Pulmonary telerehabilitation for COPD: Promising, but more data needed
An older (2016) international randomized controlled study (Zanaboni et al, https://doi.org/10.1186/s12890-016-0288-z) comparing long-term telerehabilitation or unsupervised treadmill training at home with standard care included 120 participants with COPD and had 2-years of follow-up. Telerehabilitation consisted of individualized treadmill training at home. Participants had scheduled exercise sessions supervised by a physiotherapist via videoconferencing following a standardized protocol. Participants in the unsupervised training group were provided with a treadmill only to perform unsupervised exercise at home. They also received an exercise booklet, a paper exercise diary to record their training sessions, and an individualized training program but without regular review or progression of the program. For the primary outcomes of combined hospitalizations and emergency department presentations, incidence rate of hospitalizations and emergency department presentations was lower with telerehabilitation (1.18 events per person-year; 95% confidence interval [CI], 0.94–1.46) and with unsupervised training group (1.14; 95% CI, 0.92–1.41) than in the control group (1.88; 95% CI, 1.58–2.21; P < .001 compared with intervention groups). Both training groups had better health status at 1-year, and achieved and maintained clinically significant improvements in exercise capacity.
Access to pulmonary rehabilitation
Continuing evidence of clear telerehabilitation benefits is good news, especially in the light of impediments to attendance at in-clinic programs. Although the COVID-provoked disincentives have been diminishing, persisting access issues remain for substantial portions of eligible populations, according to a recent (2024) cross-sectional study (PA Kahn, WA Mathis, doi:10.1001/jamanetworkopen.2023.54867) looking at travel time to pulmonary rehabilitation programs as a marker for pulmonary rehabilitation access. The report, based on US Census designations (lower 48 states and Washington, D.C.) found that while 80.3% of the population lives in urban or suburban areas within a 30-minute drive of a pulmonary rehabilitation program, travel time exceeds that in rural and other sparsely populated areas with more than 14 million people residing in areas demanding more than 1-hour for travel. A further analysis showed also that nearly 30% of American Indian and Alaska Native populations live more than 60 minutes from a pulmonary rehabilitation program.
Aside from the obvious restraints for homebound patients or those lacking transportation or who need medical transport, other common impediments inhibit on-site pulmonary rehabilitation attendance, said Corinne Young, MSN, FNP-C, FCCP. Ms. Young is the director of Advance Practice Provider and Clinical Services for Colorado Springs Pulmonary Consultants, president and founder of the Association of Pulmonary Advance Practice Providers, and a member of the CHEST Physician Editorial Board. “I have some patients who say ‘There’s no way I could do onsite pulmonary rehab because of my knee — or back, or shoulder.’ But in their own home environment they may feel more comfortable. They may be willing to try new things at their own pace, whereas for them a program may feel too regimented.” For others, Ms. Young said, aspects of a formal program are a clear plus factor. “They love to hear their progress at the end of — say a 12-week program — where their virtual respiratory therapist records and reports to them their six-minute walk and other test results. Feedback is a great reinforcer.” Quality of life improvements, Ms. Young commented, were one of the very impressive benefits that appeared in the initial studies of pulmonary rehabilitation for COPD patients. “Being patient-centric, you want to improve quality of life for them as much as possible and we see telerehabilitation as a great opportunity for many,” she added.
“I would like to see head-to-head data on outpatient versus at-home pulmonary rehabilitation on hospitalizations, time to exacerbation and, of course, mortality. We have all that for outpatient rehab, but it would be great to be able to compare them. Knowing that would influence what we recommend, especially for patients who could go either way. Also, you have to assess their motivation and discipline to know who might be more appropriate for unsupervised pulmonary rehabilitation.”
The current reality for Ms. Young is that in her Colorado Springs vicinity, where both in-patient programs are only 15 minutes apart, she knows of no telerehabilitation programs being offered. While there are contract telerehabilitation providers, Young said, and her organization (The Association of Pulmonary Advanced Practice Providers) has been approached by one, none are licensed in Colorado, and telerehabilitation is not a billable service.
“As of yet, I’m not aware of any telemedicine pulmonary rehab available at our institution,” said pulmonologist Mary Jo S. Farmer, MD, PhD, FCCP, Associate Professor of Medicine at UMass Chan Medical School – Baystate, Springfield, MA, and a member of the CHEST Physician Editorial Board. A brief internet search identified a telerehabilitation contract provider available only in Arizona.
Reimbursement will also be a foundational concern, Ms. Young commented. While a physician, nurse practitioner, or physician virtual visit for education may be billable, telerehabilitation reimbursement is new territory. “How that all is going to work out is a big unknown piece,” she said.
