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Pulmonary rehabilitation programs have been linked to numerous benefits in relevant populations. For example, in patients with chronic obstructive pulmonary disease (COPD), outcomes include reduced dyspnea and increased exercise capacity, improved functional health status, and reduced healthcare use after exacerbations.1 These programs emphasize self-management training to increase the patient’s self-efficacy in achieving long-term behavior changes.
According to the consensus definition of pulmonary rehabilitation, education and supervised exercise training are key aspects of this model.2 “Pulmonary rehabilitation typically has little or no direct effect on lung function; rather it addresses systemic effects of the respiratory disease and secondary morbidities, such as ambulatory muscle dysfunction and maladaptive behaviors,” wrote the authors of a review published in the American Journal of Respiratory and Critical Care Medicine.1
Despite the documented benefits of these programs and recommendations for their use in clinical guidelines,3 rates of use are extremely low. A study published in 2018, for example, investigated rates of use in 223,832 Medicare beneficiaries who had been hospitalized for COPD within the 2 years after Medicare began providing reimbursement for pulmonary rehabilitation.4
Their findings showed use rates of only 2.7% within 12 months of hospitalization. Older age (≥75 years) and lower socioeconomic status were 2 factors associated with nonuse, and patients living >10 miles away from a pulmonary rehabilitation facility were also less likely to initiate the service (odds ratio, 0.42; 95% CI, 0.39-0.46).
Among the various reasons for underuse, professional organizations have identified a lack of awareness and knowledge of this resource among providers, patients, and payers, and lack of access to such programs.1 Although COPD affects millions of people in the United States, there were only 831 pulmonary rehabilitation centers in the country at the time the current paper was published. In addition, many of the patients who could benefit from such programs live in rural areas, and most of the centers are located in urban areas.
“While advocacy efforts to promote the successful and traditional center-based pulmonary rehabilitation model must continue, given the availability, accessibility and uptake problems mentioned above, investigation of alternate forms of program delivery is necessary,” the review authors stated.1 To that end, they explored the evidence pertaining to home-based and community-based programs, which have mostly been studied in patients with COPD.
Of the studies reviewed, 3 were equivalence trials comparing outcomes of home-based vs center-based programs that included structured exercise regimens (eg, aerobic and strength exercise 3 times weekly for 8 weeks) and contact with healthcare providers via occasional telephone calls and in-person visits.5-7 Completion rates were higher in the home-based vs the center-based programs, and no serious adverse events were reported.1
In all 3 studies, the home-based groups demonstrated improvements in health-related quality of life and exercise performance compared with baseline, and in 2 of 3 studies, the home-based intervention was noninferior to the center-based program in terms of their primary outcomes (Chronic Respiratory Questionnaire Dyspnea and the 6-minute walk distance).1
Other studies have shown similar improvements in outcomes, although findings have been mixed overall. Researchers have recently begun to examine the use of telehealth in home-based programs, and in one noninferiority trial, outcomes (quality of life and exercise capacity) were similar between patients participating in a community-based program using this technology and those participating in a center-based program.1 It is anticipated that the study and use of digital interventions in this population will increase in the near future.
“We would maintain that the future of pulmonary rehabilitation and the health of our patients depend on our ability to be pliable and open to newer ways to deliver an evidence-based intervention that we (and our patients) passionately believe in,” the authors concluded.
“Balancing increasing availability with maintaining quality will require continued development of innovative models supported by rigorous clinical research and robust quality assurance processes.”
Pulmonology Advisor checked in with Jessica Bon Field, MD, associate professor of medicine at the University of Pittsburgh Medical Center in Pennsylvania, to learn more about the potential directions of pulmonary rehabilitation.
Pulmonology Advisor: What are the aims of moving pulmonary rehabilitation into the home?
Dr Bon Field: Home-based pulmonary rehabilitation addresses several barriers to pulmonary rehabilitation uptake and referral. These barriers include access issues that are a result of travel distance and/or transportation and a lack of available facilities. Patients with severe chronic respiratory disease may also lack motivation to attend a facility-based program 2 or 3 times per week because of the burden of their illness, but may look favorably on a home-based program that allows them to remain at home and exercise.
Pulmonology Advisor: Is this easier to implement with certain conditions?
Dr Bon Field: Home-based pulmonary rehabilitation has been most studied in individuals with COPD. This is not to say that patients with other chronic lung diseases would not benefit from it.
Pulmonology Advisor: Overall, what does the research suggest thus far regarding home-based pulmonary rehabilitation?
Dr Bon Field: Home-based pulmonary rehabilitation has been shown to be safe and viewed favorably by patients. In small studies, such programs have been shown to improve exercise capacity, dyspnea, and quality of life, and reduce readmission rates in COPD.1
Pulmonology Advisor: What should be the focus of future research in this area?
Dr Bon Field: We need additional randomized controlled trials comparing home-based programs with traditional facility-based pulmonary rehabilitation. We also need to further understand what the essential components of a home-based program are and how these can best be delivered (eg, 1:1 vs group video-conferencing, and self-directed exercises with regularly scheduled health coaching. Further research will be needed to determine the performance of these home-based programs in a nonacademic setting.
References
1. Nici L, Singh SJ, Holland AE, ZuWallack RL. Opportunities and challenges to expanding pulmonary rehabilitation into the home and community [published online May 3, 2019]. Am J Respir Crit Care Med. doi:10.1164/rccm.201903-0548PP
2. Spruit MA, Singh SJ, Garvey C, et al; ATS/ERS Task Force on Pulmonary Rehabilitation. An official American Thoracic Society/European Respiratory Society statement: key concepts and advances in pulmonary rehabilitation. Am J Respir Crit Care Med. 2013;188(8):e13-64.
3. Global Initiative for Chronic Obstructive Lung Disease. Pocket guide to COPD diagnosis, management and prevention. A guide for health care professionals. 2018 report. https://goldcopd.org/wp-content/uploads/2018/02/WMS-GOLD-2018-Feb-Final-to-print-v2.pdf. Accessed June 12, 2019.
4. Spitzer KA, Stefan MS, Priya A, et al. Participation in pulmonary rehabilitation after hospitalization for chronic obstructive pulmonary disease among Medicare beneficiaries. Ann Am Thorac Soc. 2019;16(1):99-106.
5. Maltais F, Bourbeau J, Shapiro S, et al. Effects of home-based pulmonary rehabilitation in patients with chronic obstructive pulmonary disease: A randomized trial. Ann Intern Med. 2008;149:869-878.
6. Holland AE, Mahal A, Hill CJ, et al. Home-based rehabilitation for COPD using minimal resources: A randomised, controlled equivalence trial. Thorax. 2017;72(1):57-65.
7. Horton EJ, Mitchell KE, Johnson-Warrington V, et al. Comparison of a structured home-based rehabilitation programme with conventional supervised pulmonary rehabilitation: A randomised non-inferiority trial. Thorax. 2018;73:29-36.
