COPD Pulmonary Rehab Referral Rates Remain Low, Despite Guideline Recommendations

Peter K. Lindenauer, MD

Despite Medicare beginning coverage of pulmonary rehabilitation—a medication-free treatment for breathing problems, including chronic obstructive pulmonary disorder (COPD) — in 2016, referral rates are still extremely low, according to a new study.

In an assessment of patients immediately following hospitalization for COPD and for the year thereafter, investigators found that only 1.9% of patients that were eligible for pulmonary rehabilitation were enrolled within 6 months. By 12 months, that rate only increased to 2.7%.

Pulmonary rehab is a program of exercise and education that is proven to increase exercise capacity, reduce symptoms, and elevate quality of life for patients. The program is recommended in all major professional society guidelines in the US, Europe, and Canada. Historically, patients with stable COPD were encouraged to enroll in pulmonary rehab.

But Peter K. Lindenauer, MD, professor of medicine at the University of Massachusetts Medical School, Baystate, and co-author of this study, told MD Magazine® that line of thinking is changing. He said that, over the past 5 years, there’s been growing emphasis on encouraging patients to begin rehabilitation shortly after an exacerbation.

“That’s because exacerbations are associated with declines in physical activity that ends up being a vicious cycle,” he explained. “They get hospitalized, get stable, go home, remain sedentary, more deconditioned, with shortness of breath, which is already a characteristic of the disease, and it just gets worse.”

Part of the issue stems from awareness. A survey released by the American Thoracic Society (ATS) in November of this year, showed that among 500 COPD patients, 62% had never heard of pulmonary rehab.

In addition to the clinical benefits of rehab, Lindenhauer said patients could experience emotional and psychological improvements—with reports that the community and support of their peers had been just as valuable to them as the exercises.

For this study, data was pulled from the Centers for Medicare and Medicaid Services (CMS) for 2012 and included those 66 years or older, hospitalized for COPD, enrolled in Medicare for at least a year, and not received pulmonary rehab during the previous year.

In addition to the low rates of pulmonary rehab among the 223,832 participants, the strongest factor associated with beginning the program within 6 months was prior home oxygen use (OR: 1.49; 95% CI: 1.39 - 1.59).

Those aged 75-84 (OR: 0.71; 95% CI: 0.66 - 0.76), 85 or older (OR: 0.25; 95% CI: 0.22 - 0.29), those living over 10 miles from a rehab facility (OR: 0.47; 95% CI: 0.42 - 0.51), and those with lower socioeconomic status (OR: 0.42; 95% CI: 0.38 - 0.46) were less likely to receive rehab.

Lindenhauer said 3 main variables are at play which dictate the lowered outcome: shortage of pulmonary rehab programs, hospitalists and primary care doctors unfamiliar with the benefits of pulmonary rehab, and lack of patient education.

“With this research, we’ve defined the problem,” said Lindenhauer. “The next study in this line of research is testing interventions that help increase these rates.”

Linderhauer expressed interest in developing scalable strategies that offer COPD patients the means to overcome these barriers.

The study, “Participation in Pulmonary Rehabilitation for COPD among Medicare Beneficiaries” was published online in the Annals of the American Thoracic Society.