By Karen Edwards, MS, RRT, RCEP, FAACVPR, and Jonathan David, MSN, RN, EBP-C, CCRP, NE-BC, FPCNA, FAACVPR, FACC

Pulmonary rehabilitation (PR) is standard recommended care following an acute restrictive or obstructive respiratory disorder, such as chronic obstructive pulmonary disease (COPD), interstitial lung disease, or pulmonary hypertension. Treatment aims to relieve dyspnea and improve an individual’s functional and psychological status, exercise capacity, and quality of life.

Evolution, Evidence, Practice, and Recommendations

From its early years of trial and error, PR has advanced over the years into a guideline-oriented, evidence-based practice (see table, right). The individualized Petty’s Model as a standard for outpatient PR is accepted by the American College of Chest Physicians Committee and the American Thoracic Society (ATS). Additionally, the ATS recommendations⁴ for modern PR comprise 13 essential and four desired components, including comprehensive assessment and required clinical competencies. Emerging models for PR delivery have expanded from center-based to now also include home-based, telerehabilitation, web-based rehabilitation, PR using minimal equipment, breathlessness rehabilitation, and PR in the community and primary care settings.

Can PR Utilization Rates Increase?

Despite this progress, PR is dismally underused. In the United States, among those diagnosed, more than 14.2 million adults (6.5%)¹ are estimated to have COPD, yet fewer than 4% of the Medicare beneficiaries in this population attend PR.²  The barriers are many and include lack of systematic referral and care coordination, which hinder early enrollment and participation.³

Implementation of automatic referral and efficient transitional care processes to PR is critical to improve both utilization and overall outcomes. This begins with a systematic referral before discharge from the hospital or clinic visit, thus improving access and promoting full completion.⁴ A comprehensive assessment^4,5 of the individual’s psychological and transitional care is needed to counter barriers to communication, transport, enrollment, and participation. PR centers offering an individualized model of PR delivery via preemptive care coordination⁶ improve access through early enrollment and full participation, and successfully achieve therapeutic provider-patient clinical outcomes.

From the article “Defining Modern Pulmonary Rehabilitation, An Official American Thoracic Society Workshop Report,” May 2021⁴:

• Just 1.9% of patients recently hospitalized with COPD attend PR within 6 months of discharge
• Poor awareness and knowledge of PR by HCPs is a major barrier to patient referral
• A primary care physician survey in the U.S. in 2016 found that 12% of respondents didn’t know if PR was available in their area
  • 33% rarely or never referred to PR

In addition to addressing barriers to referral, programs can target the areas of adherence and participation for additional improvement opportunities.

Adherence and Participation Strategies Can Help Improve Utilization of PR

Adherence to pulmonary rehabilitation is crucial for achieving the best outcomes. However, maintaining consistent participation can be challenging for some patients due to factors such as transportation issues, lack of motivation, or comorbidities. Strategies to improve adherence include providing flexible scheduling, offering transportation assistance, and fostering a supportive environment that encourages peer interaction. Health care providers play a key role in motivating patients by setting realistic goals, monitoring progress, and addressing any barriers to participation. Studies have shown that patients who adhere to PR programs experience significant improvements in exercise capacity, symptom management, and overall quality of life. With that in mind:

Identify populations at risk for low engagement

• Know the characteristics that are predictive of attendance and drop-out in order to identify patients at high risk and offer them extra support

Use data to drive improvement in PR participation

• Determine PR participation metrics
• Regularly provide a dashboard with PR participation metrics, goals, and performance

Participation in pulmonary rehabilitation involves active engagement in both the exercise and educational components of the program. Patients typically attend sessions several times a week, where they perform exercises designed to improve cardiovascular fitness, muscle strength, and endurance. Educational sessions cover topics such as breathing techniques, medication management, and strategies to cope with the psychological aspects of chronic lung disease. Group settings provide an opportunity for patients to share experiences and support each other, which can enhance motivation and adherence. Overall, participation in PR not only helps patients manage their symptoms but also empowers them to lead more active and fulfilling lives. To promote greater participation:

Develop flexible delivery models that better accommodate patient needs

• Offer accelerated and/or hybrid PR programs
• Modify program structure and hours of operation to match patient preferences to accommodate more patients
• Shift from class structure to open-gym model or vice versa
• Provide case management, class coordination, or patient support services

Offer hybrid PR programs

• Make the case for offering hybrid PR
• Design and develop work processes to deliver hybrid PR
• Identify which patients may be most appropriate for hybrid PR
• Establish an approach to bill for hybrid PR
• Offer self-administered educational programs to supplement PR participation

Other Steps to Improve Utilization of Pulmonary Rehabilitation

Improving the utilization of PR involves addressing barriers and implementing strategies that make the program more accessible and appealing to patients. Here are additional ideas to enhance PR utilization.^{12, 13}

1. Increase Awareness and Education: Many patients and health care providers may not be fully aware of the benefits of PR. Conducting educational campaigns, both within health care settings and in the community, can help raise awareness. Providing information through brochures, online resources, and workshops can educate patients about how PR can improve their quality of life.
2. Enhance Accessibility: Transportation can be a significant barrier for many patients. Offering transportation services or partnering with local transportation providers can help patients attend sessions regularly. Additionally, providing flexible scheduling can accommodate patients with varying schedules.
3. Leverage Technology: Telehealth and virtual PR programs can be particularly beneficial for patients who have difficulty attending in-person sessions. Virtual programs can include live-streamed exercise classes, online educational modules, and teleconsultations with health care providers. This approach can make PR more accessible to a broader range of patients.
4. Foster a Supportive Environment: Creating a welcoming and supportive atmosphere can encourage patients to participate and adhere to the program. Group sessions where patients can share experiences and support each other can enhance motivation. Additionally, involving family members or caregivers in the program can provide extra encouragement and support for the patient.

Implementing these strategies can help improve the utilization of pulmonary rehabilitation, ultimately leading to better health outcomes for patients with chronic respiratory diseases.

REFERENCES:

1. Liu Y, Carlson SA, Watson KB, Xu F, Greenlund KJ. Trends in the Prevalence of Chronic Obstructive Pulmonary Disease Among Adults Aged ≥18 Years — United States, 2011–2021. MMWR Morb Mortal Wkly Rep 2023; 72:1250–1256. doi:10.15585/mmwr.mm7246a1
2. Spitzer KA, Stefan MS, Priya A, et al. Participation in Pulmonary Rehabilitation after Hospitalization for Chronic Obstructive Pulmonary Disease among Medicare Beneficiaries. Annals ATS. 2019;16(1):99-106. doi:10.1513/AnnalsATS.201805-332OC.
3. Hayton C, Clark A, Olive S, et al. Barriers to pulmonary rehabilitation: Characteristics that  predict patient attendance and adherence. Respiratory Medicine. 2013;107(3):401-407. doi: 10.1016/j.rmed.2012.11.016
4. Holland AE, Cox NS, Houchen-Wolloff L, et al. Defining Modern Pulmonary Rehabilitation. An Official American Thoracic Society Workshop Report. Annals ATS. 2021;18(5):e12-e29. doi:10.1513/AnnalsATS.202102-146ST
5. McNamara RJ, Dale M, McKeough ZJ. Innovative strategies to improve the reach and engagement in pulmonary rehabilitation. J Thorac Dis. 2019;11(Suppl 17):S2192-S2199. doi:10.21037/jtd.2019.10.29
6. Bernard S, Vilarinho R, Pinto I, et al. Enhance Access to Pulmonary Rehabilitation with a Structured and Personalized Home-Based Program—reabilitAR: Protocol for Real-World Setting. Int J Environ Res Public Health. 2021;18(11):6132. doi:10.3390/ijerph18116132
7. Keating, A, Lee, A, Holland, A. What prevents people with chronic obstructive pulmonary disease from attending pulmonary rehabilitation? A systematic review. Chron Respir Dis. 2011;8(2):89-99.  doi: 10.1177/1479972310393756
8. Steiner, MC, Roberts, CM. Pulmonary Rehabilitation: the next steps. Lancet Respir Med. 2016 Mar;4(3):172-3.  doi: 10.1016/S2213-2600(16)00008-4. Epub 2016 Feb 10.
9. Wadell, K, Webb, KA, Preston, ME, et.al. Impact of pulmonary rehabilitation on the major dimensions of dyspnea in COPD. COPD. 2013 Aug;10(4):425-35.  doi: 10.3109/15412555.2012.758696. Epub 2013 Mar 28.
10. Hayton, C, Clark, A, Olive S, et.al. Barriers to pulmonary rehabilitation: characteristics that predict patient attendance and adherence. Respir Med. 2013 Mar;107(3):401-7.  doi: 10.1016/j.rmed.2012.11.016. Epub 2012 Dec 19.
11. McNaughton, AA, Weatherall, M, Williams, G, et.al. An audit of pulmonary rehabilitation program. Clinical Audit, 2016:8, 7-12.
12. 12. AARC Clinical Practice Guidelines, Pulmonary Rehabilitation, www.aarc.org
13. Pulmonary Rehabilitation, www.lung.org

Jonathan David, MSN, RN, EBP-C, CCRP, NE-BC, FPCNA, FAACVPR, FACC,  serves as cardiac nurse supervisor at Stanford Health Care. He is the president-elect of the California Society for Cardiac Rehabilitation.

Karen Edwards, MS, RRT, RCEP, FAACVPR, is Supervisor of Cardiopulmonary Rehab PSR at Pulse Heart Institute – MultiCare Health System