Not All Home-based Exercise Programs Are Home-based Pulmonary Rehabilitation Programs.

To the Editor:

I read with great interest the article by Bhatt and colleagues entitled, “Video Telehealth Pulmonary Rehabilitation Intervention in Chronic Obstructive Pulmonary Disease Reduces 30-Day Readmissions” (1).

The authors delivered pulmonary rehabilitation (PR), using two-way live videoconferencing on a smartphone to 80 patients after hospitalization for a chronic obstructive pulmonary disease (COPD) acute exacerbation (AE), and compared them with 160 matched patients. They report 30-day readmission rates, either all-cause or for COPD AE, in the patients who participated in video PR that are approximately three times lower than in the comparison group.

This study highlights the question of whether issues of access and adherence to conventional in-center PR can be safely addressed by using technology to bring a program directly to patients in their homes, while maintaining fidelity to the core components of conventional PR that are known to be efficacious (2–4).

Bhatt and colleagues speculate that PR’s positive effects on “physical, psychological, and social resilience” increased the “symptomatic threshold” for an AE, and thus reduced readmission rates (1). The authors made great efforts to mirror conventional PR with 36 sessions of aerobic exercise, strength training, and education over the course of 12 weeks. Nevertheless, there are enough differences (the use of a portable foot pedaler rather than a treadmill, resistance bands instead of free weights, videoconferenced education rather than group education, and a single provider rather than a multidisciplinary team of PR professionals) that efficacy of the video intervention should be robustly assessed. Within the video PR group, at the very least, assessments of changes in exercise capacity, dyspnea, and health-related quality of life before and after the intervention should document that this new model of PR is efficacious before it is called PR and before its effects can be attributed to benefits of conventional PR. An alternative explanation of the observed results could be that these patients received individualized counseling and intensive monitoring after hospital discharge, which led to early detection of mild exacerbations treated as outpatients, thereby avoiding hospitalizations. Assessment of all AEs, including those that did not lead to hospital readmissions, is needed to support the observed results and conclusions.

If patients cannot access conventional in-center PR, the use of any intervention that can effectively promote physical activity and exercise is certainly better than nothing. Bhatt and colleagues’ video-delivered intervention may have an important role in patients with COPD. Therefore, it is critical to understand details of patient selection criteria, the intervention itself, and implementation barriers/facilitators. It is unclear whether enrolled patients were initially referred to conventional PR but refused. Also, knowing how many patients refused the video program and how many were unable to complete the 36 sessions would help define the potential for large-scale uptake of and compliance with this delivery method. Understanding how many patients achieved 60–80% target heart rate and safely tolerated exercise progression would provide a sense of the intensity of exercise delivered and physiologic training effects. Details on whether patients were directly monitored during exercise sessions and by whom would help gauge the burden of personnel resources needed. Finally, understanding the Health Insurance Portability and Accountability Act compliant application used on the smartphone would help overcome current barriers of ensuring patient privacy and information security of home-recorded data.

The authors note that the results using an “active telehealth intervention” require confirmation with a randomized controlled trial. Three groups (video PR, conventional PR, and no PR) would need to be compared before the program can be called a “video telehealth PR intervention.”