A proposal for a delayed New Years’ resolution: make use of pulmonary rehabilitation for patients who need it

)Prof Thierry Trooster Thierry Troosters: the allied health professional's perspective

27 June, 2016

Thierry Troosters: The turning of the year comes with New Year resolutions. In the United States the most frequently reported resolution was ‘Enjoy life at the fullest’, which was particularly popular among seniors1. Other popular resolutions were related to lifestyle and body weight management. And what if our patients with respiratory diseases wanted to ‘enjoy life at the fullest’? What could we offer them?

Perhaps one of our resolutions could be to help our patients achieve this goal. A way to do so is to refer more patients to pulmonary rehabilitation programmes. Over the past few decades pulmonary rehabilitation has grown from an ‘art’ to a ‘science’ and has opened up from being restricted to patients suffering from stable chronic obstructive pulmonary disease (COPD), to virtually any patient with respiratory conditions admitted to intensive care units, and to patients with early disease stages. The scientific evidence (grade A) for pulmonary rehabilitation has been summarised in several excellent and internationally endorsed statements2 and offering pulmonary rehabilitation to those patients who need it is a priority according to the National Institute for Health and Clinical Excellence (NICE) and the Global Initiative for Chronic Obstructive Lung Disease (GOLD).

The 2016 GOLD strategy document literally states : ‘All patients who get short of breath when walking on their own pace on level ground should be offered rehabilitation; it can improve symptoms, quality of life, and physical and emotional participation in everyday activities’. Despite these firm guidelines and all the knowhow on the provision of pulmonary rehabilitation the proportion of ‘candidate-patients’ that are offered rehabilitation remains intolerably low. This is particularly shocking in countries where other expensive medical treatment finds its way to patients relatively easily. In fact pulmonary rehabilitation is one of the most cost effective interventions that can be offered to patients with chronic respiratory diseases. In this case (and contrary to very cheap interventions with some effectiveness that are also called cost-effective) the benefit relies in a perceived improvement with relevant clinical consequences at a reasonable cost to a modern health care system. It was therefore timely that the American Thoracic Society and the European Respiratory Society (ERS) joined forces to draft a policy statement around getting rehabilitation to the people with pulmonary disease, rather than to summarise the evidence for it, yet again. We are now at a time where even the Cochrane Library has taken the rare decision to stop updating the systematic review on the effectiveness of pulmonary rehabilitation in COPD as conclusive evidence is present of its effectiveness3.

The burning question remains ‘how do we get people to receive this intervention and maintain its benefits’? In the policy statement4 several barriers to the implementation are identified. These lie within the patients themselves, who sometimes lack the motivation to participate, who received no, or contradicting information on the effectiveness of rehabilitation or who have simply never heard of it. Another –and perhaps easier- barrier to overcome is the accessibility of current programs in terms of travel distance or capacity and associated waiting lists. The policy statement makes a clear call to enhance the number of rehabilitation programmes, but also to investigate the effectiveness of innovative forms of delivering rehabilitation and bring it closer to patient communities or even patients’ homes.

A third source of barriers lies in the reimbursement of pulmonary rehabilitation. It is sad to see that in many countries no proper reimbursement is foreseen for rehabilitation programmes and reimbursement criteria are sometimes based on criteria that lack evidence base (such as lung function impairment). Isn’t it surprising that it takes only a few months of tough negotiations to find reimbursement schemes for new drug treatment (sometimes of borderline efficacy), whereas rehabilitation programs remain poorly funded? Perhaps this is a call to action for patient associations. These stakeholders should realise that their policymakers are withholding an effective and relatively easy to administer therapy. On the other hand, rehabilitation programmes need to provide transparent processes of care using benchmarking outcomes5 that can convince local health authorities that the best possible care is offered to patients referred to rehabilitation.

In Belgium, a formal trial was set-up under the thriving force of Professor Marc Decramer and other dedicated rehabilitation experts of the Belgian Society for Pneumology. We worked with the health authorities and shared all data from a standardised multidisciplinary rehabilitation program of several centres for a period of three years with the authorities. This showed to the authorities in a transparent way that pulmonary rehabilitation did lead to short and long-term benefits, similar (or even better) than those obtained in clinical trials. Although discussion remains on the number of centres in Belgium, authorities were convinced of the effectiveness of the intervention and the cost was justified. Perhaps this can serve as a model for negotiations in other regions and –why not- now that ERS has regional reach, they can help facilitating this in several countries at the same time.

Lastly, barriers also lie in the lack of knowledge of general practitioners (who are often the closest (trusted) healthcare provider around a patient and his/her family), and even specialists. In fact it is amazing to see how little in the curriculum of educational tracks of general medicine and even pulmonology, or internal medicine, is dedicated to pulmonary rehabilitation. The European Respiratory Society (ERS) does well as the ERS Handbook of Respiratory Medicine spends nine pages on pulmonary rehabilitation (1.5% of the volume). It’s a start. In addition the ERS has a well-functioning Pulmonary rehabilitation group (1.2) and allied health professionals group that can help with the dissemination.

Through the more intimate links that exist now between national respiratory societies, efforts can hopefully reach all regional healthcare workers in all lines of healthcare so everybody around the potential candidate can provide a similar message. With the help of patient organisations, I’m hopeful that we can provide our best care, including pulmonary rehabilitation to the largest amount of beneficiaries. This policy statement is a great kick off of efforts to achieve this mission. It has concrete suggestions for the future and provides a roadmap to achieving success. Perhaps 2016 can be a year where this New Year resolution can be carried forward.

Reference List

  1. Kirkham, E. Enjoying Life to the Fullest' Is 2016's Top New Year's Resolution, Survey Finds. 2016. http://www.gobankingrates.com/personal-finance/enjoying-life-2016s-top-new-years-resolution-survey/ accessed on 24-1-2016.
  2. Spruit, M. A., S. J. Singh, C. Garvey, R. ZuWallack, L. Nici, C. Rochester, K. Hill, A. E. Holland, S. C. Lareau, W. D. Man, et al. 2013. An official American Thoracic Society/European Respiratory Society statement: key concepts and advances in pulmonary rehabilitation. Am.J.Respir.Crit Care Med. 188:e13-e64.
  3. Lacasse, Y., C. J. Cates, B. McCarthy, and E. J. Welsh. 2015. This Cochrane Review is closed: deciding what constitutes enough research and where next for pulmonary rehabilitation in COPD. Cochrane.Database.Syst.Rev. 11:ED000107.
  4. Rochester, C. L., I. Vogiatzis, A. E. Holland, S. C. Lareau, D. D. Marciniuk, M. A. Puhan, M. A. Spruit, S. Masefield, R. Casaburi, E. M. Clini, et al. 2015. An Official American Thoracic Society/European Respiratory Society Policy Statement: Enhancing Implementation, Use, and Delivery of Pulmonary Rehabilitation. Am.J.Respir.Crit Care Med. 192:1373-1386.
  5. Spruit, M. A., I. Vanderhoven-Augustin, P. P. Janssen, and E. F. Wouters. 2008. Integration of pulmonary rehabilitation in COPD. Lancet 371:12-13.