Effectiveness of a Home-Based Pulmonary Rehabilitation Program in Veterans

Abstract

Purpose:

This study examined the effectiveness and safety of a home-based pulmonary rehabilitation (HBPR) program in Veterans.

Methods:

Patients were evaluated from five Veteran Affairs facilities that enrolled in the 12-week program. Pre- to postchanges were completed on clinical outcomes using paired t-tests and the Wilcoxon signed rank sum test. Descriptive statistics were used for patient demographics, emergency room visits, and hospitalizations.

Results:

Two hundred eighty-five patients with a mean age of 69.6 ± 8.3 years enrolled in the HBPR program from October 2018 to March 2020. There was a 62% (n = 176) completion rate of both pre- and post assessments. Significant improvements were detected after completion of the HBPR program in dyspnea (modified Medical Research Council: 3.1 ± 1.1 vs. 1.9 ± 1.1; p < 0.0001); exercise capacity (six-minute walk distance: 263.1 m ± 96.6 m vs. 311.0 m ± 103.6 m; p < 0.0001; Duke Activity Status Index: 13.8 ± 9.6 vs. 20.0 ± 12.7; p < 0.0001; self-reported steps per day: 1514.5 ± 1360.4 vs. 3033.8 ± 2716.2; p < 0.0001); depression (patient health questionnaire-9: 8.3 ± 5.7 vs. 6.4 ± 5.1); nutrition habits (rate your plate, heart: 45.3 ± 9.0 vs. 48.9 ± 9.2; p < 0.0001); multicomponent assessment tools (BODE Index: 5.1 ± 2.5 vs. 3.4 ± 2.4; p < 0.0001), GOLD ABCD Assessment: p < 0.0009); and quality of life (chronic obstructive pulmonary disease assessment test: 25.4 ± 7.7 vs. 18.7 ± 8.5; p < 0.0001). No adverse events were reported due to participation in HBPR.

Conclusions:

The HBPR program is a safe and effective model and provides an additional option to address the gap in pulmonary rehabilitation access and utilization in the Veterans Affairs.

Introduction

Patients diagnosed with chronic pulmonary disease can experience dyspnea, limitations in exercise and physical activities of daily living, depression and anxiety, malnutrition, and reduced quality of life, all which can lead to pulmonary exacerbations and hospitalizations.^1
–3 Pulmonary rehabilitation (PR) is an essential behavioral lifestyle treatment that comprised multiple components focusing on physical and psychological improvement in patients with chronic respiratory disease.¹ PR has been shown to be effective in reducing dyspnea, improving function and quality of life, and in the reduction of rehospitalizations.^4

–7

Despite evidence and guidelines^1,3,8
–10 supporting PR for the management of pulmonary disease, there continues to be insufficient access to services and underutilization. Recent analyses showed that only 2–2.7% of Medicare^11,12 and 1.5% of Veteran Affairs (VA) patients,¹¹ discharged due to a chronic obstructive pulmonary disease (COPD) hospitalization, received PR within 1 year. Reasons for underutilization include health care system factors (e.g., lack of referral, program availability) and patient barriers (e.g., transportation, lack of perceived benefit, disruption of usual routine, influence of referring provider, symptom burden).^13
–15

Innovative strategies are imperative to improve both patient- and system-level factors inhibiting referral, enrollment, and attendance of PR.^16,17 One potential solution has been the use of home-based pulmonary rehabilitation (HBPR) models, uniquely addressing several barriers to attending in-person PR.^18

–21 However, there are few incentives to offer PR telehealth models in the United States due to lack of reimbursement and structured guidelines.¹⁹ Research has shown home-based models of PR to be effective and comparable with in-person PR programs in improvements in quality of life, dyspnea, and function in patients with COPD.^{15,20,22

–26}

Many VA facilities do not offer in-person PR services and Veterans are referred to local community PR programs; however, for many, the attendance obstacles are still present. The purpose of this study was to examine the effectiveness and safety of a HBPR model implemented in VA facilities, a program that can offer an alternative telehealth model to in-person PR services.

Methods

STUDY DESIGN

This analysis was a retrospective observational study approved by the University of Iowa Institutional Review Board and the Iowa City VA Research Committee. HBPR providers at five VA sites collected patient data at program enrollment and completion and entered it into a Microsoft Access database housed on a secure server and managed by the database manager at the Iowa City VA Medical Center. Data on patients enrolled from October 1, 2018, to March 1, 2020, were extracted from the database.

INTERVENTION

A HBPR program was supported by the VA Office of Rural Health as a solution to address access barriers to PR services for Veterans with chronic pulmonary disease. Due to similarities between patient populations and guidelines of cardiac and rehabilitation, the program is modeled on a successful VA home-based cardiac rehabilitation program implemented in facilities within the VA through mentored implementation.^27
–29

Similar to the cardiac rehabilitation program, the HBPR model is a multicomponent 12-week structured program where Veterans receive care in their home by video and/or telephone appointments.

A HBPR professional (i.e., respiratory therapist, physical therapist, nurse, or exercise physiologist proficient in PR)³⁰ provides individual consultation on exercise and physical activity, nutrition and weight management, medication adherence, psychosocial support, and tobacco cessation tailored to the patient's pulmonary disease.

An individualized exercise prescription is designed to be integrated into the patient's lifestyle and home environment focusing on not only symptom management (i.e., dyspnea) but also improvement in physical endurance and independence. Nutritional counseling and weight management are included, and patients with in-depth needs are referred to a VA dietitian. Medication nonadherence is reported to the patient's medical provider and additional services are ordered if needed (i.e., medication organizer, pharmacy consultation, home health nurse).

Patients receive individualized psychosocial education covering importance of social support, managing stress and anxiety, and learning basic breathing and stress management techniques. Patients who need additional psychosocial services are referred to mental health services. Tobacco users are provided guidance on tobacco cessation and additional resources available within the VA.

Veterans with chronic pulmonary disease (i.e., COPD, interstitial lung disease, lung cancer, and pulmonary hypertension) can be referred to the HBPR program. Eligible patients complete an in-person evaluation with a PR professional. At enrollment, patients are given an exercise peddler, pedometer, resistance bands, and educational guidebook. The program also ensures that patients have access to a blood pressure cuff, pulse oximeter, and other devices as needed (i.e., flutter device, incentive spirometer, scale). Subsequent appointments are completed by video or telephone weekly for 12 weeks. The program aims for all completion appointments to be conducted in person; however, if barriers are present, the patient is assessed via telephone and/or video in his or her home.

STUDY ENDPOINTS

Comprehensive metrics (outlined in Table 1) collected at enrollment and completion of the HBPR program were analyzed (function [Duke Activity Status Index,³¹ six-minute walk distance administered according to the American Thoracic Society Guidelines,³² self-reported pedometer daily steps collected at each appointment], dyspnea [mMRC],³³ depression [PHQ-9],³⁴ quality of life [COPD Assessment Test],³⁵ nutrition and weight management [body mass index, rate your plate, heart³⁶], medication nonadherence [extent of nonadherence],³⁷ and multicomponent assessment tools [BODE Index³⁸ and GOLD ABCD³⁹]).

Table 1.

Summary of Outcome and Performance Metrics

	METRIC	DESCRIPTION	RANGE (WHEN APPLICABLE)
Dyspnea	mMRC³³	Self-reported rating of breathlessness	0–4 (higher score reflects higher level of breathlessness)
Depression and quality of life	PHQ-9³⁴	9-item self-administered questionnaire	0–27 (higher score reflects more severe depression) Minimal or no depression (0–2) Mild depression (5–9) Moderate depression (10–14) Moderately severe depression (15–19) Severe depression (20–27)
Depression and quality of life	COPD assessment test³⁵	8-item self-administered questionnaire	0–40 (higher score reflects poorer quality of life due to disease)
Exercise capacity	6MW³²	Distance a patient can walk on a flat surface over the duration of 6 min
	Duke Activity Status Index³¹	12-item self-administered questionnaire	0–58.2 (higher score reflects a higher functional capacity)
	Weekly average of daily steps	Estimated using pedometer provided by the program
Nutrition and weight management	BMI	Weight in kilograms divided by the square of height in meters	<18.5 underweight18.5–24.9 normal25.0–29.9 overweight>30.0 obese
Nutrition and weight management	Rate your plate, heart³⁶	Self-reported eating patterns	24–72 (higher score reflects healthier nutrition choices)
Medication adherence	Extent of nonadherence³⁷	3-item self-administered questionnaire	3–15 (higher score reflects less medication adherence)
Multicomponent assessment tools	BODE Index³⁸	Survival interpretation that incorporates BMI, FEV1%, mMRC, and 6MW assessments	0–2 = 80%3–4 = 67%5–6 = 57%7–10 = 18%Higher score predicts increasing morbidity
Multicomponent assessment tools	GOLD ABCD assessment³⁹	Assessment of symptom burden and risk of exacerbation	A-D (higher letter reflects increased exacerbation history and burden of symptoms)
Patient satisfaction	Satisfaction score	6-item self-administered questionnaire using a 5-point Likert scale	0–30 (higher score reflects higher satisfaction)

6MW, six-minute walk; BMI, body mass index; COPD, chronic obstructive pulmonary disease; GOLD, global initiative for chronic obstructive lung disease; mMRC, modified Medical Research Council; PHQ-9, patient health questionnaire-9.

The American Association of Cardiovascular and Pulmonary Rehabilitation performance measures³ (i.e., six-minute walk improvement in function by 30 m,⁴⁰ one-point improvement in dyspnea measured by the modified Medical Research Council [mMRC],⁴¹ two-point improvement in quality of life measured by the COPD assessment test⁴²) were also included in the analysis. All HBPR providers were provided instruction on the administration and interpretation of patient assessments.

Demographics collected include age, gender, race, education level, referral diagnosis, rurality (based on rural–urban community area codes), and global initiative for chronic obstructive lung disease (GOLD) classification (Table 2). Patient satisfaction was collected at the completion of the 12-week program using a Likert scale assessment (Table 1).

Table 2.

Baseline Demographics of Patients Who Completed Home-Based Pulmonary Rehabilitation

DEMOGRAPHICS	N (%)
Sex
Male	168 (95)
Female	8 (5)
Age, years
30–49	3 (2)
50–64	37 (21)
65–69	33 (19)
70–74	58 (33)
75+	42 (24)
Unknown	3 (2)
Race
White	133 (76)
Black	25 (14)
Other	17 (10)
Admission diagnosis
COPD	136 (77)
Interstitial lung disease	11 (6)
Lung cancer	22 (13)
Pulmonary hypertension	1 (.6)
Other	5 (3)
Rurality
Urban	127 (72)
Rural	49 (28)
Education level
High school or less	23 (13)
Beyond high school	113 (64)
Unknown	40 (23)
mMRC
0	4 (3)
1	16 (9)
2	24 (14)
3	36 (20)
4	87 (49)
Unknown	9 (5)
GOLD classification
GOLD 1 (Mild)	12 (7)
GOLD 2 (Moderate)	77 (44)
GOLD 3 (Severe)	58 (33)
GOLD 4 (Very severe)	27 (15)
Unknown	2 (1)
GOLD ABCD assessment
A	5 (3)
B	88 (50)
C	3 (2)
D	61 (35)
Unknown	19 (11)
BODE Index
0–2	17 (10)
3–4	31 (18)
5–6	29 (16)
7–10	40 (23)
Unknown	59 (34)
PHQ-9 score
Minimal or no depression (0–4)	55 (31)
Mild depression (5–9)	49 (28)
Moderate depression (10–14)	36 (20)
Moderately severe depression (15–19)	21 (12)
Severe depression (20–27)	6 (3)
Unknown	9 (5)

Adverse events, including emergency room visits, hospitalizations, and exacerbations (defined as needing to begin an antibiotic and/or steroid without hospitalization), were identified through chart review and patients' self-report at enrollment and throughout the entirety of participation in the HBPR program, not only scheduled appointments.

STATISTICAL ANALYSIS

This analysis focuses on data from patients who completed both an enrollment and completion assessment. There was no attempt to collect data of those patients who did not complete the program. Patient demographics were analyzed using descriptive statistics. Changes from baseline to completion of the 12-week program for all interval level measures were compared using paired t-tests. For the GOLD ABCD Assessment, an ordinal variable, the Wilcoxon signed rank sum test was used to determine change.

Patient satisfaction, emergency room visits, and hospitalizations during the program were summarized using descriptive statistics. Baseline characteristics comparing completers and noncompleters were analyzed using chi-square for categorical variables and paired t-tests for continuous variables to assess for differences. All statistical tests are reported as two-tailed tests and were considered significant if p < 0.05.

Results

Of the 285 patients who enrolled in the program, 176 patients (62%) completed both pre- and postassessments. Patients were predominately Caucasian (76%) and male (95%) with a mean age of 69.6 ± 8.3 years (Table 2). Seventy-eight percent of patients enrolled in the HBPR program were referred due to COPD. Twenty-seven of the 176 participants were current smokers at enrollment into the program, and 3 demonstrated quitting by completion of the 12-week program.

Adherence to the HBPR program was defined as the number of planned sessions attended. Forty-one percent of participants (n = 118) enrolled in the program completed all the planned 12 sessions and 15% (n = 43) completed between 8 and 11 sessions. Of the 109 noncompleters, reasons included the following: 23 (21%) lost to follow-up (not showed at appointments), 23 (21%) verbally dropped out, 29 (27%) unable to continue the program (e.g., decline in health or personal factors), 29 (27%) were stopped by HBPR program staff due to noncompliance or changes in health status, and 5 (5%) died during enrollment (1 COPD exacerbation, 1 suspected drug overdose, 1 congestive heart failure, and 1 end-stage mesothelioma.

Comparing the baseline characteristics of completers and noncompleters, there were significant differences between GOLD ABCD classification (p = 0.03) and mMRC score (p = 0.002), patients with higher ABCD classification and who reported more dyspnea on the mMRC were more likely to complete the program. No other significant differences were detected between the two groups.

PRE- TO POSTCOMPARISONS

Patients who completed the HBPR program showed significant improvements in dyspnea, depression, quality of life, exercise capacity, nutrition habits, and medication adherence from baseline to program completion (Table 3).

Table 3.

Comparison of Baseline and Completion Metrics

	ASSESSMENT	n ^a	BASELINE, MEAN ± SD	COMPLETION, MEAN ± SD	p
Dyspnea	mMRC	167	3.1 ± 1.1	1.9 ± 1.1	<0.0001
Depression and quality of life	PHQ-9	167	8.3 ± 5.7	6.4 ± 5.1	<0.0001
Depression and quality of life	COPD assessment test	168	25.4 ± 7.7	18.7 ± 8.5	<0.0001
Exercise capacity	Duke Activity Status Index	167	13.8 ± 9.6	20.0 ± 12.7	<0.0001
	6MWD, m	119	263.1 ± 96.6	311.0 ± 103.6	<0.0001
	Pedometer, steps/day	142	1514.5 ± 1360.4	3033.8 ± 2716.2	<0.0001
Nutrition/weight management	BMI, kg/m²	165	29.4 ± 6.5	29.2 ± 6.4	0.11
	Weight, lb	165	199.1 ± 46.7	197.6 ± 46.6	0.03
	Rate your plate	159	45.3 ± 9.0	48.9 ± 9.2	<0.0001
Medication adherence	Extent of adherence	167	4.7 ± 2.8	3.83 ± 2.1	<0.0001
Multicomponent assessment tools	BODE Index	117	5.1 ± 2.5	3.4 ± 2.4	<0.0001
Multicomponent assessment tools	GOLD ABCD	157			<0.0009^b
Risk factor management	Systolic blood pressure, mm Hg	158	127 ± 20.2	125.8 ± 17.3	0.44
Risk factor management	Diastolic blood pressure, mm Hg	158	74.8 ± 10.4	74.3 ± 8.4	0.53

Not all participants completed all assessments.

Wilcoxon signed rank sum test used.

6MWD, six-minute walk distance; SD, standard deviation.

There were significant improvements in self-reported dyspnea as measured by the mMRC (p < 0.0001). When assessing dyspnea with the mMRC by the predefined AACVPR performance measure,⁴¹ 68% (n = 114) showed improvements in dyspnea.

Thirty-eight percent (n = 63) scored moderate or worse depression symptoms on the patient health questionnaire-9 (PHQ-9) at baseline (Table 2); 41% (n = 69) improved at least one category at program completion. Overall, patients demonstrated significant improvement (p < 0.0001) in depression at completion of the HBPR program. There were significant improvements at completion in quality of life as measured by the COPD assessment test (p < 0.0001). Based on the quality-of-life AACVPR performance measure,⁴² 77% (n = 130) improved on the COPD Assessment Test at completion of the program.

Patients demonstrated statistically significant improvements in exercise capacity in all the three assessed metrics: six-minute walk distance (p < 0.0001), Duke Activity Status Index (p < 0.0001), and self-reported daily steps (p < 0.0001). For functional improvement based on the AACVPR performance measure,⁴⁰ 61% (n = 73) of patients assessed by the six-minute walk distance improved at completion of the HBPR program.

Patients showed significant improvements in both the multicomponent assessment tools used (BODE Index and ABCD assessment classification). Sixty-nine of the 117 patients improved at least one category (50 one category; 17 two categories; and 2 three categories) in the BODE Index at completion. Forty-four patients remained in the same category. Using the Wilcoxon signed rank test, significant improvements (p = 0.0009) in ABCD assessment were demonstrated at the completion of the HBPR program. Thirty-six of the 157 patients improved at least one category (22 one category and 14 two categories) in the ABCD classification at completion. One hundred thirteen patients remained in the same ABCD classification.

Significant improvements in nutrition habits (rate your plate, heart) (p < 0.0001), body weight (p = 0.03), and medication adherence (extent of nonadherence) (p < 0.0001) were found. Patients also reported being highly satisfied with their participation, with an average score of 28.8/30 satisfaction assessment.

SAFETY

Twenty-six percent of patients (n = 45) who completed the HBPR program had at least one documented emergency room visit (30 patients had one visit and 15 had two or more) for a total of 82 emergency room visits. Nineteen patients (11%) had at least one emergency room visit related to their pulmonary disease (12 patients had one visit and 7 patients had two or more) for a total of 39 pulmonary related emergency room visits.

Fourteen percent (n = 25) were hospitalized during their program participation (21 had one hospitalization and 4 had two or more hospitalizations). Sixteen patients (9%) were hospitalized due to their pulmonary disease (12 had one hospitalization and 4 had two or more hospitalizations).

The HBPR program also tracked exacerbations, defined as a patient prescribed an antibiotic or steroid for the progression of pulmonary symptoms, however, no hospitalization was warranted. Twenty-one patients (12%) reported at least one exacerbation during the duration of the program (14 had 1; 4 had 2; 2 had 3; and 1 reported 11 exacerbations).

Discussion

Symptom burden (i.e., dyspnea, fatigue), muscle dysfunction, and eventually deconditioning can lead to systemic changes in exercise capacity, psychosocial status, and quality of life for those suffering from chronic pulmonary disease.^1,43,44 Evidence and guidelines have defined the importance of PR in the treatment of chronic respiratory disease; however, it continues to be vastly underutilized. Findings of this study demonstrated effectiveness in improving core PR outcomes (dyspnea, medication adherence, exercise capacity, depression, nutrition habits, and quality of life) in participants who completed the HBPR program.

Dyspnea associated with chronic pulmonary disease can initiate symptoms of anxiety, fear, or even depression leading to avoidance of physical or social activities and therefore negatively impact quality of life.^2,44 Participants completing this HBPR program showed significant improvements in dyspnea, depression, and quality of life. Similar improvements in the mMRC assessment have been demonstrated by others.⁷ HBPR providers teach symptom management skills including breathing and energy preservation techniques, symptom recognition, and utilization of action plans, which may account for this finding.

Previous research has found that PR improves symptoms of anxiety and depression⁴⁵ and patients with chronic pulmonary disease report higher rates of depression, anxiety, and even panic attacks compared with the general population.^1,46 Assessing for depression and anxiety at enrollment can help develop treatment plans and engage mental health providers as needed for the management of these symptoms and potentially improve dyspnea symptoms and activity.

Significant improvements were found for all three exercise assessments. The six-minute walk distance results are comparable with other HBPR studies (ranging from 29 to 65 m)^{20,22,25,26,47} and in-person PR (ranging from 43 to 75 m).^6,7,48 PR may not improve the overall lung function; however, improving symptoms and physical function is emphasized to allow patients to achieve optimal independence.² Incorporating a guided individualized exercise prescription tailored to the patients' lifestyle might not only be more sustainable for the patient,²⁰ but also ensure tailored goals that often revolve around the ability to complete necessary personal and household tasks.¹

HBPR patients also showed improvement in both the multicomponent assessment tools (GOLD ABCD assessment and BODE Index). Seventy-eight percent improved on the BODE Index at least one unit at completion of the HBPR program; similar findings at completion of PR have been reported.^7,49 These additional assessments are imperative to fully understand the severity and impact pulmonary disease has on all aspects and quality of life and drive collaborative treatment goals, referrals, and plans during HBPR participation.

The 30-day readmission rate for patients in the United States following a hospitalization for COPD is 22%.⁵⁰ PR has been shown to be effective in reducing readmissions and mortality rates.^4,51,52 The HBPR program tracked hospitalizations and exacerbations during the entirety of participation in the program. No participation-related (exercise prescription) adverse events were reported to the HBPR providers.

Only a few studies have evaluated safety, and the adverse events during participation of HBPR reported were generally mild.^22,53 Inconsistency in definition and reporting of adverse events in prior research makes it difficult to compare with our study findings. Participants in the HBPR program are counseled on exercise safety (monitoring vitals, when to stop exercising, medication adherence), when to activate emergency medical services, and the importance of monitoring and communicating changes in symptoms and concerns to their health care team. Learning these management and self-monitoring skills are vital in early recognition and treatment of potential exacerbations and can decrease hospitalizations related to their chronic pulmonary disease.

One possible reason for the improvement of patient symptoms and outcomes is that the program focuses on personalized collaborative goal setting and self-management skills to promote independence and the confidence necessary in managing their chronic pulmonary disease. Incorporation of self-management encourages the patient to be involved in treatment decisions, which may lead to an increase in confidence in the management of their health care. This approach can help optimize treatment and improve overall outcomes.⁵⁴ Standardized yet flexible educational opportunities for the patients, with an emphasis on teaching skills and providing feedback to promote confidence in self-monitoring and behavior modification needed in the management of their disease, are critical.^54
–56

Sixty-two percent of enrolled patients completed the HBPR program (defined as completion of final assessments), which was comparable with the VA Home-based Cardiac Rehabilitation Program findings with a 62% completion rate.²⁷ Research with differing criteria for completion has shown between 48% and 91% completion rates of in-person PR^13,18 and one review of home-based model demonstrated a 91% completion rate.²⁰ The VA population is generally older, sicker, and of a lower socioeconomic class compared with the general population.⁵⁷ Studies have reported the overall missed appointment rates within the VA system to be ranging between 18% and 35%,^58,59 which are comparable with our no-show rate of 21%.

Of the 109 noncompleters in our study, 42% (n = 46) were nonadherent to attending sessions or dropped out of the program, and 58% (n = 63) were unable to continue due to a decline in health status or personal factors, participation stopped by HBPR staff, or death. Patients with higher baseline mMRC and ABCD classification were more likely to complete the HBPR program. Findings from in-person PR programs have shown the opposite, those depicting the lower mMRC grade (less symptom burden) were more likely to complete PR programs.^60,61

Telehealth models in the VA have decreased missed appointments.⁶² Easier access to PR through telehealth might account for the higher adherence in patients with increased levels of dyspnea and ABCD classification at baseline. When eliminating the need to travel, it is possible that patients can focus on their PR goals while not experiencing increased levels of fatigue, dyspnea, anxiety, and exposure to allergens and illnesses. Future research of the HBPR program will allow us to evaluate long-term outcomes (dyspnea, function, quality of life, depression, tobacco cessation status), readmission, and mortality rates and identify reasons with strategies for nonadherence of HBPR.

LIMITATIONS

The analysis was based on a retrospective analysis of a clinical program and thus was not a randomized controlled study. Participants were predominately Caucasian males, which is consistent with the population of the VA, and therefore, these results may not be generalizable to the general population of individuals with pulmonary disease in the United States. There is inconsistency across the VA medical center's policies on pulmonary function measurement procedures (frequency, timing, administration protocols), which could impact FEV1% results used for GOLD classification and BODE Index results of this analysis. Finally, bias from self-reported daily pedometer readings could be present.

Conclusions

Challenges exist for effective implementation of PR, including referral, attendance, and access to services.^13,17 Furthermore, there are inadequate payment systems (e.g., lifetime limits of services, noncoverage) in the United States to support such programs despite that chronic pulmonary disease is lifelong and often worsens with time. In addition, COVID-19 has presented additional challenges in not only accessing in-person models of PR but also increasing the need for PR services for those recovering from a COVID-19 infection.

Telehealth models such as the HBPR program could help address access to PR, however, additional efforts are necessary to help support reimbursement models of home-based PR programs past the public health emergency. Similar telehealth models could be implemented in other health conditions, allowing for closer care while considering the patient's environment, limitations, and goals of care.

This study demonstrated an effective and safe telehealth HBPR program for Veterans receiving care in the VA. Continued evaluation of home-based models is necessary to compare effectiveness with traditional models of PR and inclusion of patients with non-COPD diagnoses (interstitial lung disease, bronchiectasis, lung cancer). Guidelines and recommendations comparable with established PR programs are desirable for home-based programs to ensure effectiveness, safety, and accountability. Finally, additional research is necessary to examine the long-term effects of HBPR on patient outcomes and readmissions due to chronic pulmonary disease.

Footnotes

Authors' Contributions

All authors have made substantial contributions to the design, analysis, drafting, and revision of this work. All authors have read and approved submission of the article and the article has not been published and is not being considered for publication elsewhere, in whole or part, in any language.

Acknowledgments

The views expressed in this article are those of the authors and do not represent the views of the Department of Veterans Affairs.

Disclosure Statement

No competing financial interests exist.

Funding Information

The work reported here was supported by the Department of Veterans Affairs, Veterans Health Administration, Office of Rural Health, Veterans Rural Health Resource Center-Iowa City (Award #10739), and the Health Services Research and Development (HSR&D) Service through the Center for Access and Delivery Research and Evaluation (CADRE) Center (CIN 13-412).

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