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Pulmonary rehabilitation for chronic obstructive pulmonary disease: Has it peaked?

Viewed through the lens of evidence-based health care, pulmonary rehabilitation should rightly be considered a success story. The most recent Cochrane Review which included 65 randomized controlled trials (RCT) and nearly 4000 participants with chronic obstructive pulmonary disease (COPD) showed that pulmonary rehabilitation consistently delivers clinically meaningful benefits in health-related quality of life and exercise capacity. As a result, the Cochrane Airways Editorial Board took the unusual step of closing the review, on the basis that additional RCT in this area are no longer warranted. The editorial states that ‘Those who apply the intervention, those who receive it, and those who fund it can act with confidence. Research money should now be directed elsewhere’. The proven impact of pulmonary rehabilitation should be good news for patients with COPD and those who provide their care. However, evidence for clinical benefit is only one part of the story. It does not address the extraordinary lack of progress we have made in ensuring that this effective intervention is delivered to those who need it. Across seven countries and 18 years (1995–2013), the capacity of pulmonary rehabilitation programmes was consistently <1.2% of those living with COPD. Amongst the small proportion who are referred to a programme, 33% do not attend their initial assessment and nearly 40% of those who commence will not complete. These data suggest that despite our best efforts, the traditional pulmonary rehabilitation model has not been successful for the majority. The barriers to uptake and completion have not changed in over 20 years and are most frequently related to the burden of illness, travel to programmes and insufficient health system resources. In an effort to drive the uptake of pulmonary rehabilitation worldwide, the American Thoracic Society and European Respiratory Society published a policy statement on pulmonary rehabilitation at the end of 2015. Amongst other recommendations, the policy statement recommended that ‘novel pulmonary rehabilitation should be developed and studied that will make evidence-based pulmonary rehabilitation more accessible and acceptable to patients and payers’. Suggested approaches included significant departures from the traditional pulmonary rehabilitation model, including ‘...comprehensive and well-resourced home-based or telehealth-supported programs, or other novel models of program delivery’. Over the last 12 months, the science of pulmonary rehabilitation has advanced such that these approaches may become a reality. This new science brings opportunities to extend the benefits of pulmonary rehabilitation more broadly, but also presents new challenges regarding the future definition and scope of pulmonary rehabilitation. The real question is whether novel models of pulmonary rehabilitation are as good as our traditional, centre-based ‘gold standard’ pulmonary rehabilitation programmes. Non-inferiority trials have previously been rare in this field, as participant numbers have often been too small and a no-rehabilitation comparison was still considered relevant. That is changing. In the last 12 months, we have seen RCT reporting non-inferiority of a low-cost home-based pulmonary rehabilitation programme delivered primarily using telephone calls and an internet-based exercise and education programme when compared directly to the traditional model of centre-based pulmonary rehabilitation. An RCT of unsupervised pulmonary rehabilitation using a self-guided manual also delivered clinically significant benefits in patients with COPD, although non-inferiority could not be confirmed. Whilst this evidence should be considered preliminary and requires replication by other groups, these alternate models are gaining traction in clinical practice. However, not all members of the pulmonary rehabilitation community have been enthusiastic, with criticisms of the new models as insufficiently comprehensive or multidisciplinary, and thus not really pulmonary rehabilitation at all. At the same time, there has been emergence of effective interventions focusing solely on promotion of physical activity, without formal exercise training or education, which may further blur the outlines of pulmonary rehabilitation for patients, clinicians and policy makers. If traditional pulmonary rehabilitation has truly ‘peaked’ in its ability to improve outcomes across the range of patients living with COPD, then maintaining the status quo is not an option, as current access and uptake are unacceptable. New pulmonary rehabilitation models may provide a way forward. However, this path comes with significant risks. The high-quality outcomes achieved in existing centre-based pulmonary rehabilitation programmes are not an accident. They have occurred because of the commitment of pulmonary rehabilitation providers across the world to excellence in delivery of a complex, multi-component intervention, using a structured approach and with rigorous assessment of outcomes. The ongoing programme of audit in England and Wales, conducted by the British Thoracic Society and the Royal College of Physicians, is an outstanding example of such a commitment. However, existing quality standards and audit metrics may be difficult to apply directly to new models, which usually involve fewer visits, may have little direct supervision and may engage new technologies rather than face-to-