Pulmonary Rehabilitation in Persons With COPD

Abstract

Pulmonary rehabilitation (PR) is a high-value intervention for persons with COPD and other chronic lung diseases. It is associated with improvement in exercise capacity, dyspnea, health-related quality of life, and depression as well as a reduction in hospitalization and improved survival when PR follows COPD-related hospitalizations. PR is underused in the United States and other countries despite strong evidence of both clinical effectiveness and cost-effectiveness. Additional challenges include a lack of equitable reimbursement and poor access, particularly in rural settings. Models, for example, virtual PR, may be an option for improving access but coverage in the United States by Medicare is tenuous. In addition, virtual PR models have considerable heterogeneity, which challenges uniform efficacy and selection of optimal candidates.

Introduction

Pulmonary rehabilitation (PR) is a high-value intervention for persons with COPD and other chronic lung diseases.^1-4 PR benefits in persons with COPD include improved exercise capacity, dyspnea, fatigue, depression, health-related quality of life, reduction in hospitalization,^2-6 and improved survival when PR follows COPD hospitalization.⁷ Further reinforcing the strength of evidence of PR effectiveness, a Cochrane review noted in 2015 that additional randomized control trials that compare PR and conventional care in COPD were not warranted.⁵ The review supported future research of optimal PR duration, location, supervision, training intensity, and length of treatment effects.

Review of the Literature

PR Importance and Challenges

PR includes a comprehensive, multidisciplinary approach that includes supervised exercise training, self-management education focused on behavior change, and support from peers. Despite strong evidence of multidimensional benefits of improved exercise capacity, dyspnea, fatigue, depression, health-related quality of life, and reduction in hospitalization,^2-6 and improved survival when PR follows COPD hospitalizations,⁷ PR referral and utilization is < 4% in the United States⁸ and < 10% after discharge for exacerbation of COPD.⁹ Additional barriers that challenge effective PR are numerous and include poor awareness of PR among health-care professionals and caregivers,¹⁰ transportation difficulty and long distances to be traveled to PR centers,¹⁰ geographic disparities with inadequate rural options,¹¹ and limited training opportunities for PR professionals.^9,12 Inadequate PR reimbursement further limits the impact of PR, with Medicare payments for PR < 50% of that paid for cardiac rehabilitation. This inequity occurs despite substantial clinical improvements in a more-complex patient population with multi-morbidity and greater incidence of hypoxemia and frailty versus patients in cardiac rehabilitation.

In addition to effectiveness in improving patient-centered outcomes, PR is cost-effective.¹³ In an analysis of Medicare beneficiaries receiving timely PR following COPD hospitalization, Mosher et al¹³ found that there was a net cost savings per patient of $5,721, primarily from reduced hospital and skilled nursing facility days, and improved quality-adjusted life expectancy by 0.53 years. When assuming completion of 36 PR sessions, a single PR session would remain cost saving up to $171 per session. At a willingness-to-pay of $50,000 per quality-adjusted life-year (QALY), a standard for high-value interventions, PR would remain cost-effective up to $884 per session and $1,597 per session for $100,000/QALY (Table 1).

Table 1.

Seminal Studies

PR Evidence and Guidelines

The evidence base for effectiveness of PR has grown exponentially in the past 40+ years to include several clinical practice guidelines that represent all major international pulmonary societies as well as numerous Cochrane reviews and scholarly publications. Several of these publications are summarized in Tables 1, 2 and 3. The strength of the evidence helped establish United States PR payment by Medicare and the understanding of the effectiveness of PR in a range of pulmonary diseases and settings. A recent American Thoracic Society (ATS) PR policy statement by Rochester et al¹² targeted the need to advance policy to make PR a greater priority. Priorities included the following: advancing healthcare professional, payer, and patient awareness and knowledge of PR, increasing patient access to PR, and ensuring quality of PR programs.¹² It also recommends areas of future research to establish evidence to support the development of an updated funding and reimbursement policy regarding PR.¹² The statement documents the ATS and ERS [European Respiratory Society] commitment to undertake actions to improve access to and delivery of PR services for suitable patients and invites other health professional societies, payers, patients, and patient advocacy groups to join in the commitment.¹² This statement solidifies the reality that poor access, uptake, payment, and lack of PR as a priority will overwhelm the evidence base and effectiveness of PR, and further erode access.

Table 2.

Evidence-Based Guidelines

Table 3.

Clinical Statements

PR Implementation

Important features of effective PR include a comprehensive patient assessment, which includes functional capacity, development of an exercise prescription, detailed outcome assessment, collaborative goal setting, documentation of assessment, and a plan for PR and team conferencing. Patient engagement is essential in discussing and planning the duration and frequency of PR sessions and what potential improvements the patient may achieve and methods used. Discharge planning should begin at the first meeting and focus on long-term behavior change, physical activity, and considerations for successful achievement of enduring benefits.

PR Assessment

PR should be preceded by a comprehensive assessment that identifies the current pulmonary diagnosis and optimizes medical management of lung disease and comorbidities. Elements of a PR assessment are summarized in Table 4. In addition, determination of the patient’s goals and priorities is essential to providing individualized effective PR.

Table 4.

Pre-Assessment Considerations for PR in COPD

Patients with significant orthopedic, neurologic, cognitive, or other limitations may be better served by an initial referral to physical therapy to determine if walking, strength, exercise capacity, and judgment are adequate for participation in PR. When indicated, optimizing strength and balance before PR may be appropriate.

Exercise in PR

Abnormalities of skeletal muscle function, pulmonary pathology, and symptoms contribute to inactivity, deconditioning, and disability in persons with COPD.¹⁴ PR includes progressive exercise training to improve ambulatory muscle function, dynamic hyperinflation, and symptoms.^15,16 Effective exercise begins with appropriate assessment (Table 4), including optimization of pulmonary mechanics based on medication assessment, inhaler device use, adherence, and control of adverse effects. Hypoxemia should be assessed at rest; during walking; and, for patients who are oxygen-dependent, while using their ambulatory oxygen system. Hypoxemia should be effectively managed based on evidence-based guidelines.¹⁷ Ongoing ${\text{S}}_{{\text{pO}}_{\text{2}}}$ monitoring and, when appropriate, oxygen titration are important components of PR sessions. A meta-analysis that included studies of persons with severe exertional room air hypoxemia found that supplemental oxygen was associated with a mean increase of a 6-min walk distance of 28.9 m versus room air.¹⁷ Patients who require oxygen should be trained in its benefits and limitations, the importance of adherence, safety, and considerations for interface with suppliers and insurers.

Evaluation of exercise performance should include either a submaximal field exercise test such as a 6-min walk test or maximal tests such as a shuttle walk test or a cardiopulmonary exercise test. A cardiopulmonary exercise test may offer important information with regard to mechanisms of exercise limitations, exercise safety, and development of the exercise prescription. If a cardiopulmonary exercise test is not performed, then submaximal field testing, such a 6-min walk test,^18,19 can inform establishment of the exercise prescription and ongoing exercise progress. The 6-min walk test is considered valid, reliable, and responsive to rehabilitative interventions, and is most suited as a measure of functional exercise performance versus exercise capacity.¹⁸ An initial 6-min walk test should be performed twice with the greatest distance used.¹⁸ All test features should be consistent during the initial, repeated, and post-rehabilitation testing. The standardized protocol for testing, including indications for termination of the test, should be followed.¹⁸

General guidelines for exercise prescription and progression in COPD should follow an individualized methodology of frequency, intensity, time, and type¹⁹ based on the patient’s exercise testing results, functional and cognitive capabilities, physical limitations, and clinical and patient goals. Individualized exercise should include both upper and lower body aerobic and resistance training, and be preceded by a warm-up period and followed by a cool down period consistent with American College of Sports Medicine guidelines.¹⁹ Aerobic exercise time is often gradually progressed before other elements of frequency, intensity, time, and type of methodology are increased. Intensity and duration guidelines should be considered together because they indicate the total energy expenditure of an exercise session. Standardized methodology for progression should follow evidence-based guidelines such as those published by American College of Sports Medicine for persons with COPD.¹⁹

The American College of Sports Medicine Guidelines for Exercise Testing and Prescription¹⁹ is an important resource for key concepts of exercise in COPD. The guidelines recommend that persons with mild COPD may be candidates for guidelines used for healthy older adults; however, those with severe COPD, significant deconditioning, or symptom burden may be appropriate for light-intensity aerobic exercise.¹⁹ For those with moderate-to-severe COPD, intensities representing >60% peak work rate have been recommended.¹⁹ If continuous training is not tolerated, then interval training may be suitable.¹⁹

Exercise intensity may be assessed by using the peak work rate, peak oxygen uptake, or dyspnea ratings, normally by using a Borg category ratio 10-point scale rating between 4 and 6.^14,19,20 Ventilatory limitations to exercise in pulmonary disease may limit the appropriateness of prediction of peak oxygen uptake based on the age-predicted heart rate.¹⁹ Clinicians should closely monitor the initial exercise sessions and adjust the intensity and duration based on the patient’s tolerance as well as physiologic and subjective responses. Symptoms, especially dyspnea, are of greater importance in assessing exercise tolerance, intensity, time, and progression versus other methods and components of an exercise prescription. As noted previously, a comprehensive assessment before PR exercise is essential to inform and address risk stratification. An experienced physician should be immediately available on site or virtually for any needed PR supervision and/or patient clinical instability. Ongoing staff competency is necessary to maximize management of clinical care, untoward symptoms, and medical emergencies.¹⁹

Functional capacity and ongoing exercise are central to PR; however, long-term behavior change and physical activity are equally important priorities. Inactivity is an important predicator of mortality in COPD,²¹ yet PR has variable impact on physical activity levels.²² Exercise training combined with effective bronchodilation has the potential for improving exercise tolerance in COPD,²³ although adding behavior modification is needed to yield improvement in physical activity.²⁴ Although PR may not result in improved physical activity, it improves functional capacity, which may lay the foundation to support improvement in activity. Behavior change that targets long-term exercise, adaptive behaviors, and physical activity is essential. This should include an individualized approach that incorporates the patient’s goals and engagement wherever possible.

Education

The role of education as part of PR is evolving rapidly, with important technologic advances in part as a response to the COVID-19 pandemic. Technology supported education has rapidly increased in the past decade, with ∼80% of manuscripts on this topic published since 2020.²⁵ Education studies have assessed use of social media, applications, virtual reality and/or gaming, and telehealth approaches.^26-30 Technology-supported education has demonstrated comparable improvements in knowledge acquisition and health outcomes versus traditional educational models, including improvement in quality of life, physical activity, and self-care.²⁵ Patient acceptance has generally been favorable.²⁵ There are concerns of difficulty in forming relationships with health-care providers and peers,²⁷ despite the potential for enhanced options for connecting with clinicians. Blended PR programs that combine online theory-based components with in-person training on motor skill and decision-making–based learning may offer future refinement of educational approaches.

Optimization of education models should include personalization geared toward the patient’s goals. Options may include self-management, mentoring and coaching in skill development,³¹ peer-to-peer learning via social media and apps,³² and psychomotor skill development.³³ There is growing emphasis on knowledge as a key outcome, including feedback to assess learning,³³ and optimizing application of new capabilities of daily life. Recent approaches have focused on skills acquisition, coaching, and on mentoring, and the delivery of behavior change. Evaluation of impact has targeted knowledge and health outcomes to date, which limit the determination of the scope of the impact of education. Other areas of potential importance include assessment of the impact on quality of life, physical activity levels, health behaviors, and health-care utilization. Although education may not improve health-care outcomes versus exercise programs alone,³⁴ PR attendance and completion seem to improve with patient education,^35-37 which suggests an important role in impacting population health when considering PR’s chronically poor completion rates.

Development of patient education models has expanded internationally beyond Western cultures. However, in-depth details of these international models are not fully available, which suggests a greater need for a more-robust description of learning outcomes, curriculum design, and educational approaches. The understanding of effective adaptations for culturally diverse groups is an important next step for supporting people from throughout the world to self-manage their chronic respiratory disease.

Future opportunities include technology-enabled learning, enhancement of face-to-face education through less didactic, and more active individualized learning approaches and addressing geographic barriers for accessibility and flexibility of learning. A focus on outcomes such as confidence, motivation, and adherence with long-term health behavior change are important. The many contextual factors that influence education support the importance of ongoing innovation, both at research, and individual PR program levels. There is currently no best practice model for PR education, which supports the need for ongoing investigation.

Emotional Function and PR

Anxiety and depression are common in persons with COPD and are associated with impaired health-related quality of life and adherence.³⁸ Underdiagnosis and inadequate treatment of mood disorders negatively impact function, engagement, fatigue, and health-care utilization. PR plays an important role in improving awareness of mood disorders and related symptoms via assessment, including the use of standardized, validated questionnaires before, during, and after the PR program. Any significant or new abnormal findings or symptoms, or any endorsement of suicidal ideation needs to be promptly reported to the referring clinician and primary provider, with regular follow-up by the PR clinician.

A 2015 Cochrane review found that PR is associated with statistically significant improvement in health-related quality of life when using the Chronic Respiratory Disease Questionnaire scores in domains of fatigue, emotional function, and mastery that exceed the minimum important difference of 0.5 units, including fatigue: mean difference 0.68, 95% CI 0.45–0.92; emotional function: mean difference 0.56, 95% CI 0.34–0.78; and mastery: mean difference 0.71, 95% CI 0.47–0.95.⁵

PR Models

In an attempt to address challenges to PR access, the 2015 ATS and European Respiratory Society PR policy statement recommended development of novel PR models that make rehabilitation more available and acceptable to patients and payers.¹² Studies of remote PR models have demonstrated potential efficacy and safety³⁹; however, there is heterogeneity in remote models and uncertainty with regard to patient characteristics that are best suited for virtual versus center-based PR models.^39,40 This uncertainty reinforces the importance of including essential components of PR during virtual delivery. Validated outcome measures should focus on exercise capacity, symptoms (including dyspnea), health-related quality of life, and depression, and should be assessed before and after PR. Assessment of PR’s impact on health-care utilization should include hospital admissions.

To better understand priorities for novel PR models, the ATS report “Defining Modern Pulmonary Rehabilitation” describes priorities and challenges of virtual and remote PR models.⁴⁰ The workshop confirmed the relevance of the 2013 ATS European Respiratory Society PR definition irrespective of the setting¹⁴: “PR is a comprehensive intervention based on a thorough patient assessment, followed by patient-tailored therapies, which include, but are not limited to, exercise training, education, and behavior change, designed to improve the physical and psychological condition of patients with chronic respiratory disease and to promote the long-term adherence of health-enhancing behaviors.”

The report recommends that only PR models tested in clinical trials should be considered for implementation.⁴⁰ PR components should include a comprehensive patient assessment, determination of patient goals, validated quality-assurance methods for established PR outcomes, and safety, including regular audits and reporting to the PR team and leadership.⁴⁰ The workshop describes 13 essential components of PR by focusing on patient assessment, program content, method of delivery, and quality assurance (Fig. 1).⁴⁰ Program selection may be related to the patient’s goals, needs, and preferences as well as local resources and options.⁴⁰

Fig. 1.

Essential components of pulmonary rehabilitation. From Reference 40, with permission.

PR Resources

Resources for development and improvement of clinical effectiveness of PR programs are available. The American Association of Cardiovascular and Pulmonary Rehabilitation PR guidelines, fifth edition,⁴¹ offers robust and unique guidance for PR clinicians with regard to a broad range of clinical, organizational, and regulatory areas. Areas of focus include exercise assessment and prescription, PR team considerations, billing, program certification, and extensive program resources (Table 1). A national PR program certification is available from the American Association of Cardiovascular and Pulmonary Rehabilitation that includes assessment of PR program delivery, operations, safety, staff competency, patient outcomes, and other PR-related measures (aacvpr.org/program-certification). PR staff recruitment, training, and regular competency assessment should include education and staff demonstration of understanding of evidence-based PR practices and best practices from the American Association of Cardiovascular and Pulmonary Rehabilitation,⁴¹ ATS, and American College of Sports Medicine. Other international PR guidelines may be of value in optimizing care (Table 1). Staff orientation and ongoing education and mentoring help support effective PR. Staff should also be trained in strategies for translating traditional interventions into novel PR models. A PR certificate, which targets PR clinician knowledge and skills, is available for PR staff from the American Association of Cardiovascular and Pulmonary Rehabilitation and the American Association for Respiratory Care (https://www.aacvpr.org/Pulmonary-Rehabilitation-Certificate. Accessed March 2, 2023).

Summary

PR is well established as the standard of care in persons with chronic lung disease, including COPD. Guidelines, statements, and reports from ATS^12,14,17,18 and the American College of Sports Medicine¹⁹ provide a framework for program delivery. The American Association of Cardiovascular and Pulmonary Rehabilitation guidelines⁴¹ provide information with regard to PR operations and important clinical resources (Table 1). There continues to be a need for standardized, validated training for PR clinicians, including the use of exercise assessment and prescription, validated physiologic measures and strategies for addressing self-management, and long-term behavioral change. This model ideally would involve collaboration of clinical and scientific societies, and would include a mentoring option. The American Association of Cardiovascular and Pulmonary Rehabilitation/American Association for Respiratory Care PR certificate provides an important basis for addressing this need. A multi-society interactive model has the potential for advancing an evidence-based approach tailored to the needs and goals of the patient and to optimize PR provision and outcomes.

Despite established effectiveness and the importance of PR, there are several challenges that must be addressed. PR access, awareness, and payment are inadequate and lag compared with cardiac rehabilitation. Addressing geographic disparities should be a priority for PR. Strategies should include developing approaches to improving clinician and patient awareness of the benefits of PR, staff training for providing PR, addressing payment inequities, and exploring virtual models for remote areas.¹¹ Virtual models may offer a potential for much needed access in rural settings, yet their heterogeneity and the lack of uniform long-term Medicare payment pose important barriers to success. Long-term improvements in physical activity have proved difficult to attain.²² Given the mortality risk this poses for persons with COPD, future investigation into effective treatment strategies is a high priority.

Sustaining the quality and effectiveness of PR must be a priority. There is a need for caution with regard to suggestions that non-PR models are effective and reasonable PR substitutes, for example, tai chi, yoga, self-management.⁴² Personalization of PR is an important area of future focus, including the use of collaborative management that engages and informs patient decision-making whenever possible.

Discussion

MacIntyre: That was quite an overview. I’ve been in the pulmonary rehabilitation business for a long time and this reimbursement chaos I really don’t understand. At Duke, we long ago adopted a physical therapy model for non-COPD billing, which I must admit has turned out to be a successful and stable source of revenue. As far as COPD billing, however, we have been forced to use Centers for Medicare and Medicaid Services (CMS) codes that pay far less than both physical therapy codes and cardiac rehabilitation services. It amazes me that most pulmonary rehabilitation programs are in the same building with the same administrators and the same caregivers as the cardiac rehabilitation program. At our place, cardiac has the building in the morning and we have the building in the afternoon. How did we miss out on all the wisdom of cardiac rehabilitation in constructing the pulmonary rehabilitation billing? They’re the same people, I just don’t get it.

Garvey: Yes, there’s been some discussion about this. We are too meek about the impact of pulmonary rehabilitation. Cardiac rehabilitation and cardiologists are great at tooting their own horn about how important the intervention is. Clearly, if you had an myocardial infarction or bypass surgery, it would be nearly malpractice to not send most patients to cardiac rehabilitation. It’s in numerous guidelines and supported by insurance coverage. Whereas, with pulmonary rehabilitation, fewer than 5% of the eligible patients are getting rehabilitation. We’ve not done a good job of pushing how effective pulmonary rehabilitation is and that it needs to occur. It’s a problem with COPD in general, and pulmonary rehabilitation is an example of how poorly understood and poorly used effective, safe care is. A large American Thoracic Society (ATS) working group representing several societies is working to help providers to be more knowledgeable, including giving them tools to interface with the hospital chief financial officer and the head of billing to better understand where the billing is falling short of appropriate charges for comprehensive pulmonary rehabilitation in complex patients, and tools for addressing how it needs to be modified and why. Our patients are generally much more complex and symptomatic than cardiac patients. Cardiac patients have often had a bypass or angioplasty and their heart function and symptoms are normally greatly improved. We’ve missed the boat, and we need to address these inadequacies or else we’ll be in the Smithsonian Institute with liquid oxygen. We have to take this seriously. You and I have been doing this a long time. Nobody was watching the financial books in my opinion, and so now we have to make up for lost time with regard to inadequate reimbursement. And we are. It’s slow, but we’re making progress. My goal is to provide evidence to Medicare that pulmonary rehabilitation is highly effective clinically and highly cost-effective. We also are working to help patients and the public know how important these priorities are.

MacIntyre: So let me be political here for just a moment. The American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) should represent both cardiac and pulmonary rehabilitation. Are the cardiology folks at AACVPR willing to go to bat for their little brother?

Garvey: It is getting infinitely better. I was on the board for 5 years. Years later, we noted that the board one year had included no pulmonary rehabilitation people. And I said, “so you’re planning on changing your name to the AACVR, right?” and they had to back step and try to fix that. The executive director now is on fire about improving pulmonary rehabilitation reimbursement. I sense that there is organization-wide appreciation that pulmonary rehabilitation payment needs to improve from an ethical and population health standpoint. She came up through the ranks so she gets it and she’s serious. She’s incredibly helpful, so we have to seize the moment, make this work, and not give up. I suspect that it is going to take 5 years to see improvement but we have the right people working on it, and it will happen. We just need to not give up.

Carlin: In follow-up of our previous discussion, I was part of the team that went to CMS to discuss coverage for pulmonary rehabilitation services. We were delighted that Congress did then pass a law providing coverage for pulmonary rehabilitation. We didn’t realize that the second, and probably most important, component for all of this was to determine a level of reimbursement for those services. CMS reimburses for services based on a cost analysis that is provided from the hospitals each year. What we didn’t realize is that hospitals have consistently reported cost data that is much lower than that needed to provide those services. Thus CMS would reimburse for those services at a lower rate. Unfortunately, it takes several years for that data to be processed and updated/changed. Several societies (ATS, AACVPR, AARC, ACCP) have put together a pulmonary rehabilitation reimbursement toolkit that rehabilitation programs and hospitals can use to accurately report those costs associated with pulmonary rehabilitation. (This toolkit is available on the AACVPR and AARC websites currently.) Hopefully, more hospitals will report their costs more accurately and thus result in a change (hopefully for the better) for the provision of those services. Too bad we all didn’t realize this from the start of the process. We are now nearly 15 years since the congressional law was passed and we are still trying to get more appropriate reimbursement for those services.

Garvey: And, also, cardiac rehabilitation had a survival benefit early on, which helped. That’s something we need to promote, a survival benefit. I know this is a COPD meeting but Sabina Guler⁴⁷ published a multi-center international retrospective trial in Thorax that we at University of California San Francisco were a part of. The study looked at fibrosis interstitial lung disease, and there are signals for a pulmonary rehabilitation survival benefit. We need to do further investigation to see if this is a clear outcome. Rich Casaburi and I are looking for opportunities to move this type of investigation forward.

Carlin: I have another question. What do you think are the two biggest opportunities for pulmonary rehabilitation over the next 2–3 years?

Garvey: I think getting the word out to the patients to help empower them is important. The COPD Foundation has done a great job with this. It’s important for patients and the public to know how high value pulmonary rehabilitation is given its significant outcomes, yet how poorly it is reimbursed in the United States. We also need to refine virtual models by both addressing poor coverage and payment, and assuring services meet established quality standards, including improvement in functional capacity, dyspnea, and quality of life. We need to be careful due to the risk of diluting the quality of the intervention if current ATS standards are not consistently followed. Equitable payment is equally a high priority. Virtual pulmonary rehabilitation has the potential to fill an important gap for persons in rural settings. Those are two things we need to take seriously. What’s good right now is all the major societies are working together. ACCP has a pulmonary rehabilitation advocacy group. ATS, ACCP, AACVPR, and the AARC are very involved in reimbursement and advocacy. We need to not back down and keep focused on effective approaches to improving payment, access, and awareness.

Criner: Chris, very nice talk. What would be your recommendation on the ideal format for a pulmonary rehabilitation program? If you could create one, what would that structure look like?

Garvey: I think virtual models are potentially very important, yet we need assure that they include all the key elements of the center-based programs. The before and after rehabilitation assessment needs to be done in person. You need to get a 6-min walk test to predict what the patient can do in terms of exercise. Otherwise you’re in uncharted waters. And, look at safety in the home. There’s some guidance by ATS and AACVPR for home exercise as part of virtual pulmonary rehabilitation. If you are referring a patient, be clear that this is a good candidate for home pulmonary rehabilitation, including screening for balance and cognitive function limitations. My coworker at University of California San Francisco helped develop virtual exercise options for rehabilitation and used skills from teaching in the community. Virtual models are different from center-based rehabilitation. In the center, we’re regularly interfacing with the patient and both distracting and supporting them. And, they often remark, “wow I’m exercising — this is great!” whereas in the home, you have to keep them excited and invigorated. It’s more of a gym experience where you’re guiding interesting and important exercise that is not boring. It’s a different mindset. So being somewhat innovative is important. Safety is a priority. For many, web conferencing calls don’t allow you to see the patient’s legs. There’s a lot you need to build in. What we’re missing in the United States is the evidence base for this intervention. It’s vital to get a before and after in-person 6-min walk test and validated assessment for dyspnea, quality of life, and mood, and that any mood issues are managed and optimized, as well as full clinical workup before rehabilitation. That’s the starting point. Also needed are training and supporting the staff who are willing to adapt to virtual models, because it’s something new to learn how to modify traditional rehabilitation to make the best model possible. It’s important to work with your colleagues and have a network statewide or nationally so you can ask questions. In California, we have a pulmonary rehabilitation society with quarterly town hall meetings. There’s a wonderful exchange between experts and novices. It’s a good opportunity for figuring this out. We just need to start slow and figure out the right methods. I think all of you are an important part of the answer because you can lead the process and help the programs.

MacIntyre: We’ve been experimenting with tele-rehabilitation, and my own bias is that the personal touch has to be a critical component. There are some who believe pulmonary rehabilitation in the home can be done entirely automatically with an app that the patients run on their own. I’m just concerned that they need to have some kind of regular contact with the team. Am I just an old-fashioned guy or does that make some sense?

Garvey: I think that’s right. There’s a subset of patients who don’t need a lot of supervision. These are people who have often always been fit and maybe they can get back on track without much supervision. But, the majority have disabling symptoms, many have mood disorders, and they’re often complex. It takes an expert or somebody knowledgeable, and, if they aren’t there, it takes a multidisciplinary team to provide the best care. About a personal touch, it’s said that “they don’t care how much you know until they know how much you care.” That sort of connection. I care about you, this time is for you, let’s help you be the person you want to be and get your life back to the best degree possible. You’re right, it should be as personal as is appropriate.

Mike Hess: One group I haven’t seen pop up, particularly with physicians, is primary care. And I know a lot of primary care physician are reluctant to refer for a variety of reasons. My question to you is do you think that barrier is more therapeutic nihilism or ignorance of pulmonary rehabilitation? And, how do we overcome that?

Garvey: I think it’s both. It’s partly that we haven’t done a good job of making it easy for them and giving them tools to know who they should refer. But I’m glad you brought it up because it’s something our group needs to be looking at. Pulmonologists are very busy, and patients often can’t get into the chest clinic for months. That’s too long to wait. Great point and you’re absolutely right.

Carlin: I think they’re also aware that there’s a lack of reimbursement for it, so they don’t even want to address it.

Garvey: That’s exactly right. There’s a lot of negative press out there that people just assume it’s not available. We’re trying with social media campaigns to overcome that belief, but we have a long way to go. Thank you to everybody who’s been involved in helping with this.