Virtual Pulmonary Rehab and How we Can Fill in the Gaps

This article was written by Jane M. Martin, BA, CRT

We all know that comprehensive group pulmonary rehabilitation is one of the most effective treatments for COPD with documented improvements in exercise capacity, health-related quality of life, reduced hospitalizations, and possibly improved survival. Thus, it is considered the standard of care for most patients with COPD who have activity limitation.

Despite this, it is estimated that only 2-3% of patients with COPD who are candidates for pulmonary rehabilitation in the United States undertake this treatment program. This is due, in part, to a number of barriers including lack of access, high cost, lack of transportation, poor reimbursement, and physical incapacitation.

While the COVID-19 pandemic has led to many in-person pulmonary rehabilitation programs being temporarily closed, virtual, or remote, methods through telehealth platforms has allowed continued contact with patients and delivery of pulmonary rehab to individuals in their homes.

The outcomes of these programs have been mixed. In general, patients who adhere to a remote program show improved exercise capacity and well-being, but there is a poor record of continued participation in an exercise program. The absence of a sense of community and peer interactions contribute to this poor program adherence and suboptimal outcomes. In addition, many virtual programs have not included the full range of rehab elements.

This blog post will shed light on two program models. One program is currently in the concept stage and focuses on post-Phase II peer support. The other program is up and running and is a hybrid focusing mainly on lack of access to pulmonary rehab, high cost, and lack of transportation.

Addressing poor post-Phase II participation

One way to fill this gap may be to link pulmonary rehab graduates to an ongoing, telehealth post-Phase II peer-support program. The goal would be for graduates to have better adherence to effective COPD self-management techniques learned in pulmonary rehab and sustained self-directed maintenance exercise resulting in continued improvement in overall health, functional capacity, and fewer hospitalizations.

Addressing lack of access, lack of transportation, and high cost

The VIrtual PulmonAry Rehabilitation (VIPAR) model in the U.K., designed to assess the feasibility, safety, and effectiveness of remote pulmonary rehab in a real-world setting, is based on the “hub” and “spoke” principle. Rather than having patients participate from home, they attended a spoke site.

Hub and Spoke Hybrid Pulmonary Rehabilitation*

The “hub” is located in a hospital cardiopulmonary center, where patients received standard evaluation and outpatient, multi-disciplinary pulmonary rehab. All participants attended the hub for pre-assessment one to two weeks prior to starting pulmonary rehab. They then were assigned to attend the program nearest to their home, either at the hub or at a spoke location.

Two spoke sites were used, one in a rural village hall and the other in a community independent living center. The hub and spoke sites were linked with a Video Conferencing System (VC) and interactive screens. Participants attended the spoke site for the same seven-week hub program, simultaneously. There were six to ten patients at each site.

*This is the summary of a service evaluation. The authors did not seek research ethical approval. All participants attending either the hub or spoke site between September 2017 and April 2018 were included. The majority of participants had predominately COPD (GOLD 2019). All participants with COPD were in the moderate to severe stages with a minority having predominately other chronic lung conditions. For complete information see the endnote reference.

Staff

The hub had a senior physiotherapist, occupational therapist, exercise assistant, and guest lecturer. The spoke usually had only an exercise instructor and nurse present.

A physiotherapy technician at the spoke site helped deliver the personalized exercise component under the direct observation of the staff at the hub site through VC. A respiratory nurse helped monitor participants’ safety and prepare gym equipment and VC capabilities.

The educational components were primarily delivered via VC from the hub in real time. Hub staff were available to travel to the spoke site on their own discretion if they thought more support was needed for a couple of sessions for more complex patients.

Results

Attendance at both hub (79%) and spoke (75%) sites were essentially the same. Both groups showed clinically relevant and statistically significant improvements in disease-specific quality of life questionnaires, and the spoke group achieved similar results within functional exercise.

VIPAR satisfies the need for social interaction with a community-based program. It also offers a degree of supervision, while also suggesting how simple technology can reduce distance and travel time and improve access.

Travel

Perhaps the most remarkable result of the VIPAR project is that a total of 8,610 miles of traveling was saved for spoke patients by enabling them to attend a site closer to their homes (this is the equivalent to driving from the UK to the US and back). Also, 4,750 minutes of traveling was saved, which is equivalent to 10.24 days. This is likely to improve outcomes as distance and travel time are independent predictors of poor PR attendance in addition to representing a significantly lower ecological impact.

Summary

Improving access to pulmonary rehabilitation in both pandemic and non-pandemic times continues to be a challenge. Paying attention to program concepts that have found their way around various barriers, even if those exact methods are not feasible in all settings, can lead to a better understanding, development, and implementation of solutions.