COPD is the fourth leading cause of death in the United States, where it is estimated that 16 million people have the disease. It is debilitating, leading to the inability to conduct one’s normal activities of daily living due to shortness of breath and deconditioning.
A 2020 study, recently published in JAMA, found that COPD patients who participated in a pulmonary rehabilitation program within 90 days of hospitalization for exacerbation of their disease experienced a dramatic decrease in mortality rate within the first year after their hospitalization, compared to those who did not receive pulmonary rehabilitation. The one-year mortality rate for pulmonary rehabilitation participants was 7.3%, compared to 19.6% for those who did not go through a pulmonary rehab program within 90 days of hospital discharge. The retrospective study, which looked at nearly 200,000 Medicare beneficiaries in 2014, also found that if patients completed a few extra rehab sessions, the mortality rate was even lower after one year.
These and similar results have been repeated in study after study, year after year, throughout the world. Yet this study also found that the incidence of patients who were referred to pulmonary rehabilitation after hospitalization was “rare.” Only 1.6% of the entire cohort that was the subject of this study was referred to a pulmonary rehabilitation program. Medicare data suggests that 3-4% of eligible beneficiaries receive pulmonary rehabilitation.
Why is the enrollment rate so low when the outcomes are so great? After all, pulmonary rehabilitation is nothing new. This author has been developing and implementing pulmonary rehab programs throughout the United States for nearly 30 years, and they were not new 30 years ago. The joint European Respiratory Society/American Thoracic Society recommends that COPD patients enroll in pulmonary rehab within 3-4 weeks of hospital discharge. The Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease (GOLD), stated that “Pulmonary rehabilitation is the most effective strategy to improve dyspnea and exercise capacity and tolerance, and the program is essential treatment for all patients with clinically significant COPD symptoms or with prior exacerbations.” Despite the global consensus on the important role of pulmonary rehabilitation in the treatment of patients with COPD, the overwhelming majority of patients are denied access to these invaluable programs.
Availability of pulmonary rehabilitation programs across the country varies, but in general, it is low. This may be partly explained by the fact that even under Part A Medicare, reimbursement to hospitals is low for pulmonary rehab. When faced with the choice to use the square footage to build a cardiac catheterization lab or a pulmonary rehab program, the lab wins every time.
Lack of education, poor health literacy, living in a rural area, and lack of transportation are some other cited reasons why patients may not have access to pulmonary rehabilitation. But the greater responsibility for lack of access falls on the medical profession. Medical schools do not generally address the existence of pulmonary rehabilitation, let alone the potential cost-effectiveness and value to COPD patients. If pulmonologists or PCPs do refer their patients, they often do so as a last resort. They clearly do not understand that pulmonary rehab “incorporates lung exercise training, patient education, and behavioral changes,” because if they did, they would enroll their patients sooner, rather than later.
In the editorial that accompanied the research article in JAMA, Carolyn Rochester, MD, and Anne Holland, PT, suggested an increase in training for physicians. Rochester also made the following recommendations to the Centers for Medicare and Medicaid Services (CMS): “to require referrals of suitable patients to pulmonary rehabilitation as part of national health care quality metrics,” citing the findings as “a mandate for greater access and utilization of pulmonary rehabilitation in the treatment of patients with COPD. [CMS] should drive healthcare systems to offer this, and patients to advocate more for it.”
Now more than ever, as baby boomers continue to grow older, our COPD patients need access to pulmonary rehab. The onus is on all concerned stakeholders to emphasize the importance of opening up this simple yet incredibly effective modality to the majority of patients with COPD.
Boyles S “Early Rehab Following COPD Hospitalization Shown to Save Lives” 2020. https://www.medpagetoday.org/pulmonology/smokingcopd/86793?_ga=2.21120763.1785153780.1593025205-242973380.1593025205
Lindenauer PK, et al “Association between initiation of pulmonary rehabilitation after hospitalization for COPD and 1-year survival among Medicare beneficiaries” JAMA 2020; 323(18): 1813-1823.JAMA 2020; DOI: 10.1001/jama.2020.4437
Rochester CL, Holland AE. Pulmonary Rehabilitation and Improved Survival for Patients With COPD. JAMA. 2020;323(18):1783–1785. DOI:10.1001/jama.2020.4436