Can Telehealth Bridge Disparities in Access to Pulmonary Rehab?

Chronic obstructive pulmonary disease (COPD) is the fourth leading cause of death in the United States, and pulmonary rehabilitation has been shown to improve outcomes and reduce hospital readmissions among these patients. However, studies have shown that only a fraction of patients who need pulmonary rehabilitation actually receive it.

Disparities in access and the emergence of telehealth as a modality to more conveniently deliver pulmonary rehabilitation received significant attention during a session titled “Pulmonary Rehabilitation 2019” at the American Thoracic Society Meeting 2019 held May 17 – 22, 2019, in Dallas, Texas. Several studies were presented that revealed new insights into both areas of research. 

The rehab gap

Carolyn Rochester, MD, Medical Director of the Yale COPD Program, Yale School of Medicine in New Haven, Connecticut, highlighted top research in pulmonary rehabilitation for 2018-2019. One study of particular interest highlighted significant problems with geographic access to hospital outpatient pulmonary rehabilitation programs, with a focus on rural areas. Published in the journal Chest in April 2019, the study found that there were 1,776 counties in the United States lacking a hospital outpatient pulmonary rehabilitation program in a short-term acute care general medical or surgical hospital. The regions with the greatest disparities to access were in the South (for which only 39% of hospitals had a program) and West (for which only 35.5% had a program).

These findings dovetailed with new research presented during the session that explored whether geographic variation in access to pulmonary rehabilitation could explain why rates of use are lower among African-American patients compared to whites.

Is geographic variation in access a factor?

Rates vary by hospital-referral region. Using the hospital-referral region as a measure of geographic location, study researchers found that a median of 2% of Medicare beneficiaries (range, 0.5% – 7.1%) included in the analysis received pulmonary rehabilitation after hospital discharge for COPD exacerbation. This rate varied across hospital-referral region, with higher rates in the Midwest and hospital-referral regions with greater pulmonary rehabilitation program density.

However, the median rate of pulmonary rehabilitation was lower among African-Americans (1.2%; IQR, 1.1 – 1.2) compared to whites (2.1%; IQR, 1.5 – 2.9). Furthermore, while program density was associated with higher rates of pulmonary rehabilitation among white Medicare beneficiaries (P<.0001), no such association was seen among African-Americans. These findings suggest that the lower rates of pulmonary rehabilitation receipt among African-Americans cannot be explained by geographic differences.

“We need to add more [pulmonary rehabilitation] programs definitely, but adding more programs is not going to solve this disparity that we’re seeing,” said study presenter Kerry Spitzer, PhD, MPA, Institute for Healthcare Delivery and Population Science, Baystate Health, in Springfield, Massachusetts.
 

Would telehealth be helpful?

Telehealth for pulmonary rehabilitation. Pulmonary rehabilitation not only has low uptake but also high dropout rates, and telehealth has emerged as a modality to help counteract this problem. In fact, Yale's Dr Rocheter highlighted a recently published study showing pulmonary rehabilitation delivered via video-based telehealth could reduce 30-day hospital readmissions among patients with COPD.

Specifically, the all-cause remission rate was significantly lower among telehealth group participants compared to those in the standard of care group (6.2% vs 18.1%; P<.013). The acute exacerbation COPD readmission rate was also lower among the telehealth group (3.8% vs 11.9%; P=0.040).

Also discussed during the session were results of a multicenter, randomized controlled trial conducted to determine if telehealth could deliver outcomes superior to conventional pulmonary rehabilitation among patients with advanced COPD. 

The trial enrolled 134 patients with severe and very severe COPD and randomly assigned them to either pulmonary tele-rehabilitation (n=67) or conventional pulmonary rehabilitation (n=67). The tele-rehabilitation intervention consisted of 60 minutes 3 times per week for 10 weeks, and the conventional pulmonary rehabilitation program consisted of 90 minutes 2 times a week for 10 weeks. The primary outcome was difference in 6-minute walk distance.

The study failed to showed superior 6-minute walk distance among patients in the tele-rehabilitation group or higher adherence rates compared to the conventional program group, but did show higher completion rates in the former (odds ratio=3.18; 95% CI, 1.37 – 7.35; P<.01).

Study authors note that tele-rehabilitation could potentially provide an equally effective alternative to conventional pulmonary rehabilitation but implementation would require evidence from a randomized controlled trial designed to explore noninferiority.