Experts discuss benefits, integration of tele-rehab for COPD

There has been increasing use of and research on home-based pulmonary rehabilitation during the COVID-19 pandemic, bringing to light numerous benefits of telehealth rehabilitation along with traditional center-based rehabilitation.

Pulmonary rehabilitation has demonstrated proven benefits for patients with COPD. However, challenges remain, as only around 10% of eligible patients are referred, with lower referral rates among patients with socioeconomic disadvantages. In addition, fewer than 5% of patients hospitalized for acute COPD exacerbations received pulmonary rehabilitation within 90 days of discharge, and fewer than 50% of referred patients enroll and participate, according to recent research.

Reasons for underutilization of pulmonary rehabilitation include health system barriers such as low numbers of programs, limited program capacity, low insurance reimbursement rates and low referral rates, and patient-related barriers such as limited geographical access, transportation issues, program timing, routine disruption, competing priorities, comorbid illnesses and insufficient knowledge of rehabilitation benefits.

Tele-based pulmonary rehabilitation at home is generating interest as a rehabilitation option to address the challenges above and to increase patient uptake and access.

Benefits of tele-rehab

Home-based pulmonary rehabilitation can be delivered via several models. Tele-rehabilitation, or home-based pulmonary rehabilitation, is the delivery of rehab services using phone- or computer-based applications to aid the patient in performing exercises at home. This mode of rehabilitation is beneficial if the patient is unable to travel to a traditional rehabilitation center, as was the case for many during the COVID-19 pandemic.

To date, numerous clinical trials have evaluated the benefits of home-based pulmonary rehabilitation in patients with moderate-to-severe and severe COPD. Most studies assessed aerobic conditioning and strength training using minimal resources in patients’ homes and program durations ranged from 5 to 12 weeks.

According to Carolyn L. Rochester, MD, professor of medicine in the department of pulmonary, critical care and sleep medicine at Yale University School of Medicine, most research thus far has demonstrated significant improvements of home-based pulmonary rehabilitation on measures of exercise capacity, dyspnea and quality of life. In many, but not all studies, these improvements have been generally comparable to those observed in studies that evaluated center-based rehabilitation.

The benefits of home-based pulmonary rehabilitation have been observed regardless of patients’ socioeconomic status, gender and older age thus far, without increased risk for adverse events compared with center-based rehabilitation. Also, home-based rehabilitation has been demonstrated to be effective among patients who require long-term oxygen and/or noninvasive ventilation and has been proven to improve or stabilize 6-minute walk test distance in patients on lung transplant waitlists.

“Home-based pulmonary rehabilitation appears to be safe as well as effective,” Rochester said during her presentation. “Tele-pulmonary rehab is particularly suited to increase access in remote areas that lack center-based programs [and] is suitable to provide pulmonary rehab in the context of a pandemic.”

Home-based rehabilitation is also a cost-effective option, where studied. The costs appear roughly equivalent to the costs of delivering center-based rehabilitation programs, at least some health care systems, Rochester said. According to Rochester, a previously prospective economic analysis demonstrated a benefit of home-based rehabilitation for lower costs and increased utility.

Rochester said patients generally report that home-based rehabilitation positively impacted their physical fitness, breathing and mood, and that they value the flexibility and convenience. In one study, 83% of patients reported feeling much or a little better after home-based rehabilitation, which suggests that this type of rehabilitation was acceptable and appreciated by patients while aiding in overcoming some barriers to participation, according to Rochester.

However, the optimal candidates to participate in novel models of pulmonary rehabilitation such as tele-rehabilitation or other models of home-based rehabilitation are not yet certain. Provider and patient conversations are important when deciding on tele-rehabilitation or other models of home-based rehabilitation vs. traditional center-based pulmonary rehabilitation for patients with COPD. Center-based models may be optimal for those with complex multimorbid chronic illness.

“Shared decision-making between patients and health care professionals is important to address patients’ preference, as this may improve patients’ motivation, completion of the program as well as patient outcomes,” Rochester said. “Maintenance of patients’ safety is also of paramount importance.”

’Personalized medicine for pulmonary rehabilitation’

Combining aspects of both tele- and center-based pulmonary rehabilitation could yield stronger benefits and implementation.

“Many patients [participating in] rehabilitation of any sort say, ‘Well, I’m in rehabilitation, I don’t need to do anything in the house, I just need to do it when I’m with the health care professional in the medical setting.’ False,” Barry J. Make, MD, professor of medicine at National Jewish Health, Denver, said during his presentation. “Appropriate frequency of exercise is at least three to four times a week. I like four to five times a week for aerobic lower-extremity exercise for my patients. Can you do that in the medical setting? No.”

According to Make, it is beneficial to utilize both a medical setting and home setting to meet the goals of pulmonary rehabilitation.

To improve a patient’s physical condition, the physician should assess what the condition is and determine whether it is safe for the patient to exercise, which is generally done in a medical setting or by interacting with a therapist. After these assessments, a physician can then instruct their patient on safe and effective exercise techniques beginning in a medical setting and then translating to the home.

Another goal of pulmonary rehabilitation is to ensure the patient can continue lifelong adherence to health-enhancing behaviors, including exercise. Make noted that physicians should monitor that the patient is actually performing the exercises requested while at home via in-person follow-up.

In addition, pulmonary rehabilitation should also improve a patient’s psychological condition. During the COVID-19 pandemic, many patients with COPD may not have been able to leave the house or be socially engaged. However, it is important for patients to connect with patients with similar problems to discuss ways to overcome their, which may not be suitable through telehealth for all patients, Make said.

“We know patients have trouble with transportation getting to pulmonary rehabilitation, financial burden and interruption with daily routines. But, in addition, patients accept rehab because they like [the] support [and] encouragement from health care professionals and from others as well,” Make said. “Personalized medicine for pulmonary rehabilitation, I think, is a key component.”

Make said personalized medicine for pulmonary rehabilitation entails collaborating with patients to aid in self-managing their COPD at the right time, with the right type of therapy, in the right setting. It is important to ask patients how to overcome barriers to rehabilitation with combining center-based, home-based, hybrid programs, telehealth and telemonitoring, Make said.

Ongoing discussion

Research on home-based pulmonary rehabilitation and telemedicine continues to evolve. One challenge is that few outcomes have been assessed, to date, and trials have been of short durations and at a small number of centers worldwide. As a result of these challenges, Rochester noted that home-based pulmonary rehabilitation is not yet widely funded or reimbursed.

“Further research is needed to assess the efficacy, candidacy and cost-effectiveness in pragmatic real-world trials,” Rochester said. “The successes and outcomes likely will ultimately depend on the precise model of home-based pulmonary rehab delivered and on the health system in which it is operating.”

While current evidence suggests that home-based pulmonary rehabilitation is effective, safe and has potential for certain individuals, it is not meant to replace center-based pulmonary rehabilitation but meant to complement it as an additional resource for patients with COPD, Rochester said.

“I propose that continued research and practical or widespread implementation of home-based pulmonary rehab using various models, including tele-pulmonary rehab, will prove valuable both to patients and the health care system,” Rochester said.

Reference:

• Make BJ, et al. Home Pulmonary Rehabilitation is Not the Standard of Care. Presented at: American Thoracic Society International Conference; May 14-19, 2021 (virtual meeting).