Pulmonary rehabilitation, along with advances in lung-disease pharmacology, provides a path to vastly improved quality of life.

The elderly man was becoming short of breath with the least exertion and was no longer even able to walk out to the mail box. Unable to do all the things that made his life worth living, he visited his physician. After an examination and a few tests, he received the news—emphysema.

Forty years ago he would have been told, “There’s not much we can do. Just take it easy, don’t exert yourself, and we’ll arrange for the oxygen when the time comes.”

Today, the patient and his physician have other options. Pulmonary rehabilitation, along with advances in lung-disease pharmacology, provides a path to vastly improved quality of life, fewer hospitalizations, and savings to the health care system measured in billions of dollars.

The development of pulmonary rehabilitation can be traced in the scientific literature on lung disease. By 1969, pioneers such as Haas¹ and Petty² were publishing papers about the benefits of increased exercise and activity and of educating and training patients to deal with their diseases.

Through the 1970s, 1980s, and 1990s, the supporting scientific evidence steadily piled up. Pulmonary rehabilitation really works. Well-designed studies—Goldstein’s 1994 randomized trial showing the benefits of pulmonary rehabilitation,³ and Griffiths’ 2000 large randomized trial demonstrating multiple benefits, including reduction in health care use⁴—have been published. This data has confirmed that pulmonary rehabilitation decreases dyspnea, improves quality of life (QOL), and decreases health care costs.⁵ Pulmonary rehabilitation is a proven therapy and the standard of care.⁶ Yet, only a small fraction of patients with respiratory disease are ever referred.

What Is Pulmonary Rehabilitation
What is pulmonary rehabilitation? Why is it not widely available? What are the obstacles, and how can they be overcome?

Pulmonary rehabilitation combines education, training, exercise, and support. Patients are taught about their particular lung disease and how to deal with it. At the same time, they begin an exercise and conditioning program that progressively takes them from very limited activity to once again participating in a full life.

All of this happens in a series of outpatient visits, two or three times per week over 6 to 12 weeks. Pulmonary rehabilitation programs may involve many different health care professionals: the respiratory care practitioner, nurse, physical therapist, occupational therapist, exercise physiologist, dietitian, pharmacist, social worker, and others.

The American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) defines pulmonary rehabilitation thus: “Pulmonary rehabilitation is a multidisciplinary program of care for patients with chronic respiratory impairment that is individually tailored and designed to optimize physical and social performance and autonomy.⁷”

So why is it not more widespread? One of the reasons that pulmonary rehabilitation has been slow to gain acceptance is that it does not improve pulmonary function test (PFT) results. The benefits are simply not reflected in the measurements of lung mechanics.

The Problem with Medicare
As early as 1981, Medicare (then overseen by the Health Care Financing Administration, now the Centers for Medicare and Medicaid Services or CMS) recognized that these services deserved to be covered. Yet, 24 years later, Medicare has yet to develop a national policy of recognition, a National Coverage Determination, for pulmonary rehabilitation. Currently, whether or not to pay claims and how much to pay is left to the Fiscal Intermediaries—insurance companies that handle Medicare claims.

Services are billed using temporary G-codes, and the actual dollar reimbursement varies widely across the country. In some states, payment is virtually nonexistent. In other states, payment for services is barely adequate to keep programs alive.

Encouraging Things Are Happening
To address the reimbursement issue, the AACVPR, the American College of Chest Physicians, and the American Hospital Association have been meeting face-to-face with CMS officials. These groups have formally requested a National Policy Determination from CMS. There has been no concrete action so far, in part because of the recent election, but at least the interested parties are talking.

Separately, legislative language has been proposed to be included in the upcoming Medicare bill expected to make its way through Congress in 2005. This language would provide recognition of both pulmonary and cardiac rehabilitation in a law passed by Congress and signed by the president. The effect would be to mandate CMS to develop a national policy and to reimburse for these services.

In the meantime, a coalition of health care professional organizations, patient organizations and foundations, individuals, and government agencies has formed under the banner of US COPD Coalition (www.uscopd.com). This coalition brings together the strength of many groups that are focused on helping respiratory patients.

Senator Mike Crapo (R-Idaho) has stepped up to the plate by forming the congressional COPD Caucus, which is associated with the US COPD Coalition. For the first time, COPD patients and the health care professionals who serve them have a voice in the US Congress.

Also encouraging is the ongoing work of GOLD (Global Initiative for Chronic Obstructive Lung Disease). It is a collaborative project of the US National Heart, Lung, and Blood Institute and the World Health Organization. Its goals are to increase awareness of COPD and decrease morbidity and mortality from this disease. GOLD aims to improve prevention and management of COPD through a concerted worldwide effort of people involved in all facets of health care and health care policy, and to encourage a renewed research interest in this extremely prevalent disease. ⁶

To this end, GOLD has included pulmonary rehabilitation in its statements on the management of COPD.

Pulmonary Rehabilitation Program Certification
Medicare and private insurance companies want to know what they being asked to pay for—a legitimate question, since the number of patients that could benefit from pulmonary rehabilitation is estimated at well over 20 million.⁹

As pulmonary rehabilitation evolved, professional societies such as the American Thoracic Society began to publish statements to specify the content and quality expected in these programs.⁹

AACVPR has taken this process a step further with the publication of comprehensive guidelines, now in their third edition⁷ and a system of program certification (www.aacvpr.org) that has achieved national recognition. Their simple, yet powerful mission statement for certification says it all: “The goal of program certification and recertification is the assurance of the highest standards of pulmonary care.”¹⁰

In 1999, AACVPR began certifying pulmonary rehabilitation programs. CMS has already signaled a strong interest in program certification. In the future, reimbursement for pulmonary rehabilitation services will almost certainly be tied to program certification.

What Can You Do?
COPD patients need your help. They need to break the cycle of exacerbation, hospitalization, and return home again only to wait for the next time. Every time you see a patient with shortness of breath and a decreased QOL tell them about pulmonary rehabilitation. That may be in the emergency department, the intensive care unit, on the floor, or even in the PFT lab. Do not miss the chance. Pick up the phone and call your nearest program.

Respiratory therapists, nurses, and other health care professionals can play a major role in getting that patient into a pulmonary rehabilitation program. If there is no program in your area, start one. Talk to your manager, your doctors, and your hospital administrator.

By the way, our patient is a real person, and it was thrilling to see him once again be able to walk with his grandchildren, drive his car, get out on the golf course, and attend his church. Pulmonary rehabilitation works.

Carl W. Willoughby, RRT, RCP, is pulmonary rehabilitation coordinator, Mad River Community Hospital, Arcata, Calif.

References
1. Haas A, Cardon H. Rehabilitation in chronic obstructive pulmonary disease: a 5- year study of 252 male patients. Med Clin North Am. 1969;53(3):593-606.
2. Petty TL, Nett LM, Finigan MM, Brink GA, Corsello PR. A comprehensive care program for chronic airway obstruction: methods and preliminary evaluation of symptomatic and functional improvement. Ann Intern Med. 1969;70(6):1109-20.
3. Goldstein RS, Bort EH, Stubbing D, Avendano MA, Guyatt GH. Randomized controlled trial of respiratory rehabilitation. Lancet. 1994;344(8934):1394-1397.
4. Griffiths TL, Burr ML, Campbell JA, et al. Results at 1 year of outpatient multidisciplinary pulmonary rehabilitation: a randomized controlled trial. Lancet. 2000;355(9201):362-368.
5. California Pulmonary Rehabilitation Collaborative Group. Effects of pulmonary rehabilitation on dyspnea, quality of life, and healthcare costs in California. J Cardiopulm Rehabil. 2004;24(1):52-62.
6. Global Initiative for Chronic Obstructive Lung Disease. Available at: www.goldcopd.com/exec_summary/summary_2001/3comonents.html.   Accessed December 22, 2004.
7. American Association for Cardiovascular and Pulmonary Rehabilitation. Guidelines for Pulmonary Rehabilitation Programs. 3rd ed. Champaign, Ill: Human Kinetics; 2004.
8. American Lung Association. Number of COPD conditions in adults aged 18 years and older. 1997-2002. Available at: www.lungusa.org/data.html. Accessed December 22, 2004.
9. American Thoracic Society. Pulmonary rehabilitation. Am J Resp Crit Care Med. 1999;159(5 pt 1):1666-82.
10. American Association for Cardiovascular and Pulmonary Rehabilitation. Pulmonary rehabilitation program application for certification. Available at: www.aacvpr.org/certification. Accessed December 22, 2004.