Patients with Chronic Obstructive Pulmonary Disease Require More Than Pulmonary Rehabilitation to Improve Outcomes

To the Editor:

We read with great interest the publication by Nici and colleagues summarizing the evidence that supports expansion of pulmonary rehabilitation beyond traditional center-based settings, and calling for research on new models of delivery to expand the reach of this intervention (1). As the authors highlight, increasing evidence indicates that home- and community-based programs offer improvements in outcomes equivalent to those achieved by center-based programs, and technology-based delivery will further increase the reach of these programs. In looking to the future, they describe several challenges to be addressed through research in developing new models of pulmonary rehabilitation: 1) promoting referrals, 2) increasing patient uptake, 3) tailoring the program type to the severity of the patient’s impairment, 4) optimizing cost-effectiveness, 5) optimizing the robustness and fidelity of the intervention, and 6) ensuring that health professionals acquire skills in behavioral-change techniques and new technologies. A challenge not mentioned is the decline in benefits after about 12 months of participating in pulmonary rehabilitation and the need for interventions to sustain improvements. These many challenges emphasize the complexity of developing and delivering new models of pulmonary rehabilitation.

Although technical fixes, such as an opt-out option for automated order-sets to increase referrals and educating physicians about pulmonary rehabilitation, may partially address some of these challenges, they will not address adaptive behaviors that limit patient uptake of pulmonary rehabilitation or other interventions to promote self-management behaviors. Results from qualitative studies of patients and providers may lead to improved interventions and help patients adapt to their chronic conditions by ensuring that their support needs are met (2–4).

Patients with chronic obstructive pulmonary disease (COPD) require ongoing cognitive and behavioral changes tailored to their specific needs and preferences (4), which cannot be accomplished during an 8- to 12-week period of pulmonary rehabilitation and may partly explain the decline in benefits after rehabilitation. Moreover, we are just beginning to understand the factors that affect the adoption and maintenance of new behaviors, such as increasing and sustaining physical activity after pulmonary rehabilitation (3). Further research is needed to identify facilitators of and barriers to self-management behaviors, and to use this information to tailor interventions that will help patients effectively adapt to their chronic illness.

Finally, as described by Nici and colleagues in the American Thoracic Society report on integrated care for patients with COPD, pulmonary rehabilitation alone is insufficient to address all the needs of such patients (5). Moreover, most healthcare systems are not structured to provide optimal care for chronic illnesses, and because of an insufficient workforce pipeline in all professions, there are ongoing gaps in providing chronic-illness care. Expanding the workforce to provide health coaching and other services with community health workers and peer support offers other potential solutions (6). It is evident that these challenges will require comprehensive and complex policy and health system solutions to address the unmet needs of patients with COPD and other chronic illnesses.