Home-based pulmonary rehabilitation has been slowly gaining momentum for chronic obstructive pulmonary disease (COPD), but access is still a challenge.
"The science shows that there is greater benefit from pulmonary rehab than any pharmacology we can give a COPD patient, so a patient will get more bang for their buck out of doing pulmonary rehab than taking all of their bronchodilators," Linda Nici, MD, of the Warren Alpert Medical School of Brown University in Providence, Rhode Island, told MedPage Today. Improvements in shortness of breath, functional exercise capacity, and quality of life have been observed, as have improvements in overall survival and rehospitalization.
Much like cardiac rehabilitation for patients with heart disease, pulmonary rehab is a multi-domain medical intervention that incorporates education on disease, medication, behaviors, and how to change those behaviors, as well as individualized exercise plans.
However, fewer than 5% of patients who are eligible for pulmonary rehab actually get it, according to Medicare data. One big problem is that relatively few of these traditionally hospital-based programs are available nationwide.
"They often are not accessible to people in rural or near-rural areas and some of the elderly COPD patients have difficulty with transportation, so access and availability have been huge issues," Nici said.
Christopher Mosher, MD, MHS, medical director of Duke University's pulmonary rehabilitation program in Durham, North Carolina, noted that home-based pulmonary rehabilitation, also known as virtual or telehealth pulmonary rehabilitation, could be one solution.
"It's very much at the infancy stage," he told MedPage Today. "Currently they are available through a number of commercial entities that take advantage of some billable coding, but these are oftentimes not associated with any kind of healthcare hospital system in terms of academic centers or even community practice groups."
One U.S. center, the University of Alabama at Birmingham, which has been pioneering real-time video pulmonary rehabilitation for adults with COPD too far from the center to attend in person or without insurance coverage for it reported no difference in improvements in shortness of breath or exercise capacity compared with conventional in-person attendance, nor were there any safety events.
The biggest evidence base is a Cochrane review from Australia in 2021 that pooled together data from 15 studies. It concluded that teleprograms had equivalent improvements in exercise capacity and quality of life to in-person pulmonary rehabilitation, "which is a huge deal," Nici said. "The challenge is the small number of studies, small number of patients, very heterogeneous in what the intervention was. But that gave us a lot of evidence that this is actually something to pursue."
While Australia, the U.K., and Canada have been more forward in adopting it, U.S. centers that had begun to experiment with virtual pulmonary rehab during the COVID-19 pandemic stopped as public health emergency funding expired in 2023. Now, "CMS does not have a way to reimburse for virtual programs through those locations," Mosher noted.
The little data that have been published from that time have been positive.
The VA Boston Healthcare System turned its center-based pulmonary rehabilitation program into a synchronous virtual program in response to the COVID pandemic using a secure two-way audiovisual communications technology platform. Comparison with participants during the pre-pandemic period showed similar safety, acceptability, and completion of classes.
One important question is whether synchronous exercise from home together with a group that's in a center -- "which we think is probably the one that has the most fidelity to center-based pulmonary rehab," Nici said -- is on par with asynchronous exercise on a mobile app or website not done at the same time with an exercise physiologist or a physical therapist.
Even more critical is the question of how to reimburse telerehabilitation going forward.
"You just can't get around that," Mosher said. "If health systems can't be reimbursed for that service, then there's just no way that it can be effectively delivered, even if they were to partner with some kind of commercial entity that can provide maybe some of the software or interfacing."
There's strong advocacy to push for a legislative solution to get reimbursement for telerehabilitation and even improve what center-based programs are getting, Nici said. Bills in the Senate and House, though, would only cover virtual rehab if it was delivered through two-way audiovisual communication in a synchronous manner.
"We did advocate to have bills put to the floor for reimbursement, but it's been very, very slow. And I think part of that is the current political climate. You know, it's on page 47 of priorities, I'm sure," she said. "It has been slowly gaining some steam over the last year or two. But, you know, that's anyone's best guess right now."
For now, patients who are unable to access a center can still be encouraged to get moving at home and progress to greater levels of activity aiming for 150 minutes per week at moderate intensity.
Senior centers, the SilverSneakers program, the YMCA, walking clubs, or just getting a walking partner can all be options.
"If there's any kind of mall or grocery store, even some kind of large business that they could go to and then walk in there, that's also an option for them to just kind of think creatively," Mosher said. "If they want to look into doing other things like resistance bands or weight, that's great ... But starting with 5 minutes three times a week, that's a perfectly good place to start and then just increasing from there in terms of other lifestyle changes."
Nici noted that "activity is great, and we love people that use pedometers and walking apps and motivational apps. But to really do pulmonary rehab, you need an exercise prescription and exercise training." She recommended checking the American Thoracic Society's pulmonary rehab locator first: "Do a little research; make sure that there isn't availability."
Disclosures
Nici disclosed no relevant relationships with industry.
Mosher disclosed research funding from the NIH, AstraZeneca, and the Patient-Centered Outcomes Research Institute, as well as consulting for the COPD Foundation, GSK, Genentech, Guidepoint, and International Consulting Associates.
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