Use of pulmonary rehabilitation in 2019 low in adults with COPD
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Key takeaways:
- Less than 5% of adults with COPD used pulmonary rehabilitation in 2019.
- One reason for low use of pulmonary rehabilitation is that clinicians and patients are unaware of the benefits it offers.
A small proportion of adults with COPD used pulmonary rehabilitation in 2013, and this did not change much in 2019, according to results published in Annals of the American Thoracic Society.
“Pulmonary rehabilitation is remarkably effective in improving exercise tolerance and respiratory symptoms, perhaps significantly more effective than the pharmacologic medications available for COPD,” Surya P. Bhatt, MD, MSPH, professor in the division of pulmonary, allergy and critical care medicine at The University of Alabama at Birmingham, told Healio. “It is imperative that we as clinicians make an effort to refer more patients to pulmonary rehabilitation and also make sure that there are enough centers for them to be able to attend rehabilitation.”
In a retrospective analysis of a 20% Medicare beneficiary population, Bhatt and colleagues evaluated adults with COPD to see how use of pulmonary rehabilitation has changed from 2013 to 2019.
Researchers also used bivariate and multivariable logistic regression models to find factors that make patients more likely to use pulmonary rehabilitation.
In the 2013 cohort, 2.5% of patients used pulmonary rehabilitation, and this proportion slightly went up over the years. By 2019, 4% of patients used this therapy
As Healio previously reported, the number of individuals with COPD who received pulmonary rehabilitation rose from 2.6% in 2003 to 3.7% in 2012. With this in mind, Bhatt said the small change observed above from 2013 to 2019 was surprising.
“Given the increasing awareness of pulmonary rehabilitation and its benefits, and the changes in the payment structure, we were hoping to see an increase in the utilization rate and were quite surprised to see that there has been no change over the past decade,” Bhatt told Healio.
When evaluating days of pulmonary rehabilitation use across the seven years, 1-to-4-day use had a large proportion of patients (47.7% to 53.6%), with a smaller proportion (25.2% to 33%) using the therapy for more than 8 days.
Compared with 2013, researchers found elevated odds for pulmonary rehabilitation use in 2019 (adjusted OR = 1.49; 95% CI, 1.43-1.55) in a model accounting for “age, sex, race, socioeconomic status, comorbidity score, region, opioid use disorder, urban or rural residence and provider type.”
One of the reasons for low use of pulmonary rehabilitation among adults with COPD is the small number of available centers, Bhatt said.
“The number of rehabilitation centers is not sufficient for the number of patients who are eligible,” he told Healio. “Centers also appear to be closing down due to poor reimbursement from Medicare.”
Bhatt said another reason is that clinicians and patients are unaware of the benefits this therapy offers. Research has shown that patients with COPD who completed an 8-week pulmonary rehabilitation program had sustained improvements in anxiety and quality of life at 2-year follow-up. Additionally, for patients with COPD hospitalized with acute exacerbations, pulmonary rehabilitation during hospitalization vs. usual care resulted in better exercise capacity, quality of life and lower limb strength.
The final reason for low use of this therapy, according to Bhatt, is that it can be a challenge for some patients to pursue.
“There are other barriers to attending treatment that requires a visit to a center that is often perceived as time-consuming and is difficult for patients who have significant co-pays, difficulties with transport, live alone or have significant disease burden and comorbidities,” Bhatt told Healio.
Notably, researchers found reduced odds for pulmonary rehabilitation use based on several variables:
- older age (≥ 85 years vs. 66 to 74 years; aOR = 0.66; 95% CI, 0.64-0.69);
- Black race vs. white race (aOR = 0.9; 95% CI, 0.85-0.95);
- other race vs. white race (aOR = 0.62; 95% CI, 0.58-0.66);
- low vs. higher socioeconomic status (aOR = 0.68; 95% CI, 0.65-0.7);
- nonmetropolitan urban vs. metropolitan area living (aOR = 0.89; 95% CI, 0.87-0.92); and
- rural vs. metropolitan area living (aOR = 0.78; 95% CI, 0.72-0.85).
In contrast, having a higher vs. lower Elixhauser comorbidity score (3 or more vs. 0) was linked to greater odds for therapy use (aOR = 1.17; 95% CI, 1.1-1.25). Compared with patients with only a primary care provider, those managed by a pulmonary provider had higher odds for pulmonary rehabilitation use (aOR = 1.25; 95% CI, 1.16-1.33), as did those co-managed by primary care and pulmonary providers (aOR = 1.79; 95% CI, 1.75-1.83).
“More research is needed to understand factors that lead to dropout after [pulmonary rehabilitation] program enrollment and those that promote retention of patients in [pulmonary rehabilitation] programs,” Bhatt and colleagues wrote.