The advent of virtual care offers exciting new possibilities for expanding healthcare access. While this is a net positive for patients and providers, healthcare experts are warning that in some cases, virtual care may not be able to offer the gold standard of medicine, while curbing access to needed in-person care.
Virtual pulmonary rehabilitation is one such case. Though health systems are increasingly collaborating with virtual-first pulmonary rehab providers, experts in the field have cautioned against a no-holds-barred approach to replacing in-person pulmonary rehab with virtual programs.
"I think the major concern now is that the healthcare systems may be led by digital health specialists or administrators who aren't as familiar with what's happening on the front lines with patients directly, and they may find [virtual programs] to be an easy solution to offering pulmonary rehab to patients," said Marilyn Moy, M.D., associate professor of medicine at Harvard Medical School and chair of the American Thoracic Society's (ATS) Pulmonary Rehabilitation Assembly.
Moy worries that “center-based programs are going to be erased, that they're going to actually do away with their center-based pulmonary rehab programs.”
“And there's still not enough evidence to support just using virtual programs, especially for our sickest patients," Moy noted, adding that her statements do not reflect the official views of Harvard or the ATS.
However, the cost of running center-based programs is proving too high, and many health systems are forced to limit or close those programs. In these cases, virtual pulmonary rehab is preferable to no rehab option for pulmonary disease patients. Still, health systems must carefully vet and continually assess the virtual pulmonary rehab model they choose to implement.
GAPS IN VIRTUAL PULMONARY REHAB
Center-based pulmonary rehab -- considered the gold standard of care by the leading experts in the field -- involves patients coming in person to a rehab center and engaging in various exercises and activities supervised by pulmonary rehabilitation experts, Moy explained. These typically include a nurse practitioner, pulmonologist, respiratory therapist and physical therapist.
"It's very safe because we can respond to their vital signs, their oxygen saturation, their heart rate, their shortness of breath symptoms and take care of issues that come up in real time because when patients are exercising, that's when a lot of bad things can happen, like they're getting short of breath or having chest pain or more wheezing," Moy said.
In addition, pulmonary rehab specialists offer disease education, explaining the underlying issues causing the symptoms and how best to manage them.
The primary difference between center-based and virtual pulmonary rehab is that the former is backed by 40 years of evidence.
"We have head-to-head trials with usual care, randomized controlled trials showing that it does improve exercise capacity and shortness of breath symptoms, as well as health-related quality of life compared to usual care," Moy said. "And so, we know that if patients do what we prescribe, they're going to get those expected benefits."
Virtual pulmonary rehab lacks that evidence base, leaving room for a variety of approaches. For instance, Moy noted that some virtual programs are synchronous, meaning the rehab sessions occur in real time via video, with patients being observed remotely. While others are asynchronous, with patients receiving videos and instructions on their exercise regimens and performing them at home without direct supervision.
"We found that in the United States, it's very heterogeneous, so we don't know which ones are safe, what the best model is to even recommend," Moy said.
Linda Nici, M.D., former chief of the pulmonary and critical care section at the Providence Veterans Administration Medical Center and founder and former medical director of the Providence VAMC Pulmonary Rehabilitation Program, echoed Moy, adding that virtual programs may not be able to perform the necessary in-person assessments effectively.
We're worried that center-based programs are going to be erased, that they're going to actually do away with their center-based pulmonary rehab programs. And there's still not enough evidence to support just using virtual programs, especially for our sickest patients.
Marilyn Moy, M.D.Associate professor of medicine at Harvard Medical School and chair of the American Thoracic Society's (ATS) Pulmonary Rehabilitation Assembly
Nici noted that these assessments are critical for the specialist to understand where the patient is at, what their goals are for treatment and what they can handle with regard to exercise.
Additionally, the growing use of virtual rehab could result in the shuttering of center-based pulmonary rehab programs, which would be a great loss for the field as a whole.
"If you lose, center-based pulmonary rehab, you lose basically those experts, the people who have done this for years, understand the physiology, understand how to deliver this," Nici said. "You lose that huge resource because those are exactly the people who should be working with commercial entities, with business entrepreneurs, with digital departments and hospitals to say, okay, we want to try to deliver this remotely, but how do we do it the right way?"
Not only that, but the loss of center-based pulmonary rehab could adversely affect patients who are not good candidates for virtual care, like lung transplant patients. Nici explained that the transplant process is predicated on the patient's ability to do pre- and post-transplant rehab. Virtual programs would likely not be safe for these patients, especially in the pre-transplant phase.
BUT VIRTUAL PULMONARY REHAB IS STILL NEEDED
Though virtual pulmonary rehab may not be able to replace in-person rehab as the gold standard, an alternative to center-based pulmonary rehab is sorely needed.
Lauren E. Eggert, M.D., clinical assistant professor and director of airways disease at Stanford University School of Medicine and medical director at Stanford Health Care - TriValley Pulmonary Rehabilitation, detailed the urgent need to expand pulmonary rehab options.
"I think center-based rehab is the gold standard, and I wish every patient could have access to it, but it's not a viable financial model, and centers have been closing left and right," she said.
This is what happened at Stanford, too. Eggert emphasized that pulmonary rehab is reimbursed very poorly, and as a result, Stanford's center-based pulmonary rehab "perpetually ran in the red." Recognizing the importance of center-based pulmonary rehab, Stanford did all it could to make the program work financially, making cuts where possible. But the program ultimately closed.
The growing trend of center-based pulmonary rehab closures has exacerbated access issues, leaving patients to travel long distances to remaining centers and fight for a decreasing number of appointments.
Virtual pulmonary rehab has emerged as an approach to fill this gap. Stanford Health Care partnered with Kivo Health to launch this virtual option, though Eggert notes that it is not the ideal form of rehab.
"Is it the exact same? Is it as well studied? Is it as perfect as in-person traditional models? Probably not," she said. "But is it a really viable alternative that fits with the realities of the situation? I believe so. And it really seems to be the way medicine is moving because of just the cost realities of medicine."
The virtual pulmonary rehab program also allows Stanford to expand access across California and into Nevada and provide a more convenient rehab option for chronic obstructive pulmonary disease (COPD) and chronic lung condition patients with other comorbidities, she added.
KEY CONSIDERATIONS FOR VIRTUAL PULMONARY REHAB
The challenges of delivering in-person pulmonary rehab make virtual programs a necessary option in today's healthcare landscape. However, Moy, Nici and Eggert agree that virtual programs should be offered alongside in-person programs and must be assessed carefully.
I think center-based rehab is the gold standard, and I wish every patient could have access to it, but it's not a viable financial model, and centers have been closing left and right.
Lauren E. Eggert, M.D.Clinical assistant professor and director of airways disease at Stanford University School of Medicine and medical director at Stanford Health Care - TriValley Pulmonary Rehabilitation
For instance, Eggert noted that Stanford selected Kivo Health as a virtual pulmonary rehab partner after viewing data from the University of California, Los Angeles, which had previously implemented the program.
The health system is currently working on collecting data, including generalized patient-reported outcomes and PHQ-9 scores, to ensure its efficacy, she shared. Additionally, the clinical teams continually review adverse events and patient safety data.
"We're very closely keeping an eye on the data," Eggert said. "We have about 40 to 50 patients who've now gone through the program since we've started promoting it. We're collecting data regularly… [and] we're hoping to publish some of this data at least in abstract form by the end of the year."
Growing the clinical evidence base for virtual pulmonary rehab will be critical to cementing its place alongside in-person rehab.
Moy pointed out several gaps in the current research, including a lack of evidence showing that third-party virtual pulmonary rehab providers are reaching the vast number of patients they claim they are reaching.
"There's no study of their zip codes to say that 'Oh, these are the rural patients we're saying that we're going to access,'" she said. "There's no evidence that they actually have. And they may in fact be only reaching urban patients who would've gone to center-based pulmonary rehab. We don't know. And so that's a simple question that can be looked at with some research, because this is what they're proposing to fill the gap for."
Virtual pulmonary rehab companies are working to bolster the clinical evidence and fill the research gaps.
Victor Sadauskas, MD, co-founder and CEO of Kivo Health, highlighted some studies showing the efficacy of virtual pulmonary rehab, but he also noted that the company is actively working with its clinical partners to "publish research around optimizing patient selection, identifying methods to increase patient participation, and more."
"We do not want to replace in-person care, but rather believe that virtual pulmonary rehab is an important and necessary complement to in-person care," he said.
While research on virtual pulmonary rehab is ongoing, Nici noted that health systems looking to implement these programs can rely on the expertise of pulmonary rehab specialists. Dialogue between digital health leaders and pulmonary rehab experts can help ensure that the programs effectively reach and treat the appropriate patient populations.
This dialogue, alongside the other strategies explored above, will be vital as health systems work to ensure access to pulmonary rehab in today's access-strapped healthcare landscape.
"We need to make the virtual piece of this as effective and have as much fidelity to the [in-person] intervention as possible," Nici said. "And that's not happened yet. And then once that happens, I think they still have to coexist. Coexist in a way that enriches the other."
Anuja Vaidya has covered the healthcare industry since 2012. She currently covers the virtual healthcare landscape, including telehealth, remote patient monitoring and digital therapeutics.
