LAUSR

Pulmonary rehabilitation (PR) is one of the most effective interventions for improving the health of individuals with chronic obstructive pulmonary disease (COPD) and other chronic respiratory diseases (1–3). Poor access to PR centers often results in the omission of PR from treatment armamentaria (4, 5). Fewer than 2% of patients with COPD have access to PR worldwide (6). Access is particularly limited in rural areas (7); travel distance impacts the odds of participation (4). Over the past several years, and accelerated by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic, PR delivery via telehealth has emerged as an attractive alternative to center-based PR to overcome some barriers to access. However, despite the expansion of telehealth to the delivery of many aspects of patient care, tele-PR has been largely limited to the research setting. In this issue ofAnnalsATS, Alwakeel and colleagues (pp. 39–47) report on the feasibility, safety, and efficacy of a practical, real-world strategy to implement tele-PR throughout the Quebec province in Canada (8). In this prospective study, individuals with COPD referred for PR were enrolled in a center-based PR program with extensive rehabilitation experience or in communitybased tele-PR at satellite centers with exercise equipment. The PR sessions occurred concurrently at the primary and satellite centers via videoconferencing, facilitated locally by PR staff at each site. Of seven satellite sites, six continued to participate by 3 years. Comparable improvements in the 6-minute-walk distance (46 vs. 53 m) and reduction in the COPDAssessment Test scores (4.0 vs. 2.7 units) were seen after PR, without between-group differences. Notably, compared with center-based PR, the tele-PR program was associated with a higher completion rate (83% vs. 72%), without major adverse events. Strikingly, over the 3-year study period, the implementation of tele-PR at the satellite centers doubled the number of patients enrolled and quadrupled the number of sessions attended as compared with the primary PR center alone. Although participants were not randomized, individuals at the center and satellite sites had comparable baseline characteristics. The study investigators are to be applauded, as their well-designed model of tele-PR delivery not only demonstrates realworld feasibility, safety, and efficacy of telePR but also confirms the ability of tele-PR to improve access to PR and illustrates a possible pathway forward for more widespread implementation of tele-PR. Several issues regarding tele-PR are, however, worthy of additional consideration. Tele-PR has been defined and delivered in several ways. Both asynchronous interventions, wherein patients exercise on their own or with the aid of instructional videos with periodic check-in, and synchronous interventions via real-time videoconferencing have resulted in significant improvements in functional capacity, quality of life, and hospitalizations (9–16), but outcomes are heterogeneous. Tele-PR heterogeneity is compounded further by variable exercise training intensity and whether exercise equipment is used or not. These issues have raised concerns about the standardization and benefits of tele-PR. The low-intensity exercise training provided in some tele-PR programsmay result in improved walking endurance without changes in aerobic fitness; this limitationmay be offset by better patient uptake of, adherence to, and completion of tele-PR. The diversity of exercise prescriptions and varying degrees of supervision have, however, made it difficult to generate an evidence base to support widespread implementation of tele-PR (17). It is therefore appealing to develop a solution whereby access to PR is improved while also retaining the exercise intensity and standardization associated with center-based PR. In addition to patient-related barriers to tele-PR implementation, which include lack of exercise equipment, electronic devices, and/or internet access, or lack of skills to use them, health system–related barriers include a lack of consistent “real-world” approaches, accepted quality standards, and national metrics for This article is open access and distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives License 4.0. For commercial usage and reprints, please e-mail Diane Gern ([email protected]).