Should we treat COPD exacerbations like we treat heart attacks?
Different diseases, sure—but the treatment intensity and structure aren’t all that different. If you show up with a heart attack, you’re getting aspirin, a heparin drip, nitroglycerin, and likely heading straight to the cath lab. Afterwards, it’s aspirin for life, Plavix for a year, a beta blocker… and cardiac rehab.
For a COPD exacerbation, you’ll get oxygen, nebulizers, steroids, and maybe antibiotics. It’s a big physiologic hit—just like an MI. However, after the dust settles, we don’t have an automatic follow-up plan. One highly effective treatment is often left out: pulmonary rehab.
Pulmonary rehabilitation is a comprehensive program—exercise training, education, behavior change (like smoking cessation)—designed to improve function and quality of life for people with chronic lung disease.
It’s now a strong recommendation for people with COPD, both during stable disease and after hospitalization for an exacerbation. It reduces dyspnea, improves exercise tolerance and emotional well-being, boosts quality of life—and, most importantly, reduces hospital readmissions and mortality.
Yet, despite this, less than 5% of eligible patients ever enroll.
Lower readmissions and lower mortality. Two phrases hospitals love. So what’s the hold-up?
Why isn’t pulmonary rehab used more?
Insights
Root Cause Analysis: 5 Whys
The 5 Whys process in root cause analysis involves repeatedly asking "Why?" five times to drill down into the root cause of a problem by exploring the cause-and-effect relationships underlying the issue.
The problem: Fewer than 5% of eligible patients with COPD receive pulmonary rehabilitation (PR).
Why aren’t more COPD patients enrolled in pulmonary rehabilitation? Physicians and care teams often don’t refer patients to PR programs after hospitalization or during outpatient management.
Why don’t physicians refer patients to PR? Many are unaware of the strength of the evidence supporting PR or are unfamiliar with referral processes.
Why are physicians unaware or unfamiliar with PR? PR is underemphasized in clinical training, lacks visibility in care pathways, and isn’t reinforced by standardized discharge protocols.
Why is PR underemphasized in training and workflows? PR programs are inconsistently integrated into hospital systems, are underfunded, and lack institutional support, making them peripheral rather than core components of COPD care.
Why are PR programs underfunded and poorly integrated? Reimbursement is low, infrastructure is limited (especially in rural areas), and there is insufficient policy-level prioritization of non-pharmacologic interventions like PR.
Impact Analysis
Impact analysis is the assessment of the potential consequences and effects that changes in one part of a system may have on other parts of the system or the whole.
Patient: The underuse of pulmonary rehabilitation means missing out on one of the most effective interventions available for COPD. Without PR, patients are more likely to suffer from persistent breathlessness, reduced physical function, and emotional distress—all of which compound their risk of future hospitalizations and premature death. The American Thoracic Society strongly recommends PR for both stable COPD and post-hospitalization recovery, yet access remains limited, leaving many patients unsupported during a critical recovery window.
Clinician or Provider: The absence of PR in routine COPD care narrows the clinical toolkit. Despite robust evidence showing improvements in dyspnea, exercise capacity, and quality of life, PR often isn’t integrated into discharge plans or outpatient workflows. This forces physicians to rely heavily on pharmacotherapy, while knowing a non-pharmacologic, guideline-backed option exists but is rarely accessible or reimbursed adequately.
System: Overlooking PR is a high-cost oversight. Hospital readmissions for COPD are frequent and expensive—but pulmonary rehab can reduce those readmissions by over 50% when initiated within three weeks of discharge. According to Medicare modeling, this translates to an estimated cost savings of $8,226 per patient. Yet despite these benefits, fewer than 5% of eligible patients ever enroll. This mismatch between evidence and implementation not only worsens outcomes but also leads to unnecessary spending, inefficient care, and widening health disparities—especially in rural or underserved populations where PR access is even more limited.
Solutions
PR@Home... Bring rehab to the patient: Adapt the Hospital-at-Home model to pulmonary rehab by delivering PR directly to the patient’s home through respiratory therapist-led programs. These home-based interventions have been shown to reduce 30-day readmissions from 22.3% to 12.2% by focusing on personalized care, education, medication management, and ongoing monitoring—especially effective post-exacerbation.
Smarter, tech-enabled COPD care bundles: Develop more robust COPD discharge bundles that use AI to identify high-risk patients early and fast-track them into pulmonary rehab. Hospitals could partner with transportation services like Lyft or Uber to reduce logistical barriers and boost PR attendance—especially in communities where access is limited.
Reimbursement reform for PR services: Follow the money. Increasing reimbursement for pulmonary rehab—similar to how physical therapy is supported in many states—would create stronger incentives for hospitals and health systems to build and expand programs. Better funding leads to better access, broader reach, and higher referral and enrollment rates.