Reply to Moy: Not All Home-based Exercise Programs Are Home-based Pulmonary Rehabilitation Programs

From the Authors:

We thank Dr. Moy for her interest in our study and her thoughtful comments. The central premise of her letter is that home-based pulmonary rehabilitation (PR) programs are not equivalent to traditional center-based PR because of perceived differences in the level of exercise achieved and the professionals administering the intervention. We agree with Dr. Moy that there are many unanswered questions, for which we also support further study. Our team was indeed multidisciplinary and involved an exercise physiologist to administer live instructions and monitoring, a respiratory therapist to provide education on disease management and inhaler training, a psychologist to deal with anxiety and depression, and a pulmonologist to manage disease and comorbidities. Patients also received smoking cessation and dietary advice when applicable. We agree with her that although we mimicked the components of traditional PR, the intensity of exercise achieved was different, and in most cases lower. We also agree with her that the intensity of exercise is linearly associated with improvements in exercise endurance, but there is now ample evidence to suggest that home-based interventions that use minimal equipment and are less intense result in improvements in 6-minute-walk distance and quality of life that are similar to those achieved with traditional PR (1, 2). Although there were significant improvements in 6-minute-walk distance, muscle strength, and quality of life in the telehealth arm, our research letter did not describe these results because these measures were not acquired in control subjects. One also has to weigh the physiological benefits of a traditional PR intervention that has a 50% chance of completion against those of a less intense intervention that has a higher likelihood of completion (3). Our intervention was safe and none of the subjects reported any adverse events. We first approached potential patients to participate in the telehealth intervention, as our traditional PR participation rate after discharge has been approximately 5% (4), a number reflected in the data for control subjects in this study. The videoconferencing sessions were performed using a Health Insurance Portability and Accountability Act–compliant app, and no video data were recorded. Although there are privacy concerns with conducting live monitoring at a patient’s home, we believe these are no greater than those possible in supervised home PR sessions and perhaps group activities in traditional PR.

Dr. Moy suggests that the observed benefits of our video intervention were possibly due to individual counseling and monitoring that could have led to earlier detection of exacerbations and outpatient therapy. Although this is possible, we believe this is unlikely to explain the benefits, as patients who were not exposed to the telehealth intervention also received daily phone calls for 2 weeks and then weekly phone calls for 3 months (4).

Dr. Moy also calls for a randomized controlled trial with three arms comparing video PR, traditional PR, and no PR before video PR attains PR status. An important distinction to make in comparing our video telehealth PR program with other center-based and home-based programs is the indication for receipt of telehealth PR in our study (5). Our patients were enrolled during hospitalization and had extremely poor functional capacity at discharge. Their ability to participate in an optimal-intensity PR program was thus limited. We also believe we should not be too dogmatic about the notion that PR interventions can be called PR only if they involve attending sessions at a center with access to expensive equipment and a team of experts. Although this is ideal, this approach has clearly failed in the real world (6), and efforts should be made to test and invest in new and alternative methods for delivering PR (7). These approaches include alternative exercise strategies such as tai chi and yoga (8), interactive web-based PR (9), home-based supervised PR, and video telehealth PR (5).