Researchers Find Low Referral Rates to Pulmonary Rehab for Eligible Patients With COPD

Christina Mattina

Less than 10% of patients with chronic obstructive pulmonary disease (COPD) who may benefit from pulmonary rehabilitation (PR) received a referral from their physician, according to a new study. However, there was no association found between referral status and COPD exacerbations.

The study, published in Chest, included more than 100,000 British adults with COPD.1 Of the 69,089 who were deemed eligible for PR based on diagnosis codes, test scores, or exacerbation history, just 6436 (9.3%) received a referral to or completed the rehabilitation. An additional 634 patients were referred but declined the referral.

PR is a major tool in the management of COPD and has been demonstrated to improve patient quality of life, breathing ability, exercise capacity, muscle strength, and more. The evidence for the benefits of rehabilitation is so strong that a recent Cochrane Review stated that no additional reviews are required to show that it improves patient-related outcomes.

However, despite these benefits, the current study found that eligible patients who received a referral to PR did not have fewer physician visits or hospital admissions for acute exacerbations of COPD in the year after rehabilitation compared with those who were eligible but not referred. The group receiving a referral had a slightly higher exacerbation rate of 2.83 exacerbations per person-year compared with 2.17 in those who were not referred, but this difference was not significant, the authors wrote.

Patients referred to rehabilitation also had a slightly but not significantly higher exacerbation rate after going through rehabilitation than they had prior to it. This pattern remained even after restricting the analysis to patients who were proven to have completed PR.

The study authors noted that their findings differed from those of randomized controlled trials, which demonstrated the efficacy of PR in reducing exacerbations. They suggested that the rehabilitation regimens delivered in the controlled trials may have had more effective content and delivery compared with the programs attended by patients in this observational study.

Despite the lack of evidence supporting a reduction in healthcare utilization stemming from PR, the researchers wrote that the other benefits of rehabilitation, such as better quality of life and less activity limitation, “may be arguably more important to patients who experience COPD than reducing healthcare consumption, and thus PR remains an important intervention to patients.”

Considering the proven value of PR in improving patient outcomes, the finding of underuse indicated the need to explore further why eligible patients may not be referred to such programs, according to the authors.

An accompanying editorial in Chest discussed the findings and concurred that not enough patients are receiving the PR interventions that could significantly improve their quality of life.2 Considering the success of rehabilitation programs in reducing breathlessness and boosting exercise capacity, the task of preventing exacerbation-related utilization may be best accomplished through other strategies in the COPD treatment arsenal.

“In this respect, PR can provide a clear voice as the ‘lead singer’ but is not a one-man band,” the editorial concluded.

1. Moore E, Newson R, Joshi M, et al. Effects of pulmonary rehabilitation on exacerbation number and severity in people with COPD. Chest. 2017;152(6):1188-1202. doi: 10.1016/j.chest.2017.05.006.

2. Evans RA, Steiner MC. Pulmonary rehabilitation: the lead singer of COPD therapy but not a “one-man band.” Chest. 2017;152(6):1103-1105. doi: 10.1016/j.chest.2017.06.040.
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