Implementing a Pulmonary Rehabilitation Program

In 1994, a National Institutes of Health (NIH) Workshop on Pulmonary Rehabilitation defined pulmonary rehabilitation as “a multidimensional continuum of services directed to persons with pulmonary disease and their families, usually by an interdisciplinary team of specialists, with the goal of achieving and maintaining the individual’s maximum level of independence and functioning in the community.”1 In 1996, Wilson et al2 estimated the cost of chronic obstructive pulmonary disease (COPD) in the United States to be $14.5 billion. In today’s health care environment, pulmonary rehabilitation programs not only must improve the chronic lung disease patient’s level of independence and functioning, as implied by the NIH definition above; they also must demonstrate a concomitant reduction in health care utilization by their program’s graduates. Policy-makers and health care administrators, like Mary Shelley’s Dr Frankenstein, want to build a “perfect beast.” The perfect beast would be a pulmonary rehabilitation program that is able to improve the patient’s quality of life and also reduce hospitalization for acute care (the primary cost driver for COPD patients).

Setting Up A Program

In 1997, Thomas Mahrer, MD, and a group of respiratory care practitioners at Kaiser Permanente’s Los Angeles Medical Center planned and implemented a pulmonary rehabilitation program. The program serves Kaiser Permanente members who are referred by pulmonologists and have chronic lung disease in Los Angeles, San Bernardino, and Orange counties. The program was designed for members suffering from moderate to severe chronic lung disease. It was modeled on the highly successful University of California San Diego pulmonary program, led by pulmonary rehabilitation pioneer Andrew Ries, MD. The 6-week program meets three times a week for 2 hours. The first hour is devoted to the monitored exercise program. The exercise program utilizes treadmills, stationary bicycles, free weights, and upper-body ergometers blended together to achieve a balanced workout. The member’s progress on all exercise stations is carefully recorded every day. A pulmonologist visits the class every week and adjusts each member’s exercise prescription based on their perceived breathlessness (Borg scale) and oxygen saturation. The starting speeds for the treadmills are ascertained during the member’s initial evaluation and the program always runs its treadmill at a zero grade.

During the second hour, members attend an interactive mini-lecture concerning aspects of their lung disease. The program’s educational topics include respiratory physiology, medications, safety, exercise, Borg scale, breathing retraining, nutrition, stress management, relaxation techniques, oxygen use, advance directives, and when to talk to your doctor. Participants were required to become tobacco-free prior to beginning the pulmonary rehabilitation program. The program is colocated with a preexisting cardiac rehabilitation program.

After the first 5 years, the team was curious about the effect of the program on health care utilization by the pulmonary rehabilitation graduates within the Kaiser Permanente system. Kaiser Permanente is the ideal venue to study the impact of pulmonary rehabilitation on health care utilization because it is a relatively closed system. Few members seek care outside the Kaiser Permanente system; moreover, each pulmonary rehabilitation graduate’s medical record can be assessed centrally, which includes all information relating to hospital admissions, emergency department (ED) visits, and pulmonary-related primary clinic visits. Therefore, a true picture of the rehabilitation program’s impact could be developed.

It was decided that the health care utilization of the initial 30 patients who were referred and accepted into the pulmonary rehabilitation program would be systematically reviewed for 1 year prior to and post program completion. All hospital admissions, ED visits, and lung-related visits to primary clinics were tabulated. Each of the primary care visits was individually reviewed by Mahrer. He would determine if the primary care visits were lung related.

Patient Participation

Of the 30 patients referred and accepted into the pulmonary rehabilitation program, only 28 patients successfully completed the program. Two patients stopped attending due to self-described foot pain or back problems, which interfered with their ability to exercise. Five patients died within a year of completing the program and were thus excluded from data analysis. The causes of death for these members were: two, due to lung cancer diagnosed after they completed pulmonary rehabilitation; one, due to respiratory failure at home (the patient did not desire mechanical ventilation and the death was expected); one patient died of a massive gastrointestinal hemorrhage; and one patient had multisystem organ failure during an intensive care unit admission. Only one patient left the Kaiser Permanente system and was lost to follow-up. A lung transplant patient was excluded from data analysis due to the great number of lung-related primary care visits that were prescheduled by the organ transplant program. This left 21 patients for full data analysis. The demographics of the 21 pulmonary rehabilitation participants were as follows (average values reported):

• 54% male vs 46% female;
• 70 years old;
• 76% Caucasian, 14% African-American, and 10% Asian-American;
• 81% primary pulmonary diagnosis was COPD;
• 54 pack years of cigarette smoking;
• 20% used oxygen at home; and
• forced expiratory volume in 1 second (FEV1) was 43% normal.

For the year prior to pulmonary rehabilitation, the 21 patients required a total of 58 medical visits (hospital admissions, ED visits, and lung-related primary care visits). For the year post-completion of the pulmonary rehabilitation program, the 21 patients required only 33 medical visits. This result was statistically significant (P=.001). There was no significant reduction in the number of hospital admissions or ED visits; however, there was a marked decrease in the number of lung-related primary care visits post-participation in the pulmonary rehabilitation program.

Results

In general, the team was quite pleased with the results of the initial 30 pulmonary rehabilitation participants. The reduction in utilization of the health care system was striking. It was somewhat surprising that pulmonary rehabilitation did not reduce hospital admissions or ED visits; however, the literature concerning pulmonary rehabilitation’s ability to reduce hospital admissions is mixed. In 1997, the Joint American College of Chest Physicians/American Association of Cardiovascular and Pulmonary Rehabilitation Evidence-Based Guidelines for Pulmonary Rehabilitation3 rated the evidence in support of pulmonary rehabilitation’s ability to reduce the need for hospitalization presented thus far as a “B” (scientific evidence provided by observational or controlled trials with less consistent results). One could question if it is a reasonable assumption to expect that people suffering from chronic lung disease are not going to occasionally suffer an exacerbation that will land them in the hospital or ED even if they do participate in a pulmonary rehabilitation program. Perhaps such a program coupled with aggressive case management might be able to accomplish the lofty goal of reducing hospital admissions and ED visits in this patient population. The mortality rate of roughly 16.7% is not surprising given the patients’ age and the severity of their chronic lung disease. Secondary outcome measurements of the members who completed the rehabilitation were very encouraging. For example, the average distance on the treadmill that the 21 members accomplished during their initial screening was 0.28 mile; after the program was over, the members could complete 0.93 mile.

Conclusion

A conclusion that can be drawn from the study is that pulmonary rehabilitation may be able to reduce the overutilization of the primary physician clinic. Kaiser Permanente’s financial analysts estimate that the reduction of lung-related primary care visits of this magnitude translates into 29% cost savings for the year post-pulmonary rehabilitation. We are unsure if this reduction in the utilization of primary care clinic persists for periods of time longer than a year. It may be that the cost of running the program is approximately the same as any cost savings achieved. Still, these results were obtained using a very modest amount of start-up capital, which suggests that most facilities with an existing cardiac rehabilitation program could replicate our experience with little difficulty. Although achieving a cost savings is important, pulmonary rehabilitation’s effect on participants’ quality of life is what motivates our team. In every class, we have people who progress from barely walking to near normal activity levels.

Obviously, we would like to continue to improve the services that we offer to our members. In order to build a better beast, we have recently started using the SF-36 quality of life instrument to more formally look at our participants’ quality of life. The decision has also been made to benchmark our program against other pulmonary rehabilitation programs using a computerized database and Internet tools. In the future, we may enhance our program’s maintenance program by adding an RCP case manager.

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Wayne A. Wallace, MBA, RRT, RCP, is the education development consultant for respiratory care for the Los Angeles Metropolitan Service Area for Kaiser Permanente.

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Acknowledgement

An abstract/poster presentation regarding the pulmonary rehabilitation program was presented at the 2001 American Association for Respiratory Care International Respiratory Congress in San Antonio.

Special thanks goes out to our pulmonary rehabilitation therapists Phyllis Kovac, RRT, RPFT, and Jerry Lisiecki, RRT, RPFT, who do a great job running our program. Michael McLaughlin, MS, RRT, is our able administrator. Thomas Mahrer, MD, is our medical director and is renowned for spending a great deal of time with each rehabilitation participant. There are many other dedicated employees who contribute greatly to this program’s success. Finally, we are sad to report the loss of one of the founding team members this past winter; Morris Lott, CRT, CPFT, was a good friend and a wonderful respiratory therapist.

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References

1. Fishman AP. Pulmonary rehabilitation research: NIH workshop summary. Am J Respir Crit Care Med. 1994;149:825.
2. Wilson L, Devine EB, So K. Direct medical costs of chronic obstructive pulmonary disease: chronic bronchitis and emphysema. Respir Med. 2000;94:204-213.
3. ACCP/AACVPR Pulmonary Rehabilitation Guidelines Panel. Pulmonary rehabilitation: joint ACCP/AACVPR evidence-based guidelines. Chest. 1997;112:1363-1396.