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Welcome! Here we publish our views on new research and insights from the field of pulmonary medicine, most often focusing on topics related to exercise, nutrition, and other self-management techniques for those who suffer from chronic shortness of breath.

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Monday, October 19, 2009

Pulmonary rehabilitation – an upside down approach to patient care

One of the strange circumstances that confronts people with COPD is that the medical profession seems most likely to offer pulmonary rehabilitation as a treatment option to those who are in the worst condition instead of those who are early in the development of lung disease when it would likely have greater and more lasting impact.

The reasons for this upside down view of patient care seem to stem from the following observations:

  1. There is not consensus among physicians regarding the impact of pulmonary rehabilitation for those with lesser degrees of lung disease
  2. There is not enough health care resource capacity (medical professionals/physical locations with necessary equipment) to treat a larger, broader range of patients
  3. Reimbursement for pulmonary rehabilitation services through Medicare (and many insurance companies) is largely provided only for patients with moderate to severe conditions.

From an outsider's point of view, these reasons make no sense at all.

On the first point, regarding consensus among physicians about the effectiveness of pulmonary rehabilitation for those with lesser degrees of COPD, if physicians believe that regular exercise is vital for healthy adults to maintain a vibrant lifestyle, why should they disagree that regular exercise for people with lung conditions is any less valuable? I actually don't think you'd find many physicians who would disagree that regular exercise is valuable for people with COPD. Instead, I think some might argue whether it is appropriate for medical professionals to intervene and provide a structured pulmonary rehabilitation program for those with mild COPD or pre-COPD conditions from a cost/benefit standpoint given current healthcare resource constraints. Some others might cite that there is not much research evidence that people with mild to moderate COPD benefit dramatically from pulmonary rehab. While it is true that most of the studies in the field have been conducted on patients with moderate to severe COPD, there have been a number of studies published that show beneficial results of pulmonary rehab for mild COPD patients, such as Rossi G, et al. Length and Clinical Effectiveness of Pulmonary Rehabilitation in Outpatients With Chronic Airway Obstruction. Chest 2005; 127(1): 105-109. Full text of the study is available to access for free at http://chestjournal.chestpubs.org/content/127/1/105.long


Reading between the lines here, I think the real reason why pulmonary rehab isn't offered to people earlier in the development of lung conditions is more related to the second and third reasons identified above than whether pulmonary rehab is an effective treatment option.

Because Medicare and many insurance companies limit reimbursement for pulmonary rehab to moderate to very severe cases of COPD, physicians have no financial incentive to offer pulmonary rehab to those with mild COPD or pre-COPD conditions. In our current health care system, why should respiratory care professionals go out of their way to offer a service for which they can't be reimbursed? Hospital administrators who oversee the operations of pulmonary rehab programs are loathe to offer wide scale, free extended medical care (understandably) and from the stories I've heard from respiratory therapists who work in these programs very few patients are self-pay. From my conversations with pulmonary rehab practitioners and from sessions I've attended at pulmonary medicine conferences, I know pulmonary rehab professionals would love to provide services to a broader range of patients and they cite reimbursement limitations as being the prime impediment to do so.

Further, since reimbursement levels for pulmonary rehabilitation in general are not attractive amounts compared to the cost incurred to provide these rehab services (especially when compared to other therapy forms for which a hospital receives more attractive reimbursement), many hospitals simply don't offer pulmonary rehab programs. Additionally, for these same reasons, hospitals who do offer pulmonary rehab services do don't devote a significant amount of human resource, physical space and equipment to outfit a sizeable rehab facility.

The result is too few pulmonary rehab programs to serve the full range of COPD and pre-COPD patients who could benefit from this valuable treatment option. In this circumstance, it makes intuitive sense that practitioners offer the limited spaces in their programs who those who are in the worst condition (what they refer to as prioritization of care). But it creates the crazy situation that in order to get admitted to a pulmonary rehabilitation program a pre-COPD or mild COPD patient (and even a good block of moderate COPD patients) must wait until their lung function has deteriorated significantly and for the most part, irreparably.

I ask you – does this treatment approach really make sense given the alarming growth rates of COPD? It feels more like a battlefield triage scenario to determine who gets access to pulmonary rehabilitation rather than a proactive strategy to confront the inevitable crushing and costly impact of severe COPD cases to come.