxiety and depression that often comes with the breathlessness and the progression of the disease.

So, we looked for a company that could help us deliver a programme of pulmonary rehabilitation remotely, and we selected Concept Health Technologies (CHT), as they were already doing a pilot of their service in Lincolnshire, that looked like what we had in mind.

GPs in Staffordshire & Stoke on Trent became one of the first in UK to deploy the service at scale. We worked with them to design a complete course of PR that could be done from the convenience of a patient’s own home using a virtual reality set, with the confidence that they are being supervised remotely by a therapist which evaluates the exercise and that key vitals are monitored in real time. Together, we wrote a bid for an NHS Estates and Technology Transformation Fund (ETTF) grant to run it as a pilot and assess how beneficial and cost-effective it would be.

In February 2020 we found out that our application was successful, and began preparations to launch our pilot service, but just as we were about to start, COVID hit the UK and everything had to be delayed while we readjusted to the situation. A few months in the value of this pilot became even more apparent because of the risk of coronavirus infection, we decided to open it to all eligible COPD patients since the start in August 2020, included the shielding patients and later on included eligible Long COVID patients.

The system is based on a Virtual Reality set which includes a headset, a connected pulse oximeter and a mobile internet device. Patients can unbox the kit and start using it. Internet connectivity to access the PR classes is provided by a free small 3G router pre-coupled with the kit, to require minimal levels of digital literacy.

Once connected to the system, the sessions can be accessed using the set at any time and consists of standard exercises and tests provided in a virtual environment, with a virtual instructor and monitored by an artificial intelligence that can give feedback on the exercise and monitors the patient’s vitals in real time. The Artificial Intelligence (AI) can detect any potentially concerning signs and alert a central hub, staffed 24/7, which can escalate things to the GP or emergency services.

The pilot was supposed to last for 12 months, but given the delays imposed by the pandemic, we have been allowed a few more months to collect data, which is already proving encouragingly positive.
PR in VR has been incorporated into our existing Pulmonary Rehabilitation pathway as a part of a service redesign, with the outcome measurements in terms of:

• 1-minute Sit, Stand and Sit Test (IMSTS) to assess the improvement if patient’s functional ability
• COPD Assessment Test ( CAT) score to assess a reduction in patient’s COPD specific symptoms
• PHQ-9 and GAD-7 scores to assess mental health improvement
• Health service utilisation eg, exacerbations requiring primary care visits or hospitalisation
• Health status and patients satisfaction

The AI can also extrapolate the likeliness of an exacerbation in the near future using the data it collects during the PR sessions, and when it does so, it alerts the GP through the central hub, and the patient is either seen by community respiratory team, the GP surgery, or directly referred to hospital if required. All data during exercise is collected automatically.

On the organisational side of things, we have purchased 80 VR kits to deliver the intervention to 400 plus patients, which is based on a 6-week course of pulmonary rehabilitation per patient. We have monthly meetings with CHT’s clinical lead of the service, the Staffordshire STP’s Digital lead, the GP lead, Community conventional PR service representative, project service nurse, Project IT support staff and a commissioning manager to take stock and discuss progress and improvements.

Referrals to the service are extremely straightforward, we integrated it into the GP system, so that when a GP wants to refer a patient to the PR in VR pilot, all they need to do is to select it as an intervention, and the system collect all the required patient data and observations which can then be sent via email to the central hub. Community and hospital conventional PR teams can also refer patients to the pilot.
Not all patients are eligible, and these include, for example, people suffering from epilepsy, vertigo, recent MI or just out of surgery among others. But if they are suitable, generally within a week, they receive the kit and are on-boarded into the service. If needed, a technician can also visit, in a COVID-secure way, and help with setting things up for the patients.

So far, we have 250 patients referred to the programme, with fantastic feedback from them. People are excited with the possibilities offered by the technology, they feel more secure, it allows them to exercise around their own commitments. We are only at mid-way point of the project, but the initial data evaluation demonstrates a significant improvement in physical and psychological well-being of the participants.

30 practices within the Staffordshire and Stoke on Trent STP have joined the pilot at this stage, but if the pilot is successful, we plan to put in a business case to expand the service to the whole ICS, making PR in VR available to all eligible COPD sufferers within the 1.5m people living in the area.

I would like to close with a great thanks to everyone involved with this project including the patients, practices, CHT, community service provider(MPFT) and special thanks to the PR in VR Team