Geriatric Medicine
General
Summary
- 73-year-old male with severe COPD with poor follow up with pulmonology
- PCP interested in the benefit of pulmonary rehab
eConsult Transcript
PCP submission
73 y/o male w/ severe COPD on 3L O2 24/7. I can’t locate his last PFTs but I assume FEV1 < 1L. He’s on Trelegy; he stopped smoking 5 years ago. I’m waiting for him to reestablish w/ pulmonology. Do these folks benefit from pulmonary rehab even without recent inpatient admission/ED visit? Any evidence of cost-effectiveness/benefits of pulm rehab? What are pulm rehab criteria for medicare?
Specialist response
Thanks for your question. Yes, there are benefits for pulmonary rehab, but there has to be willingness to participate, so you want to chose the ideal candidate. There are many studies about the benefits of pulmonary rehabilitation in patients with COPD. It has been shown to lead to improvement in exercise capacity, health-related quality of life, and work efficiency in patients with COPD. Therefore, pulmonary rehab has been recommended as an integral part of management for these patients. The American Thoracic Society recommends pulmonary rehab for patients with persistent exercise intolerance despite receiving optimal medical therapy. According to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) consensus document on the management of COPD, pulmonary rehab should be considered in symptomatic patients with a FEV1 below 80%. Medicare Part B covers pulmonary rehab for patients with “moderate to very severe COPD.” You do not need a recent inpatient admission or ED visit. I would have the patient check with the pulmonary rehab facility to see if he will be responsible for a copay (sometimes there are hospital fees if the outpatient facility is associated with a hospital). Let me know if any questions. Thank you for the consult.
PCP follow up
Any landmark studies on the benefits/cost-effectiveness?
Specialist follow up
Here are some of the landmark studies: McCarthy B, Casey D, Devane D, Murphy K, Murphy E, Lacasse Y. Pulmonary rehabilitation for chronic obstructive pulmonary disease. Cochrane Database Syst. Rev. 2015: CD003793 [This analysis was accompanied by a powerful editorial with a clear statement that the evidence in support of pulmonary rehabilitation was now ‘conclusive’ and no further update of the systematic review would be required] For cost-effectiveness, there are two: Griffiths TL, Burr ML, Campbell IA, Lewis-Jenkins V, Mullins J, Shiels K, Turner-Lawlor PJ, Payne N, Newcombe RG, Ionescu AA et al. Results at 1 year of outpatient multidisciplinary pulmonary rehabilitation: a randomised controlled trial. Lancet 2000; 355: 362–8. Griffiths TL, Phillips CJ, Davies S, Burr ML, Campbell IA. Cost effectiveness of an outpatient multidisciplinary pulmonary rehabilitation programme. Thorax 2001; 56: 779–84
