Authors: Surya P. Bhatt, Richard Casaburi, Christopher L. Mosher, Carolyn L. Rochester, Chris Garvey
Categories: Viewpoint: Turning the Air Blue
Source: American Journal of Respiratory and Critical Care Medicine
Pulmonary rehabilitation (PR) is a highly effective therapy for patients with chronic respiratory disease (1). PR is delivered most commonly at outpatient rehabilitation centers associated with hospitals. This delivery model is, however, at a crossroads. With stagnant Centers for Medicare and Medicaid Services reimbursements currently at approximately half the rate for cardiac rehabilitation, PR centers face substantial financial challenges to stay afloat (2, 3). Patients face significant barriers to accessing PR, such as distance and travel time, parking and copayment fees, and hurdles imposed by social isolation and medical morbidity (2). The SARS-CoV-2 pandemic hastened closure of several PR centers. There are now approximately 1,700 PR centers in the United States (4). With approximately 14 million patients with chronic obstructive pulmonary disease (COPD) eligible for PR, this translates to about 8,235 patients per center. A 2011 international survey indicated that median PR program capacity was 40 to 75 individuals per year (5), meaning that it would take roughly 137 years for all existing patients with COPD to participate in PR.
Telehealth PR, especially when delivered to a patient’s home with synchronous two-way video communication between the patient and a rehabilitation professional, is an attractive additional delivery model to increase PR access (6). Many recent studies have demonstrated clinical benefits associated with telehealth PR similar to those achieved in center-based PR; this is acknowledged in the recent American Thoracic Society (ATS) PR clinical practice guidelines (1).
The ATS PR clinical practice guidelines state that adults with stable chronic respiratory disease should be offered the choice of center-based PR or telehealth PR; this was based on moderate-quality evidence supporting similar improvements in 6-minute-walk distance and low-quality evidence supporting comparable improvements in dyspnea and quality of life (1). It is pertinent to note that the guidelines also pointed out the considerable heterogeneity in the telerehabilitation interventions studied and therefore were unable to recommend any specific model of telehealth PR (1).
Before concluding that telehealth PR yields outcomes comparable to those achieved with center-based PR, attention should be paid to some nuances (6). First, not all studies in the clinical practice guideline evidence base reported data on safety. Second, all studies in the evidence base required initial in-person evaluation to ascertain an individual’s suitability for telehealth PR and to address any safety concerns. Third, telehealth PR is relatively new, and most telehealth PR studies excluded patients with significant multimorbidity. Patients with more severe disease, such as those requiring high levels of home oxygen or with comorbidities such as severe heart failure or pulmonary hypertension have, for pragmatic reasons, been excluded from these studies. Fourth, there is insufficient data to suggest that telehealth and center-based PR are interchangeable for non-COPD conditions such as interstitial lung disease and pulmonary hypertension.
Most medical interventions in the United States are subject to minimum standards for accreditation and reimbursement. Over the past few years, the gap in PR availability has led to the mushrooming of several commercial entities offering telehealth PR. Given the shortcomings in center-based PR capacity in the United States, we welcome efforts to provide alternative avenues for rehabilitation through virtual PR, provided they deliver equivalent effectiveness and safety (7). Innovation in PR is desperately needed but should not come at the cost of patients deriving reduced benefit or suffering harm. An examination of websites of several newly established commercial telehealth PR programs did not reveal details about patient selection, patient assessments, monitoring, exercise prescription standards, and outcomes evaluated. Exercise programs are the cornerstone of PR; progressive high-intensity exercise training has been established as providing the greatest benefit. In these commercial telehealth programs, exercise intensity level is generally not well described. Telehealth PR often involves lower-intensity exercises, although it possibly compensates for this by greater convenience and better adherence and more closely matching patients’ day-to-day needs.
Some might consider that there is ambiguity between PR, physical therapy, and the physical activity and exercises offered in home health programs. Components of effective PR are well defined, however, including a template for what constitutes modern PR (7). The ATS workshop titled “Defining Modern Pulmonary Rehabilitation” clearly identified 13 essential components of PR. These encompass an initial in-person comprehensive evaluation that includes tests of exercise or functional capacity as well as measures of quality of life, dyspnea, nutritional status, and occupational status; exercise regimens that include endurance and resistance training; individualized prescription for initial exercise and progression; and delivery of these components by trained exercise professionals. Although the clinical trials included in the ATS PR clinical practice guidelines included the core components of PR, many U.S. commercial virtual PR programs do not provide an in-person assessment or exercise evaluation before PR, which may limit both exercise safety and exercise prescription development. Although no cost-effectiveness studies of telehealth PR are available in the United States, telehealth is generally perceived to be less expensive to health systems. At the end of the pandemic, the Centers for Medicare and Medicaid Services revoked payments for telehealth PR provided by hospital outpatient PR centers. Commercial entities likely use a mix of therapeutic monitoring codes and subscription payment options. As payers look to reduce costs, there is fear that some of these shortcomings will be ignored by decision makers, who may eliminate financial reimbursement for center-based PR altogether, further imperiling the continued existence of the center-based PR gold standard. We assert that center-based programs are critical for optimal health outcomes in patients with chronic respiratory disease, especially for those with multimorbidity, severe disease, or risk of complications that cannot be safely and effectively managed remotely.
Telehealth PR is here to stay, and we welcome innovations in this space. We do, however, need checks and balances to ensure that the appeal and benefits of telehealth PR are not misused by inexperienced or unscrupulous providers. To ensure that there are no dilutions in standards and outcomes achieved by patients, we advocate for requirements that telehealth PR programs demonstrate delivery of the essential components and expected outcomes of PR, implementation of only those interventions that have proven efficacy in clinical trials, increased funding to improve access to telehealth and center-based programs of proven effectiveness, more research funding to harmonize the most effective telehealth programs in comparison with center-based PR, and incentives from payers to discern between the levels of effectiveness provided by telehealth- and center-based PR. It has taken decades for center-based PR to be acknowledged as a standard of care for exercise-based improvements in health outcomes, and we should make every effort to maintain its high evidence-based standards.