Summarized by Chris Garvey, FNP, MSN, MPA, MAACVPR; Brian Carlin, MD; Gerene Bauldoff, PhD, RN, FCCP, MAACVPR, FAAN; and Trina Limberg, BS, RRT, FAARC, MAACVPR
The American Thoracic Society (ATS) is pleased to offer the first U.S. evidence-based Clinical Practice Guideline (CPG) for Pulmonary Rehabilitation since 2007. The update, published in the American Journal of Respiratory Critical Care Medicine,1 revisits the evidence of PR effectiveness. This CPG has the potential to improve effective PR delivery, including referrals and reimbursement, for people with chronic respiratory disease.
The multidisciplinary panel2 developed the CPG based on six research questions that addressed PR for persons with COPD, interstitial lung disease and pulmonary hypertension and for PR delivery models including telerehabilitation and maintenance programs. The panel used systematic reviews to quantify the effects of treatment, and employed the Grading of Recommendations, Assessment, Development and Evaluation approach to formulate clinical recommendations. They include both ‘strong’ recommendations, signaling the committee’s certainty that the desirable consequences of a recommendation outweigh the undesirable consequences, as well as ‘conditional’ recommendations.
The Takeaways
- Strong recommendation for PR for adults with stable COPD (moderate-quality evidence)
- Strong recommendation for PR for adults with stable COPD (moderate-quality evidence) after hospitalization for COPD exacerbation (moderate-quality evidence)
- Strong recommendation for PR for adults with interstitial lung disease (moderate-quality evidence)
- Conditional recommendation for PR for adults with pulmonary hypertension (low-quality evidence)
- Strong recommendation for offering the choice of center-based PR or telerehabilitation for patients with chronic respiratory disease (moderate-quality evidence)
- Conditional recommendation for offering either supervised maintenance PR or usual care after initial PR for adults with COPD (low-quality evidence)
Dr. Carolyn Rochester, lead guidelines editor, notes, “We hope that these Clinical Practice Guidelines for PR will be a call to action to clinicians to refer suitable patients to PR and encourage their participation in treatment, as well as foster pulmonary specialists’ communication with healthcare professionals in other disciplines (for example, primary care and cardiology) about the benefits of PR for patients.”
In the United States, an estimated 30 million Americans suffer from COPD. Despite the prevalence of the condition, only 3-4% of Medicare patients with COPD have been prescribed PR, according to a 2019 study in the Annals of the American Thoracic Society.3 The reasons PR is rarely part of the treatment plan are varied and include reimbursement issues, healthcare disparities and a lack of knowledge on the part of both clinicians and patients.
REFERENCES
[1] Rochester C, Alison A, Carlin B, Jenkins A, Cox N, et al. Pulmonary Rehabilitation for Adults with Chronic Respiratory Disease: An Official American Thoracic Society Clinical Practice Guideline. Am J Respir Crit Care Med. 2023 Aug 15;208(4):e7-e26. doi: 10.1164/rccm.202306-1066ST. PMID: 37581410 DOI: 10.1164/rccm.202306-1066ST
[2] Carolyn L Rochester, Jennifer A Alison, Brian Carlin, Alex R Jenkins, Narelle S Cox, Gerene Bauldoff, Surya P Bhatt, Jean Bourbeau, Chris Burtin, Pat G Camp, Thomas M Cascino, Grace Anne Dorney Koppel, Chris Garvey, Roger Goldstein, Drew Harris, Linzy Houchen-Wolloff, Trina Limberg, Peter K Lindenauer, Marilyn L Moy, Christopher J Ryerson, Sally J Singh, Michael Steiner, Rachel S Tappan, Abebaw M Yohannes, Anne E Holland
[3] Spitzer, K, Stefan M, Priya A, Pack Q, Pekow P, et al. Participation in Pulmonary Rehabilitation after Hospitalization for Chronic Obstructive Pulmonary Disease among Medicare Beneficiaries. Ann Am Thorac Soc. 2019 Jan; 15(1), doi: 10.1513/AnnalsATS.201805-332OC