Promoting Long-TermBenefits of PulmonaryRehabil itation
Pulmonary rehabilitation arguably provides themost beneficial effects of any treatment in theoutcome areas of dyspnea, exercise performance,functional status, health status, and health careuse. Despite this impressive track record, there is
An example of this is given in Fig. 1.
the progressive nature of the underlying respira-tory disease, the development of comorbidity,exacerbations of the respiratory disease, and sub-optimal adherence to the long-term exercise pre-scription. Perhaps it is too much to administerwhat is often a short-duration, acute care interven-tion and expect it to achieve long-term benefits in
can span several decades. Instead,habilitation must be fitted into a
quality of life, but these positive outcomes tend to diminish gradually over time.
Although a key focus of pulmonary rehabilitation is to provide strategies to maintain long-term ben-efits from the intervention, the most effective approaches to achieve this goal are not currentlyknown.
Extending the duration of pulmonary rehabilitation seems to prolong its benefits, but this may not befeasible in all areas.
Exacerbations of COPD are associated not only with substantial deteriorations in symptoms, func-tional status, and health status, they also negatively impact long-term adherence with the adaptivebehaviors achieved in pulmonary rehabilitation.
Targeting the exacerbation through nonpharmacologic interventions, such as pulmonary rehabilita-tion or its components, should prolong the long-term benefits from pulmonary rehabilitation.
.comClin Chest Med - (2014) --Conflict of Interest: None.Care Management, Mayo Clinic Hospital, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USE-mail address: Fahy.email@example.comThere are multiple reasons for this drop-off inoutcomes months after the formal pulmonaryrehabilitation program has ended. These include
chronic care model of disease management.Thus, this intervention must promote self-efficacyin its patients, with the adoption of healthy behav-iors, such as regular exercise in the home or
Funding Sources: None.often a gradual decline in benefit over time afterthe formal pulmonary rehabilitation intervention.1
a disease thatpulmonary re Pulmonary rehabilitation generally provides substantial benefits in exercise capacity, dyspnea, and
KEY POINTSThe Role of ReducingRespiratory Exacerbat
Bonnie F. Fahy, RN, MN, CNS
Pulmonary rehabilitation Chronic obstructive Exacerbation Self-management Hospital reahttp://dx.doi.org/10.1016/j.ccm.2014.02.0070272-5231/14/$ see front matter 2014 Elsevier Inc. Allhe Impact ofns
monary disease Maintenance programissionrights reserved. che
to the rehabilitation team
7. Providing weekly supervised hospital-basedexercise sessions8
8. Actively determining barriers to maintainingexercise by interview during formal rehabili-tation, then working to reduce their impact9
9. Incorporating a home plan of exercisetraining early on in the formal rehabilitation
Fahy2community setting, and the use of collaborativeself-management strategies at the time of the res-piratory exacerbation.There have been several systematic efforts to
Fig. 1. Long-term effects of comprehensive pulmo-nary rehabilitation (x-axis) on submaximal exercise ca-pacity (y-axis) in patients with COPD. Compared witha control group that was given didactic education,the pulmonary rehabilitation group had a significantincrease in exercise capacity out to about 18 months.Thereafter, exercise capacity in both groups wassimilar and seemed to diminish gradually in time,possibly reflecting the progression of the disease.(Data from Ries AL, Kaplan RM, Limberg TM, et al.Effects of pulmonary rehabilitation on physiologicand psychosocial outcomes in patients with chronicobstructive pulmonary disease. Ann Intern Med1995;122(11):82332.)prolong the beneficial effects of pulmonary reha-bilitation. These are listed in Box 1. Some of theapproaches are clearly not practical or financiallyfeasible, and none has unequivocally been shownto work. However, they provide current thinking onhow the problem of drop off in outcomes might beapproached.These approaches either have had some suc-
cess in maintaining the benefits or conceptuallyshould do so. The remainder of this article dis-cusses three additional approaches to prolongthe beneficial effects of pulmonary rehabilitation.The first approach is to get patients to begin pul-monary rehabilitation in the first place. It shouldbe obvious that prolongation of beneficial out-comes can be maintained only if the patient partic-ipates in pulmonary rehabilitation to achieve theseinitial positive outcomes. The second approach isto offer long-term postrehabilitation maintenanceprograms. To promote long-term gains, many pul-monary rehabilitation programs have set up main-tenance programs. However, the benefits ofparticipation in on-going, postrehabilitation exer-cise maintenance programs are not as widelyresearched, and consequently there is less aware-ness of this option among health care providers,hospitals, third-party payers, and most importantlyBox 1Initiatives aimed at prolonging the benefits ofpulmonary rehabilitation
1. Extending pulmonary rehabilitation out forlonger duration (lifetime would be best)2
2. Arranging for monthly patient visits to therehabilitation center, supplemented by tele-phone calls in the interim3
3. Providing weekly telephone contacts andmonthly supervised reinforcement sessions4
4. Giving repeated pulmonary rehabilitation atintervals (booster shots; these could be givenin the periexacerbation period, which oftenleads to prolonged physical activity)5
5. Providing user-friendly pulmonary rehabili-tation in the home setting, supplementedby visits to professionals in the center6
6. Offering structured daily self-monitoredpostrehabilitation walking exercise trainingat home, possibly incorporating feedback
7patients. The third approach is to prevent exacer-bations of chronic obstructive pulmonary disease(COPD). It is known that respiratory exacerbationsresult in increased symptoms, decreased func-tional status, increased health care use, andincreased mortality risk. Additionally, exacerba-tions play a prominent role in reducing long-termadherence to the adaptive behaviors (eg, regularexercise training) that had resulted from pulmo-nary rehabilitation. Thus, respiratory exacerba-tions should be discussed when dealing withlong-term maintenance of benefits following pul-monary rehabilitation.
GETTING PATIENTS TO PARTICIPATE INPULMONARY REHABILITATION
Initial patient enrollment into a pulmonary rehabili-tation program can be challenging for several rea-sons. First, health care providers may not beaware of the effectiveness or availability ofhospital-based, inpatient, community-based, orhome-based pulmonary rehabilitation in their
program that fits the needs of the specificpatient
receiving the individualized care characteristic of
center. Although this was a single-arm study
Maintenance of Pulmonary Rehabilitation 3pulmonary rehabilitation they usually becomemotivated to continue. However, some of the pre-viously mentioned issues reappear or the patientsmedical condition changes, making continuationin the process problematic.The beneficial effects of pulmonary rehabilita-
tion have been demonstrated across all venuesof delivery. However, the out-patient, hospital-based setting is most common in the UnitedStates. Canada has been the leader in assessingthe effectiveness of home-based pulmonary reha-bilitation. A recent study from that country demon-strated that 8 weeks of home-based exercisetraining following center-based education wasnot inferior to outpatient center-based pulmonaryrehabilitation in improving dyspnea, exercise to-lerance, and health status.10 Additionally, rehabili-tation given in both venues was safe. Additionally,a 12-week home-based program using computer-based exercise for patients with COPD was foundto be an effective alternative to traditional pulmo-nary rehabilitation.11 Giving pulmonary rehabilita-tion in the home setting might be expected topromote long-term adherence to positive healthcare behaviors, such as regular exercise training.However, there is little to suggest this in the litera-ture.10,12 What is not known is if the patients arechoosing not to continue participating in mainte-nance programs, hospital-based or other, or ifstudies evaluating the effects of maintenance pul-monary rehabilitation are not being undertaken.
MAINTENANCE PROGRAMS FOLLOWINGPULMONARY REHABILITATION
Pulmonary rehabilitation staff frequently tells theirpatients that the healthy behaviors learned andrealized in the program must be continued indefi-nitely to ensure long-term benefits. However, inmany health care systems only a limited numberof pulmonary rehabilitation sessions are allowed,and adherence often falls off after the formal pro-cess has ended. A low-cost, ongoing exercisemaintenance program should prove beneficial ingeographic area. Second, patients are often reluc-tant to begin the process, thinking how can Ipossibly exercise if I cannot walk across theroom? This early inertia is a significant problem.Spouses or caregivers frequently share the sameopinion, thereby offering little if any support. Third,logistic problems, such as missed work or trans-portation issues, may be substantial. Finally, insuf-ficient third-party payment may make thistherapeutic option too expensive for some pa-tients. Once patients begin the process and beginthis regard. Not only would patients exercisewithout a control group, the data suggested thatfor patients with moderate to severe COPD thistype of case managerfacilitated maintenance ex-ercise program in the community was feasible(70% adherence) and could maintain exercise ca-pacity and health-related quality of life comparedwith baseline out to at least 1 year. Controlled trialsusing this approach are warranted.Somewhat less encouraging long-term results
came from a controlled trial evaluatingcommunity-based pulmonary rehabilitation studyof patients with less severe COPD.14 Patients inthe intervention arm initially participated in4 months of multidisciplinary pulmonary rehabilita-tion, exercising twice a week and receiving individ-ualized education. This was followed by 20monthsof exercise at home. This was supplemented bymonthly home visits by a physical therapist thatmonitored exercise capacity and adherence totraining and provided encouragement to continueexercising. Those patients having an exacerbationwere allowed to have six additional training ses-sions with a physical therapist over 6 weeks.Compared with a usual care control group, theintervention group had significant improvementsin quality of life, dyspnea, and exercise perfor-mance at 4 months. However, at the 2-year testingthese favorable differences, although still signifi-cantly improved compared with usual care, haddiminished in magnitude. Additionally, the inter-vention group did not have a decrease in exacer-bation frequency compared with controlsubjects. Impressive was the finding that only9% of the home exercise intervention group drop-ped out because of unwillingness to participate.
PROLONGING THE BENEFICIAL EFFECTS OFPULMONARY REHABILITATION INDIRECTLYTHROUGH REDUCING THE FREQUENCY OFEXACERBATIONSReduced Hospital Admissions Rather thanReduced Number of Exacerbations as anOutcome in Pulmonary Rehabilitation
The long-term maintenance of functional out-comes after pulmonary rehabilitation is negativelyregularly, but they would also have an ongoinginteraction with the staff.A recent study evaluated the feasibility and out-
comes of a community-based, twice-weekly main-tenance exercise program that followed atraditional hospital-based pulmonary rehabilitationprogram.13 Transition to the community was facil-itated by a casemanager, and exercise was super-vised by fitness consultants at a local communityaffected by respiratory exacerbations.3 Thereby,
pharmacologic means. Reducing the total number
activity, 5 or more days a week. Yet, almost 60%
Fahy4exacerbations may not be an attainable outcomein pulmonary rehabilitation because of itsemphasis on exacerbation identification in theself-management education. This type of educa-tion may actually increase the number of reportedexacerbations, many of which may have gone un-noticed by the patient. However, a reduction in se-vere exacerbations, resulting in hospitaladmissions or readmission, through their earlyrecognition and treatment is perfectly feasiblefrom this intervention. Indeed, this may be consid-ered a desirable goal of pulmonary rehabilitation.In the United States in 2006, hospitalizations
represented 52% to 70% of direct per patientcosts to care for COPD, with exacerbations beingthe major contributor of 50% to 75% of the totaldisease costs.15 The current estimated cost ofcare for the COPD exacerbation is $15 to $17billion a year in the United States.16 These costs,combined with the statistic that COPD contributes22.6% of all Medicare readmissions, led to theestimate that $12 billion dollars a year is spenton potentially preventable hospitalizations for thisdisease.17 As a consequence, the Centers forMedicare and Medicaid have added COPD to thelist of diagnoses that are penalized if Medicare re-admission rates within 30 days of dischargeexceed a predetermined threshold. This monetarypenalty to hospitals, contained in H.R. 3590: thePatient Protections and Affordable Care Act(Public Law 111-148, Section 3025), takes effecton October 1, 2014.In addition to the financial burden of the hospi-
talization for COPD exacerbation, decreased func-tional status, impaired health-related quality of life,and increasedmortality risk are prominent.18 In theUnited Kingdom, 15% of patients admitted withexacerbations die within 90 days of admission,19
and in France mortality over the 4 years followinghospital admission was 45%.20 Of note, nearlyhalf of all emergency department visits by patientswith COPD result in admission to the hospital.21
Repeated hospitalizations for COPD exacerba-tions result in a rapid health decline and high mor-tality in the weeks after the events.22
Pulmonary Rehabilitation and COPDExacerbations
Pulmonary rehabilitation has the potential toreduce severe exacerbations in COPD, andreducing the frequency of exacerbations may indi-rectly prolong the beneficial effects of pulmonaryrehabilitation. The frequency of exacerbations inCOPD can be reduced by pharmacologic and non-thereby reduce health care use for patients.fulfilled the recommended duration of exercisewhen their exercise was accumulated by sessionsof 10 or more minutes of exercise throughout theday, as is often the format of pulmonary rehabilita-tion. Furthermore, postrehabilitation exercisemaintenance programs provide a venue to en-courage exercise training and physical activity.Because a lower level of physical activity is an