2015+ats／ers政策声明：加强肺康复的实施、使用和交付

1AMERICANTHORACICSOCIETYDOCUMENTSAnOfficialAmericanThoracicSociety/EuropeanRespiratorySocietyPolicyStatement:EnhancingImplementation,Use,andDeliveryofPulmonaryRehabilitationCarolynL.Rochester,IoannisVogiatzis,AnneE.Holland,SuzanneC.Lareau,DarcyD.Marciniuk,MiloA.Puhan,MartijnA.Spruit,SarahMasefield,RichardCasaburi,EnricoM.Clini,RebeccaCrouch,JudithGarcia-Aymerich,ChrisGarvey,RogerS.Goldstein,KylieHill,MichaelMorgan,LindaNici,FabioPitta,AndrewL.Ries,SallyJ.Singh,ThierryTroosters,PeterJ.Wijkstra,BarbaraP.Yawn,andRichardL.ZuWallack;onbehalfoftheATS/ERSTaskForceonPolicyinPulmonaryRehabilitationTHISOFFICIALPOLICYSTATEMENTOFTHEAMERICANTHORACICSOCIETY(ATS)ANDTHEEUROPEANRESPIRATORYSOCIETY(ERS)WASAPPROVEDBYTHEATSBOARDOFDIRECTORS,OCTOBER2015,ANDBYTHEERSSCIENCECOUNCIL,SEPTEMBER2015Rationale:Pulmonaryrehabilitation(PR)hasdemonstratedreviewers.Aftercyclesofreviewandrevisions,thestatementwasphysiological,symptom-reducing,psychosocial,andhealthreviewedandformallyapprovedbytheBoardofDirectorsoftheATSeconomicbenefitsforpatientswithchronicrespiratorydiseases,yetitandtheScienceCouncilandExecutiveCommitteeoftheERS.isunderutilizedworldwide.Insufficientfunding,resources,andreimbursement;lackofhealthcareprofessional,payer,andpatientMainResults:Thisdocumentarticulatespolicyrecommendationsawarenessandknowledge;andadditionalpatient-relatedbarriersallforadvancinghealthcareprofessional,payer,andpatientawarenesscontributetothegapbetweentheknowledgeofthescienceandbenefitsandknowledgeofPR,increasingpatientaccesstoPR,andensuringofPRandtheactualdeliveryofPRservicestosuitablepatients.qualityofPRprograms.ItalsorecommendsareasoffutureresearchtoestablishevidencetosupportthedevelopmentofanupdatedObjectives:TheobjectivesofthisdocumentaretoenhancefundingandreimbursementpolicyregardingPR.implementation,use,anddeliveryofpulmonaryrehabilitationtosuitableindividualsworldwide.Conclusions:TheATSandERScommittoundertakeactionsthatwillimproveaccesstoanddeliveryofPRservicesforsuitablepatients.TheyMethods:MembersoftheAmericanThoracicSociety(ATS)callontheirmembersandotherhealthprofessionalsocieties,payers,PulmonaryRehabilitationAssemblyandtheEuropeanRespiratorypatients,andpatientadvocacygroupstojoininthiscommitment.Society(ERS)RehabilitationandChronicCareGroupestablishedaTaskForceandwritingcommitteetodevelopapolicystatementonKeywords:pulmonaryrehabilitation;policy;healthcare;chronicPR.Thedocumentwasmodifiedbasedonfeedbackfromexpertpeerrespiratorydiseases;accessContentsPatientAwarenessandLimitationsonPREligibilityOverviewKnowledgeBasedonCOPDDiseaseIntroductionIncreasingPatientAccesstoPRSeverityMethodsLackofAdequatePRLimitationsonPREligibilityoverBackground:PRInfrastructureandInadequateTimeIncreasingAwarenessandProgramCommissioningPatient-LevelBarrierstoPRKnowledgeofPRGeographicInaccessibilityLimitedNumberofPRHealthcareProfessionalImprovingAccesstoPRforHealthcareProfessionalsAwarenessandKnowledgePersonswithNon-COPDEnsuringQualityofPRProgramsPayerAwarenessandRespiratoryDisordersFutureResearchToAdvanceKnowledgeEvidence-basedPolicyinPRORCIDID:0000-0002-6343-6050(C.L.R.).Thisarticlehasanonlinesupplement,whichisaccessiblefromthisissuestableofcontentsatwww.atsjournals.orgAmJRespirCritCareMedVol192,Iss11,pp13731386,Dec1,2015Copyright©2015bytheAmericanThoracicSocietyDOI:10.1164/rccm.201510-1966STInternetaddress:www.atsjournals.orgAmericanThoracicSocietyDocuments1373guide.medlive.cn AMERICANTHORACICSOCIETYDOCUMENTSOverviewimplementation,use,anddeliveryofPRperformancemetricstoenablethatarediscussedinthisstatementincluderecommendationsforinternationalPulmonaryrehabilitation(PR)isathefollowing:standardsbasedonevidenceandbest“comprehensiveinterventionbasedonapractice.dPhysicianandalliedhealthcarethoroughpatientassessmentfollowedbydFurtherresearchshouldbeundertakenprofessionaltraineeswhotreatpatientspatient-tailoredtherapiesthatinclude,buttoadvanceevidence-basedpolicyinPR,withchronicrespiratorydiseasesshouldarenotlimitedto,exercisetraining,includingfurtherinvestigationregardinghaveformaltraininginthescience,education,andbehaviorchange,designedthecost-effectivenessofPRforchronicprocess,andbenefitsofPR.Trainingtoimprovethephysicalandpsychologicalrespiratorydisorders,innovativemodelsrequirementsshouldbespecifiedinconditionofpeoplewithchronicofPRdeliverythatwillimprovepatients’nationaltrainingcurriculumdocuments,accessanduptake,andthebarriersandrespiratorydiseaseandtopromotetheandconsistencyshouldbemaintainedinfacilitatorsofPRprogramreferral,long-termadherencetohealth-enhancingprogramsforeachhealthcaredisciplineaccessibility,enrollment,andadherence.behaviors”(1).PRreducespatients’andacrossdisciplines.symptoms;improveslimbmusclefunction,dPhysiciansandotherhealthcareexercisecapacity,emotionalfunction,professionalsinclinicalpracticeshouldIntroductionqualityoflife,knowledge,andself-efficacy;haveeducationalopportunitiesinthehashealtheconomicbenefits(1–12);andisprocessandbenefitsofPRconsistentPulmonaryrehabilitation(PR)hasanessentialcomponentoftheintegratedwithevidence-basedstatementsanddemonstratedphysiological,symptom-careofpatientswithchronicrespiratoryguidelines.reducing,psychosocial,andhealthdiseases.However,despiteitsclearbenefits,dToincreasepayerawarenessandeconomicbenefitsinmultipleoutcomeareasPRisgrosslyunderutilizedandisfrequentlyknowledgeofPR,healthcareforpatientswithchronicrespiratoryinaccessibletopatients.Insufficientprofessionalsandpatientadvocacydiseases(1–8,10–12,15–49).Assuch,itfunding;limitedresourcesforPRprograms;groupsshoulddevelopanddisseminateshouldbeastandardofcarealongsideotherinadequateallocationofhealthsysteminformationontheprocess,benefits,well-establishedtreatments(suchasreimbursementforPR;lackofhealthcarecosts,andcost-effectivenessofPRtopharmacotherapy,supplementaloxygen,orprofessional,payer,patient,andcaregiverpayers.noninvasiveventilation)forpatientswithaawarenessandknowledgeregardingthedToincreasepatientawarenessandchronicrespiratorydisease.Yet,PRprocessandbenefitsofPR;suboptimaluseknowledgeofPR,professionalsocietiesremainsgrosslyunderutilizedworldwideofPRbysuitablepatients(13,14);andandpatientadvocacyandeducation(15,50);itisfrequentlynotincludedinthelimitedtrainingopportunitiesforPRexpertsshouldcollaborateintheintegratedcareofpatientswithchronicprofessionalsallcontributetothegapdevelopmentoflanguage,education-respiratorydisordersandisoftenbetweenthescienceandbenefitsofPRlevel,andculturallyappropriateinaccessibletopatients.Indeed,a(1,11,15)andtheactualdeliveryofPReducationmaterialsinmultipleformatssubstantialgapexistsbetweenknowledgeservices.forpatientswithchronicrespiratoryregardingthescienceandbenefitsofPRDetailsofthescienceanddeliveryofPRdiseaseregardingtheprocessand(11,12,15)andtheactualdeliveryofPRwerehighlightedinthe2013AmericanbenefitsofPR.Communicationservices(15,50).ReasonsforthisgapThoracicSociety/EuropeanRespiratorycampaignsregardingPRshouldbeinclude:insufficientfunding;limitedSocietyStatementonPR(1).Thisnewaddressedtothegeneralpublic.resourcesforPRprograms;inadequatePolicyStatementhasadifferentfocus:itdPatientaccesstoPRshouldbeimprovedallocationofhealthsystemreimbursementprovidespolicyrecommendationswiththebyaugmentingprogramcommissioningforPR;lackofhealthcareprofessional,principalobjectiveofexpandingthethroughincreasedsustainablepayerpayer,patient,andcaregiverawarenessofprovisionofPRtosuitableindividualsfunding,creatingnewPRprogramsandknowledgeregardingtheprocessandworldwide.ItrepresentstheconsensusofingeographicareaswheredemandbenefitsofPR;suboptimaluseofPRbyinternationalexpertsinthefieldofPR,exceedscapacity,anddevelopingandsuitablepatients(13,14);andlimitedexpertsinprimarycare,andinternationalinvestigatingnovelPRprogrammodelstrainingopportunitiesforPRprofessionals.patientadvocates.Itprovidesthatwillmakeevidence-basedPRmoreTheseissuesappeartobeworldwideinrecommendationsthataddresskeyaccessibleandacceptabletopatientsandscope(15).Importantly,also,althoughprocessescentraltoachievingourobjectivespayers.SelectioncriteriaforPRshouldintensiveinpatientrehabilitationservicesofenhancingimplementation,use,andreflectcurrentpublishedevidence.forthesickestpatientsarewidelydeliveryofPR,includingincreasingdPRprogramsshouldfollowrelevantdistributed,availabilityofoutpatientorhealthcareprofessional,payer,andpatientevidence-basedclinicalguidelinesandcommunity-basedPRprogramsisawarenessandknowledgeofPR;increasingdemonstratethemeasurementofinsufficientorlackinginmanygeographicpatientaccesstoPR;andensuringqualitystandardoutcomestodocumentbenefits,areas.Moreover,withinandamongofPRprograms.Italsoprovidesquality,andsafety.countries,PRisheterogeneousregardingsuggestionsforactionableitemsthatwilldAcoresetofprocessesandoutcomesprogramstructure,content,staffing,fosterimplementationofthepolicyshouldbeestablishedtoenablenationalavailableresources,andpatientreferralrecommendations.NoteworthypolicyandinternationalbenchmarkinginPR;practices(15,50,51).Thisheterogeneityrecommendationstoincreasethisshouldincludebothprocessandhasthepotentialtocompoundtheissues1374AmericanJournalofRespiratoryandCriticalCareMedicineVolume192Number11|December12015guide.medlive.cn AMERICANTHORACICSOCIETYDOCUMENTSlistedaboveandtoadverselyaffecttheconsensusprocesswasfollowedtodevelopadvancesinthescienceanddeliveryofPRqualityofprograms.thispolicystatementbetweenMay2013werehighlightedinthe2013ATS/ERSPRThisAmericanThoracicSociety(ATS)/andJanuary2015.InformalsurveysStatement(1,12).TheestablishedbenefitsEuropeanRespiratorySociety(ERS)Policyprovidedinputfrompatients,patientofPRaresummarizedinTable1.Statementprovidespolicyrecommendationsadvocacygroups(includingtheATSPublicPRisbeneficialthroughoutthecoursewiththeprincipalobjectiveofexpandingAdvisoryRoundtableandELF),insuranceofdiseaseforsymptomaticmedicallytheprovisionofPRtosuitableindividuals.Topayers,aswellasprimarycareandPRstablepatientswithCOPD(75)andotherthisend,ourgoalsareto:healthcareproviders(seedetailsoftimelinechronicrespiratorydisorders(11),andandprocessinTableE1intheonlinesupervised,center-basedPRisalsoeffective1.Raisepublicandpoliticalawarenessofsupplement).ThispolicystatementwasduringorsoonafteracuteexacerbationsofthevalueandspecificbenefitsofPR,modifiedbasedonfeedbackfromexpertCOPD(76,77).ComprehensivePRhas2.Triggeractionbyhealthcaresystemstopeerreviewers.Aftercyclesofreviewandsimilarbenefitswhendeliveredininpatient,provideadequatefundingsupportforrevisions,thestatementwasreviewedandoutpatient,andcommunity-basedsettingsPRservicesandtoincludeprovisionofformallyapprovedbytheBoardof(7,10,78,79).Generally,aminimumofPRintheirstrategicplansforcareofDirectorsoftheATSandtheScience8weeks(twotothreesessionsperweek)ofrespiratorydiseases,CouncilandExecutiveCommitteeoftheoutpatientorcommunity-basedtreatment3.Increasehealthcareprofessionals’ERS.(orcomparablenumberofcontacthours)isprescriptionofPR,neededtoachieveaneffectonexercise4.EnhancedeliveryofPRthroughperformanceandqualityoflife(1,12,15,increasedprogramaccessandcapacity,Background:PR80);longerprogramsmayproducegreater5.Raiseawarenessofpatients’experiencesgains(12,80,81),andrepeatcoursesyieldandbarriersinaccessingandattendingPatientswithchronicrespiratorydiseasesbenefitsofequivalentmagnitudetothoseofPR,experiencedisablingsymptoms(includingfirst-timeparticipation(82).Exercise6.Engagepatientswithchronicrespiratorydyspneaandfatigue)andexercisetrainingisthecornerstonecomponentofdiseasesandtheircaregiverstointolerance,havelowphysicalactivityPR.Concurrentbehavioralinterventions,knowledgablyrequestaccesstoPR,levels,andreportimpairedqualityoflifesuchaspromotingself-efficacyand7.Facilitatethedevelopmentand(4,52–62).Thetremendousburdenposedteachingcollaborativeself-managementimplementationofqualitymetricsforbytheseissuesoftenpersistsdespiteskills,arealsointegraltooptimizingpatienttheinclusionofPRintotheintegratedoptimalpharmacologictreatment.outcomes(83,84).PatientsgraduatingcareofpatientswithachronicMoreover,personswithrespiratorydiseasesfromaPRprogramstandtobenefitfromarespiratorydisease,haveheterogeneousfeatures,and,formany,home,community-based,orprogram-8.Laythegroundworkfordevelopmentofextrapulmonarymanifestationssuchasbasedmaintenanceexerciseprogramtoaprocesstoimplementthepolicyskeletalmuscledysfunction(62–69)andsupportthecontinuationofpositiverecommendationsstatedinthismedicalandpsychologicalcomorbiditiesexercisebehavior(85).document.(suchasanxietyand/ordepression)arekeyKeyprocessescentraltoachievingthesecontributorstotheirsymptomsandobjectivesinclude:increasinghealthcarefunctionallimitations(70–73).PR,asprofessional,payer,andpatientawarenessdefinedinthe2013OfficialATS/ERSTable1.BenefitsofPulmonaryandknowledgeofPR;increasingpatientStatement,is“acomprehensiveRehabilitation(1–3,5,7,10–12,16–47,accesstoPR;andpromotingqualityPRinterventionbasedonathoroughpatient49,63,140,141)programs.Itisessentialthatprogramassessmentfollowedbypatient-tailoredqualitystandardsbemetwhilemaintainingtherapiesthatinclude,butarenotlimiteddReducedhospitalizationcostefficiencytoensureoptimalclinicalto,exercisetraining,education,anddReducedunscheduledhealthcarevisitsoutcomesforpatientsaswellassustainablebehaviorchange,designedtoimprovethedImprovedexercisecapacityfundingofPRprograms.physicalandpsychologicalconditionofdReducedsymptomsofdyspneaandlegpeoplewithchronicrespiratorydiseaseanddiscomforttopromotethelong-termadherencetodImprovedlimbmusclestrengthandMethodsendurancehealth-enhancingbehaviors”(1,12).ItdImprovedhealth-relatedqualityoflifeemphasizesstabilizationand/orreversalofdImprovedfunctionalcapacity(e.g.,AnadhocTaskForcewasformed,extrapulmonarymanifestationsandactivitiesofdailyliving)composedofexpertsfromtheATScomorbiditiesofchronicrespiratorydiseasedImprovedemotionalfunctiondEnhancedself-efficacyandknowledgePulmonaryRehabilitationAssembly,theaswellastheimportanceofbehaviordEnhancedcollaborativeERSRehabilitationandChronicCarechange.PRisanessentialcomponentofanself-managementGroup,theATSandERSDocumentsintegratedcontinuumofhealthcareacrossdPotentialforincreaseddailyphysicalDevelopmentandImplementationthetrajectoryofthepatient’sillnessaswellactivitylevelsCommittees,representativesfromtheasacrosshealthcareprovidersandvenues.Note:theorderanddegreeofevidenceforeachEuropeanLungFoundation(ELF),andItisnotanewtherapy;thefirstofficialATSoftheabove-notedbenefitsvariesamongprimarycarerepresentativesfromtheconsensusstatementonitsapplicationwaschronicobstructivepulmonarydiseaseandotherUnitedStatesandEurope.Aniterativepublishedin1981(74).Majorrecentrespiratorydiseases(9,11).AmericanThoracicSocietyDocuments1375guide.medlive.cn AMERICANTHORACICSOCIETYDOCUMENTSTable2.ExamplesofTrainingawarenessofPRiscurrentlyabarriertoincreasinghealthcareprofessionalOpportunitiesinPulmonaryRehabilitationpatientreferral(86).awarenessandknowledgeofPRareforHealthcareProfessionalsHealthcaretrainees.AwarenessofPRprovidedinBoxes1and2.shouldideallybeginduringtraining.Currently,exposuretotheprocesses,PayerAwarenessandKnowledgedERSHERMESprogramindications,andbenefitsofPRaregenerallyPRisoneofthemostcost-effectivedATSandERSpostgraduatecoursesonPR(heldperiodicallyatannualinternationalnotamandatorypartoftheeducationoftreatmentinterventionsavailableforconferences)physicians,nursepractitioners,physicianpatientswithchronicrespiratorydiseasesdAmericanCollegeofChestPhysiciansassociates,oralliedhealthcareprofessionals.(93–97)andisassociatedwithasubstantialAnnualConferenceandspecialtyboardAlthoughdetailedrecommendationsforreductioninhospitalizations,otherurgentreviewmaterialstraininginPRexistinsomecountries,suchhealthcareresourceuse,andhealthcaredLungFoundationAustraliaPRtrainingOnlineastheUK(87),evenforpulmonarycosts(76,93–95,98,99).Forexample,itsdLocalcoursesinseveralcountries(e.g.,physicians,statedtrainingrequirementsarevalueissituatedfavorablywithinthetheUK,theNetherlands)oftenvagueorlimited.ThisistrueinthecontextofothercomponentsoftherapyfordCoursesonPRpromotedbyrespiratoryUnitedStates(88),Canada(89),theCOPDintheUK(Figure1)(96,97);thesocietiesinLatinAmericaNetherlands(90),Australia(91),andLatinrelativevaluecostsarenotyetstudiedDefinitionofabbreviations:ATS=AmericanAmerica(92).Furthermore,primarycareinnon-COPDchronicrespiratoryThoracicSociety;ERS=EuropeanRespiratoryandotherhealthcareprofessionals,whodisorders.Nevertheless,payerawarenessofSociety;HERMES=HarmonisedEducationinprovidecareforthemajorityofpatientsPRisoftenpoor,andfundingofPRisRespiratoryMedicineforEuropeanSpecialists;withrespiratorydisease,oftenhaveveryinadequate.AdequatefundingisvitaltoPRPR=pulmonaryrehabilitation.LungFoundationAustraliatrainingonlinecanbelittleifanyexposuretoPRinthecourseofprogramavailability,capacity,effectiveness,foundathttp://lungfoundation.com.au/theirtraining.Somepostgraduatetrainingandviability.Althoughheterogeneoushealth-professionals/training-and-education/isavailable(Table2),butitisnotpaymentstructuresandresourcesexistpulmonary-rehabilitation-training-online/.mandatory,isoftennotstandardized,andiswithinandacrosscountries(15),increasingHERMESeducationinRespiratoryMedicineprogramoftheERScanbefoundatatthediscretionofthehealthcarepayerknowledgeisthefirststeptowardhttp://hermes.ersnet.org.professional.Thereisaclearneedforsecuringadequatelong-termfunding.enhancedandmorestandardizedexposureInformaldiscussionswithrepresentativestoPRwithinexistinghealthcarefromgovernmentandprivateinsuranceIncreasingAwarenessandprofessionals’trainingprograms.payersinseveralcontinentsaspartofKnowledgeofPRHealthcareprofessionalsinclinicaldevelopmentofthisdocumentsuggestedtheirpractice.ThereisaneedformoreperceptionthatcurrentfundingandHealthcareProfessionalAwarenesseducationandlearningopportunitiesforreimbursementforPRareadequate.However,andKnowledgeestablishedpracticingprimaryandtheexistenceofpayer-relatedbarriersisPatientswillnotreceivePRunlesstheyarespecialtycarephysicians,nursesupportedbyapublishedsurveyinthereferred,whichisunlikelytooccurunlesspractitioners,physicianassociates,andUK(93)andbyaninformalsurveyhealthcareprofessionals(includingprimaryotheralliedhealthcareprofessionalsconductedbymembersoftheTaskForceforcareandspecialistphysicians,nurseabouttheprocessandbenefitsofPR.thisdocument(TableE2).Thesesurveyspractitioners,physicianassociates,andIncreasedknowledgeofPRcouldfosterpointtoaninadequateappreciationamongalliedhealthprofessionals)areawareofthedialoguebetweenhealthcareprofessionalspayersoftheclinicaleffectivenessandexistenceofPRandhaveknowledgeofitsandtheirpatients,therebypromotingcost-effectivenessofPR.Tothisend,benefits.SuboptimalhealthcareprofessionalreferralstoPR.RecommendationsforincreaseddialogueandeffectiveBox1:IncreasingHealthcareProfessionalTraineeAwarenessandKnowledgeofPRRecommendations:dPhysicianandalliedhealthcareprofessionaltraineeswhotreatpatientswithchronicrespiratorydiseasesshouldhavecoreformaltraininginPR,includingitsscientificrationale,process,andbenefits.ThisincludesuseoftrainingmodulescoveringthetopicsshowninTable3andprovisionofpractical“hands-on”experiences.dTrainingrequirementsshouldbespecifiedinnationaltrainingcurriculumdocuments,andconsistencyshouldbemaintainedinprogramsforeachhealthcaredisciplineandacrossdisciplines.ActionableItems:dEducationalauthoritiesfromrespiratory,primarycare,nursing,andotheralliedhealthcareprofessionals’societiescollaboratetodevelopspecificcurriculaforPRtrainingfortheirrespectivehealthcaretrainees.dRespiratory,primarycare,andalliedhealthcareprofessionals’societiesestablishnationaltrainingprogramcurricularregistriestocoordinateandmonitorprogresstowardcurriculadevelopment.1376AmericanJournalofRespiratoryandCriticalCareMedicineVolume192Number11|December12015guide.medlive.cn AMERICANTHORACICSOCIETYDOCUMENTSTable3.TopicsforInclusioninEducationalMaterialsforHealthcareBox2:IncreasingAwarenessandKnowledgeofPRamongProfessionalsHealthcareProfessionalsinClinicalPracticeRecommendation:dThescientificrationaleforPRdPhysiciansandotherhealthcareprofessionalsinclinicalpracticeshouldhavedEstablishedbenefitsofPReducationalopportunitiesintheprocessandbenefitsofPRconsistentwithdComponentsofamultidisciplinaryPRprogramevidence-basedstatementsandguidelines.dSelectionandreferralofappropriatepatients,includingpersonswithActionableItems:non-COPDrespiratorydisordersdPrimarycare,specialtyphysician,andalliedhealthprofessionalsocietiespartnerdPatientassessmentandoutcomesmeasurementtechniqueswithexpertsinPRtodevelopandimplementmoreevidence-based,multiformatdProgramdesignanddeliveryinthecontextpostgraduateeducationalprogramsontheprocess,benefits,anduseofPR.oflocal/regionalresourcesdRespiratorysocietiesandnationalhealthauthoritiesprovidepracticaleducationaldRoleofPRintheintegratedcareofmaterialsforclinicians(coveringtopicsshowninTable3)andacontactlistoflocalpatientswithchronicrespiratoryPRprogramsintheclinicsetting.diseasesdImportanceofpatients’long-termdIncludePRinrelevantprofessionallearningofferings,suchasscientificmeetingsadherencetohealth-enhancingandcontinuingmedicaleducationcourses.behaviors(suchasphysicalactivity,dHealthcareprofessionalsdocumentthatPRwasofferedtosuitablepatientsinimmunizations,abstinencefromclinicalsettings(includingspecificationofthereasonsfornonreferral)asareflectionsmoking)afterPR:roleofhomecaregiversandimportanceofofawarenessandknowledgeofitsindicationsandbenefitsandtosupportqualitycoordinatedcarebetweenhealthcaremetricassessment.professionalsdIncorporate“clinicalreminderalerts”forPRreferralinelectronicmedicalrecorddOpportunitiesforadvancedcareplanningsystems.inthecontextofPRdRelevantlocal,regionalornationalinformationregardingfundingandpayerreimbursementforPRawarenessandknowledgeofPRareprovidedofPRasastandardofcareandtodCurrentgapsinaccess,barrierstopatientinBox3.distinguishPRfromchestphysiotherapy.participationinPRandpotentialIncreasingtheawarenessofPRamongthesolutionstotheseproblemsPatientAwarenessandKnowledgegeneralpublicisalsoessential.Relatives,Definitionofabbreviations:COPD=chronicPatientuptakeofPRandadherencetofriends,neighbors,coworkers,andothersobstructivepulmonarydisease;PR=pulmonaryparticipationinPRarestrikinglylowcanencouragepatientstoseekoutandrehabilitation.(5,13–15,41,50,100).MuchoftheparticipateinPR.PublicawarenessofPRresponsibilityfornonreferraltoPRrestsonmaybeenhancedthroughcommunicationcommunicationareneededbetweenPRhealthcareprofessionals(7),butinsufficientcampaigns,includingsocialmediaexpertsandproviders,healthcarepublicawarenessandknowledgeoftheplatforms(suchasFacebookandprofessionals,professionalsocieties(e.g.,ATS,processandhealthbenefitsofPR(14,41)YouTube).ItisimperativethatpatientsERS,andothers),payers,andhealthpolicyalsopreventpatientsfromseekingreferralidentifiedbyevidence-basedclinicalauthoritiesregardingtheestablishedbenefitstoandcompletionofaPRprogram.managementguidelinesashavingpotentialandcost-effectivenessofPRaswellastheProfessionalsocietiesandpatientadvocacytobenefitfromPRaremadeawareofthisprioritiesandconcernsofpayers.groupscanaugmenteffortstodisseminatetherapysothattheycanadvocateforaccessRecommendationsforincreasingpayerinformationandfacilitatepatientawarenesstoitthroughtheirregionalandnationalBox3:IncreasingPayerAwarenessandKnowledgeofPRRecommendations:dHealthcareprofessionalsandpatientadvocacygroupsshoulddevelopanddisseminateinformationonthecostsandcost-effectivenessofPRtopayers.dTheprocessandoutcomesofPRshouldbemademoretransparenttopayersbyPRserviceproviders.dHealthcareprofessionalsshouldinvestigatethecost-effectivenessofPRincountrieswhereinthisinformationislacking.ActionableItems:RespiratorydiseasesocietiesandPRproviders,incollaborationwithprimarycarehealthprofessionalgroupsandpatientadvocacygroups:BDevelopmethodsofdetailingthebenefits,costs,andvalueofPRtobecommunicatedtopayers.BEnhanceplatformsandassureincreasedresourcesforcommunicatingtheeffectivenessofPRtopayers.BDevelopacoordinatedadvocacystrategytofacilitateincorporationofPRintohealthcaresystemsandpracticesasa“standardofcare”componentoftheoverallintegratedcareofpatientswithchronicrespiratorydiseases.AmericanThoracicSocietyDocuments1377guide.medlive.cn AMERICANTHORACICSOCIETYDOCUMENTSexceedsthecapacityofexistingprograms(4,15).CapacitycanbeincreasedbycreatingTelehealthforchronicnewprogramsand/orbyexpandingexistingdisease£92,000/QALY*programs.Bothapproacheswillrequiresignificantbuy-in,systemchange,andTripleTherapy£7,000–£187,000/QALYinvestmentfromhealthcareprofessionals,healthcarepolicy-makers,administrators,LABAandpayers.Thisshouldbefacilitatedby£8,000/QALYdemonstratingdatashowingreturnoninvestmentforthelocalhealthcaresystem4C/FPOTiotropiumandbyprovidingpolicyadvicefor£7,000/QALYgovernmentsandnongovernmentalorganizationswhoadvocateforpeoplewithPulmonaryRehabilitationchronicdisease.EstablishmentofnewPR£2,000–8,000/QALYprogramsandstrategiestoincreasethecapacityofexistingPRprogramsmustStopSmokingSupportwithpharmacotherapy£2,000/QALYfollowrecommendationsasdetailedintheATS/ERSPRStatement(1,12)andotherPRguidelines(3,5,7,10).ThisincludesFluvaccination£1,000/QALYin“atrisk”populationadequateinfrastructure(spaceforphysicalconditioning,exercisetraining,andFigure1.Cost-effectivenessofpulmonaryrehabilitationrelativetoothertreatmentsforchronicmonitoringequipment;resourcesforobstructivepulmonarydisease.ReprintedfromReference96.*Costperquality-adjustedlifeyearequipmentmaintenanceandreplacement;(QALY).LABA=long-actingb-agonist.andspaceandresourcesforpatientassessmentandeducation),andstaffingadvocacyrepresentatives.inadequatePRservicestomeetpatientneeds.(number,training,experience,andRecommendationsforincreasingpatientThisshortfallinPRserviceaccessibilityandcompetency[101]).TheefficiencyofawarenessandknowledgeofPRarecapacityresultsfromseveralfactorsprogramsalsoimpactscapacity.providedinBox4.consideredbelow.Measuringprocessmetrics(suchastimefrompatientreferraltoprogramuptake,IncreasingPatientAccessanduseofacentralplanningtoPRLackofAdequatePRInfrastructureadministrativestructureforpatientandInadequateProgramenrollment)isimportantinthisregard.VariableaccesstoPRcreatesCommissioningExpandingtherangeofprogrammodelsunacceptabledisparitiesinquality,evidence-DespitethehighvalueofPR(96),thedeliveredwithinexistingcomprehensivePRbasedhealthcare.Currently,therearenumberofpotentiallysuitablepatientsfarsettings(e.g.,outpatientorcommunitybased),Box4:IncreasingPatientAwarenessandKnowledgeofPRRecommendations:dProfessionalsocietiesandpatientadvocacyandeducationexpertsshouldcollaborateinthedevelopmentoflanguage,educationlevel,andculturallyappropriateeducationmaterialsinmultipleformats(e.g.,written,internetbased)forpatientswithchronicrespiratorydiseases,toenablethemtoknowledgeablyadvocateforaccesstoPR.dHealthcareprofessionalsshouldprovideinformationregardingtheprocessandbenefitsofPRtosuitablepatients.dCommunicationcampaignsshouldbeaddressedtothegeneralpublicregardingtheprocessandbenefitsofPR.ActionableItems:dProfessionalsocietiessuchastheATS,ERS,andotherspartnerwithnationalandinternationalpatientadvocacygroupstoprepareanddisseminatePR-relatededucationalmaterialsculturallyadaptedtoeachcountryandcompatiblewithpatienthealthliteracy,andtoensurethateducationalmessagesareconsistentinthematerialsforhealthcareprofessionals,patients,andfamilies.dProfessionalsocietiessuchastheATSandERSandpatientadvocacygroupsdisseminatetheabove-notededucationalmaterialstohospitals,clinics,communitycenters,andpatientsupportgroupsandmakethemavailableonline.dDevelopmediacampaignswithgovernmentalandprofessionalsocieties’supporttoincreasetheawarenessofpatientsandthegeneralpublicregardingthebenefitsofPR,exercise,andphysicalactivity.dPRproviderswithinprofessionalsocietiessuchasATSandERSadvocatethatpharmaceuticalcompanieswithaccesstopatientsspreadawarenessoftheexistenceandbenefitsofPRincombinationwithothertherapies(includingpharmacotherapyandsupplementaloxygen).1378AmericanJournalofRespiratoryandCriticalCareMedicineVolume192Number11|December12015guide.medlive.cn AMERICANTHORACICSOCIETYDOCUMENTSaddingPRasatreatmentoptionbebasedonsymptomsandfunctionalPatient-LevelBarrierstoPRwithinexistingcardiacorgeneralstatuslimitationratherthansolelyonthePatientsreferredtoPRconsistentlyreportrehabilitationprograms,oraddingadditionalseverityoflungfunctionimpairmentbarrierstoinitiationofandadherencewiththeessentialcomponentsofPR(besidesexercise(1–3,6,10,12).PReffectivelyaddressesintervention(13,14),anduptohalfofeligibletrainingthatconstitutesthecornerstoneofseveralissuesalsoexperiencedbypatientsreferredtoPRneverattend(14).IneveryPRprogram),suchasself-managementpersonswithmildtomoderateCOPD,additiontotravelandtransportationissues,trainingandpatienteducation,toincludingexertionaldyspnea(105–108),lackofsupportfromfamilymembersorinterventionscomposedsolelyofexercisedynamichyperinflation(107,108),othercaregivers,depression,comorbidillness,trainingcouldalsoincreaseprogramcapacityskeletalmuscledysfunction(63,107,anddisruptionofdailyroutineareandpatientaccesstoPR.Asignificant109),lowphysicalactivitylevels(110,particularlyimportant(14).MembersoftheincreaseinfundingsupportforPRwillbe111),depression(112),riskandimpactTaskForceforthisPolicyStatementalsoneededtoaddresseachoftheseissues.ofcomorbiditiessuchascardiovascularconductedaninformalsurveyofpatients’disease(113),exacerbationsofCOPDopinionsregardingaccesstoPRamongGeographicInaccessibility(114),andimpairedqualityoflife(115)membersofATS’PublicAdvisoryRoundtable,ELF’spatientorganizationWorldwide,accesstoPRislimitedin(Table1)(12).However,insomenetwork,theCOPDFoundation,andthemanygeographicareas,andinsomejurisdictions,accesstoPRislimitedbyPulmonaryFibrosisFoundation.ResponsescountriesPRprogramsarelackingregulationsspecifyinginsurancefrompatientswithawidevarietyofchronicaltogether(15,102).PatientscoverageofPRonlyforstablepatientsrespiratoryconditionswereincluded.KeyfrequentlycitedistanceandlackofwithCOPDwhohavemoderatetoseverepatient-identifiedbarrierstoaccessingPRtransportationasamajorreasonforpoorairflowobstruction.Suchpoliciesarenotidentifiedinasurveyof1,686respondentsprogramuptakeoradherence(14).Itisinlinewithstrongevidencefromfrom29countries(FigureE1)included(inknownthattraveltimegreaterthan30randomizedtrialsthatshowthatbothdescendingorderoffrequency)lackofminutesisabarriertopatientpatientswithunstableCOPDwhostartawarenessofPR(“neverheardofit”),participationinPR(103).ThesefactorsrehabilitationduringorafteraninsufficientinformationonprocessorshouldbeconsideredwhennewPRexacerbations(76)andpatientswithpotentialefficacy,lackofavailablePRprogramsareestablished.stablemildtomoderateCOPDbenefitservices,andlackofinsurancecoverage.Thefromrehabilitation(116–118).findingsofthispatientsurveycorroborateImprovingAccesstoPRforPersonstheissuesregardingawarenessandwithNon-COPDRespiratoryLimitationsonPREligibilityoverTimeknowledgeofPRandaccesstoPRdiscussedDisordersThebenefitsof8to12weeksofPRtypicallyabove.Importantly,manyofthesebarriersPRhasdemonstratedeffectivenessforlastupto12months(17,21,119).Yet,seemmodifiablewithorchestratedactions.severalrespiratoryconditionsotherthanpatientslivewiththeirchronicrespiratoryCOPD(2,11).Randomizedcontrolledtrialsdiseasesoverthecourseoftheirlifetime.LimitedNumberofPRHealthcaredemonstratingitsbeneficialeffectsonProfessionalsexercisecapacity,symptoms,and/orhealth-EmphasisisplacedinPRprogramsonTrainedPRhealthcareprofessionalsarerelatedqualityoflifeareavailableinhealth-enhancingbehaviorchangeforthisnecessaryforprovisionofPRtopatients.interstitiallungdisease,bronchiectasis,reason.Nevertheless,anihilisticviewAvailabilityofeducation,training,andasthma,cysticfibrosis,lungtransplantation,towardPRisoftentakenbypayersandfundingforhealthcareprofessionalswholungcancer,andpulmonaryhypertensionhealthcareprofessionalsasaresultofastrivetobecomePRprovidersvarieswithin(16–30,32–34,36,38–40,42,43,45,46,potentiallylimiteddurationofthebenefitsandacrosscountries.Althoughformal104).Theremaybespecialconsiderationsresultingfrompatients’participationinadocumentationislacking,insufficientandadditionaltrainingforPRstaffsinglePRprogramcourse.InsomeavailabilityofPRprovidershasthepotentialrequiredwhenincludingpersonswithnon-countries(e.g.,theUnitedStates),thereisatolimitpatientaccesstoPR.COPDdisorders(3,11,12).PayerpayerlimitonthetotalnumberofPRRecommendationsforincreasingpatientreimbursementofPRfornon-COPDsessionspatientscanattend.ThisisaccesstoPRareprovidedinBox5.disordersremainslimitedinsomecounterproductive,becauserepeatcoursescountries.PayersandhealthcareofPRaffordsimilarbenefitstothoseofprofessionalsrequireknowledgeregardinginitialpatientparticipation(82)and,atEnsuringQualityofPRappropriatepatientselectioncriterialeastforCOPD,PRiseffectiveafteracuteProgramsaccordingtopublishedevidence.diseaseexacerbations(76,120),whichareassociatedwithworsenedsymptoms,ThequalityofPRprogramsisreflectedinLimitationsonPREligibilityBasedonfunctionaldecline,andhighhealthcareprocessandperformancemetrics.The2013COPDDiseaseSeveritycosts(121–123).Increasingpatients’accessATS/ERSPRStatement,the2013BritishAlthoughPRbenefitspersonswithmanytoPR,includingrepeatedcourseswhereThoracicSocietyqualitystandards,andrespiratorydisorders,muchoftheclinicallyindicated,hasthepotentialtootherdocuments(1,3,6,10,12,93,116,publishedliteraturehas,historically,improvepatients’healthoverthecourseof117)summarizetheevidenceunderpinningcenteredonCOPD.ProvisionofPRtheirlivesandtoreducehealthcareusebestpracticeforPR.ProgramcertificationservicesforpersonswithCOPDshouldcosts.isameansofensuringstandardsaremet.AmericanThoracicSocietyDocuments1379guide.medlive.cn AMERICANTHORACICSOCIETYDOCUMENTSBox5:IncreasingPatientAccesstoPRRecommendations:dPatientaccesstoPRshouldbeimprovedbyaugmentingprogramcommissioningthroughincreasedsustainablepayerfunding.dNewPRprogramsshouldbecreatedingeographicareaswheredemandexceedscapacity.dNovelPRprogrammodelsshouldbedevelopedandstudiedthatwillmakeevidence-basedPRmoreaccessibleandacceptabletopatientsandpayers;thismayincludenewapproacheswithinhospital-basedprograms,community-basedprograms,comprehensiveandwell-resourcedhome-basedortelehealth-supportedprograms,orothernovelmodelsofprogramdelivery.dSelectioncriteriaforPRshouldreflectcurrentpublishedevidence.TheevidenceindicatesthatpatientswhobenefitfromPRincludenotonlypersonswithmoderatetosevereairflowlimitationbutalsothosewithmildtomoderateairflowlimitationwithsymptom-limitedexercisetolerance,thoseafterhospitalizationforCOPDexacerbation,andthosewithsymptomaticnon-COPDrespiratoryconditions.Increasingpatientaccessforthesepatientgroupswilldependonincreasedreferrals,increasedpayerfunding,andpatientdemandforservices.ActionableItems:dPRproviderssystematicallydetailanddocumentthecostsofprovidingcomprehensivequalityPRservicesandsharethisinformationwiththoseadvocatingPRpolicies’reimbursementratetofacilitateappropriateandnecessaryreimbursement.dIdentifythenumberofpatientspotentiallysuitableforPR(basedonoutpatientandhospitaldischargedatabases)withinlocalandregionaljurisdictionstoassesstheneedforestablishmentofnewPRprogramsand/orincreasedcapacityofexistingprograms.dPRproviders,localfundingagencies,healthsystems,patients,andresearcherscollaboratetoestablishtheoptimalmodelsthatwillincreasePRcapacityanduptake.dProfessionalsocieties(suchasATS,ERS,andothers)auditexistingpatientselectioncriteriaforPRandworkwithaccreditationorganizationstobroadenpatientcandidacytoincludethosewithsymptomaticnon-COPDrespiratoryconditions,thoseafterhospitalizationforCOPDexacerbation,andsymptomaticpatientswithmildtomoderateairflowlimitation.dProfessionalrespiratorysocieties(suchasATS,ERS,andothers)audittheavailabilityofPRprovidersandtrainingprogramsforhealthcareprofessionalswhostrivetobecomePRproviders.dPatientsandtheirfamiliespartnerwithhealthcareprofessionals,advocacygroups,andhealthprofessionalsocietiestopetitionforgreatercapacityandaccesstoPRintermsofthenumbersofprograms,patienteligibility,andinsurancecoverage.dPRprogramsidentifylocalbarrierstopatientuptakeandadherencetoPRandoutlinestrategiestoaddressthesebarriers.dPayersofferincentivesforsuitablepatientstoparticipateinPR.dPayerslinkhealthcareprofessionals’patientreferralstoPRto“payforperformance.”Currently,onlytheAmericanAssociationpreparedtoworkcloselywithotherindividualizedrehabilitationaccordingtoofCardiovascularandPulmonaryhealthcareprofessionalstohandlethemulti-eachpatient’sneeds.ToassessprogramRehabilitation(intheUnitedStates)(2)morbiditypresentamongpersonsreferredforquality,clinicaloutcomesmustbeandsomecountriesinEurope(124)offerPR,includingthepsychologicalimpactandmeasuredforindividualpatientsandthiscertificationprocess.Implementationmanifestationsofchronicrespiratorydisease.presentedinaggregate.EssentialoutcomesofasimilarinternationallyrelevantprocessTobeuniversallyapplicable,theseprogrammeasurementsinPRinclude,atathatevaluatesPRprogramqualityandcomponentsmustbeimplementedwithminimum,thestandardizedassessmentofrewardsqualityprogramsisneeded.Thisconsiderationoflocalresources,aswellaspatients’functionalexercisecapacity,wouldfacilitatehighlightingandcultural,economic,andhealthcaresystemdyspnea,andhealthstatus(1–3,6,10,12).disseminationofqualitystandardsforPRdifferencesacrosscountries.ThehealthSeveraldisease-relevantmethodsareprogramstohealthcarefacilities,healthcareeconomicbenefitsofPRcanpotentiallybeavailableformeasuringtheseoutcomesprofessionals,andpolicymakers.furtherenhancedbyusingtheprogramasa(11,12).AssessmentofadditionalToqualifyasPR,programsmustinclude,vehicletopromoteincreaseddailyphysicalmultidimensionaloutcomes(consideredataminimum:astructuredandsupervisedactivity,whichmayinturnreducetheriskoffurtherinthe2013ATS/ERSStatementonexerciseprogramforpatientswithavarietyofhospitaladmission(129).PulmonaryRehabilitation)(1),includingrespiratoryconditions,apatienteducation/ThequalityofPRprogramsis(butnotlimitedto)impactofPRonbehavioralprogramintendedtofosterhealth-demonstratedbytheirsuccessinimprovingpsychologicalcomorbidityandmeasuresofenhancingbehavior,patientassessmentandpatientoutcomes.PatientsenteringPRthepatientexperience,isdesirable,becauseoutcomesmeasures,andprovisionofprogramsareheterogeneousregardingpatients’responsestoPRarerecommendationsforhome-basedexercisediseasestate,symptoms,functionalmultidimensional(130).Theselectionandandphysicalactivity(1,3,5,7,10,12,93,limitations,medicalcomorbidities,andstandardizationofoutcomemeasuresfor125–128).StaffofPRprogramsmusthavepsychologicburdenofdisease.PatientthepurposeofprogramcomparisonanddemonstratedcompetenciesinprovisionofassessmentsconductedatthestartofPRbenchmarkingwillvaryamongdifferentPR(101).Theymustalsobeawareofandbecharacterizepatientstoenabledeliveryofjurisdictions,butshouldbeguidedbythe1380AmericanJournalofRespiratoryandCriticalCareMedicineVolume192Number11|December12015guide.medlive.cn AMERICANTHORACICSOCIETYDOCUMENTSBox6:EnsuringQualityofPRProgramsRecommendations:dPRprogramsshouldfollowrelevantevidence-basedclinicalguidelinesanddemonstratethemeasurementofstandardoutcomes,todocumentbenefits,quality,andsafety.dAcoresetofprocessesandoutcomesshouldbeestablishedtoenablenationalandinternationalbenchmarkinginPR;thisshouldincludebothprocessandperformancemetricstoenablerecommendationsforinternationalstandardsbasedonevidenceandbestpractice.dPRprogramsshouldencourageandfosterpatients’long-termadherencetohealth-enhancingbehaviorstooptimizepatientwellnessandreducehealthcarecosts.ActionableItems:dNationalrespiratorysocietiesdevelopkeyperformanceandprocessindicatorstoassistintheprocessofprogramaccreditation.dIndividualPRprogramsdeveloppatientregistriesforpurposesofmonitoringprogramqualityandoutcomes.dPRprogramsfollowevidence-basedclinicalguidelines,includingprocess,outcomes,quality,andsafety,tojustifyreimbursementfrompayers.dPRprofessionalswithinprofessionalsocieties(suchasATSandERS)collaboratetomodifyandexpandexistingnationalPRregistriesforinternationaluse.respiratoryscientificcommunitybasedonforPRshouldbeconsistentacrossprograms,overthelongtermareessential.disease-relevantpublishedevidence.butsolutionstoachievethesestandardsmustInvolvementofhomecaregiversandcloseProvidersshouldbeencouragedtoquantifybeappropriatetothelocale,toensurethebestcollaborationandcoordinationofcaretheeconomicbenefitsofpatientcareofpatientsinacost-effectivemanner.betweenpatients,PRprofessionals,andparticipationinPR(e.g.,reductionsinLong-termadherencetohealth-patients’otherhealthcareprovidersarehospitaladmissions)wherepossible.enhancingbehaviors,suchasexercise,crucialtoachievethesegoals.Evidenceofsafetyshouldbeassessedphysicalactivity,abstinencefromsmoking,Recommendationsforensuringqualityofbasedonstandardoperatingpolicies,andimmunization,isakeygoalofPR.PRprogramsareprovidedinBox6.riskassessments,andcriticalincidentAlthoughtheoptimalmeansofmaintainingreporting.PRprogramdirectorsshouldbenefitsachievedinPRisnotfullyclear(85,conductanannualinternalauditofprogram131),PRprofessionals’effortstoassistFutureResearchToAdvanceprocessandoutcomes.PRprogramsshouldpatientsincontinuingtoadheretoexercise,Evidence-basedPolicyinPRalsocollectandrespondtoinformationonincorporatingknowledgegainedinPRintopatientexperience,needs,andsatisfactiondailyliving,andmaintainingcollaborativeAlthoughthescientificrationaleforPRisbefore,during,andafterPR.Qualitystandardsinteractionwithhealthcareprofessionalsestablished,andtheevidenceofthebenefitsBox7:FutureResearchtoAdvanceEvidence-basedPolicyinPRRecommendations:dFurtherresearchshouldbeundertakenregardingthecost-effectivenessofPR:thismayincludeinnovativemodelsofPRdelivery,sitesand/ortimingofPR,PRforrespiratorydisordersotherthanCOPD,andrepeatcoursesofPRovertime.dFurtherinvestigationofalternativemodelsofprovidingPRshouldbeundertakentoimproveaccessanduptake,usingprogrammodelsofknownefficacy.dFurtherinvestigationofalternativemodelsofprovidingPRshouldbeundertakentoaddresstheneedsofpatientswithahighburdenofpsychologicalandmultiplemedicalcomorbidities.dFurtherresearchshouldbedoneregardingbarriersandfacilitatorsofPRprogramreferrals,accessibility,enrollment,andadherenceforpersonswithchronicrespiratorydiseases.dFurtherresearchshouldbeundertakentoassesstheimpactofPRprogramfundingsourceonpatientuseofPR.ActionableItems:dPRexpertsarticulateanddocumentprioritiesforPR-relatedresearchwithinPRassembliesofprofessionalorganizationssuchasATSandERSandcommunicatethemtopatientadvocacygroupsandfundingagenciesviastakeholderforumsandworkshops.dPRexpertslobbyprofessionalsocietiesaswellaspatientadvocacyorganizationsandfederalagenciestodirectcurrentandfuturefundingtowardPRresearch.dHealthcareprofessionalsconductpragmatic,“real-world”trialsofPR.AmericanThoracicSocietyDocuments1381guide.medlive.cn AMERICANTHORACICSOCIETYDOCUMENTSofPRforpersonswithCOPDandotherfeasibilityandsuggestthatclinicalbenefitsmaymorefundingforPRresearchintheseareasformsofchronicrespiratorydiseaseisbeachieved(132–135).Carefullystructuredwillbeneeded.extensiveandconvincing,thereareseveralhome-basedexercisetrainingandMoreinformationisalsoneededareaswhereinfurtherknowledgeisneededrehabilitationthatissupportedbyPRregardingtheclinicalandeconomicbenefitsof(TableE3)(12).Importantly,theTaskForceprogramstaffwithorwithoutspecializedrepeatcoursesofPR(especiallyforpatientsforthisPolicyStatementidentifieskeyareasexerciseequipmentmightbefeasibleinwithchronicrespiratorydisordersotherthanforfutureresearchthatwillsomehealthcareenvironments(136,137).COPD)andregardingoptimalstrategiesforimpactcommissioningpolicyforPRandwillAlternatemethodsforcomponentsofmanagingmedicalandpsychologicalmulti-inturnhavepotentialtoaugmentdeliveryofexercisetraining(suchasuseofelasticmorbidityinthecontextofPR.Also,althoughPRservicesandpatientaccesstoPR.resistancetubesratherthanspecializedtheimpactoffundingsourceonpatientuseofAlthoughthetraditionalmodelsofequipmentforresistancetraining)(138)PRisunclear,sourcesoffundingforPRinpatientandoutpatientPRaresuitableformaybeapplicableacrossabroadrangeofprogramsandreimbursementforpatientmanypatients,alternativemodelsmayalsobesettings.Robustresearchisunderwayinparticipationvarywidely,andthismayinturneffectiveandmayimprovepatientaccess,theseareas(139),andfurtherworkisneededimpactpatientenrollmentandparticipationparticularlyinregionsorhealthcaresystemstovalidatetheseapproaches.Adoptionof(15).YounghealthcareprofessionalswillalsowheretraditionalmodelsofPRarenotfeasible.alternativemodelsforPRwillrequirerequireencouragementandanincreaseinForexample,tele-rehabilitation,whichlinksdemonstrationofcomparableorgreaterinfrastructuretoenablethemtopursueexpertrehabilitationhealthcareproviderswithclinicaloutcomestothoseoftraditionalPRcareersasclinicianinvestigatorswithafocusothersataremotesiteorwithpatientsintheirprograms,aswellasevaluationofsafetyandonPR.Recommendationsforfutureresearchhomes,alsohaspotentialtoimproveaccess.cost-effectiveness,stafftraining,andguidelinetoadvanceevidence-basedpolicyinPRareInitialsmall-scalestudiesdemonstratedevelopment.Thus,tomovethefieldforward,providedinBox7.nThisPolicyStatementwaspreparedbytheATS/ERSTaskForceonPolicyinPulmonaryRehabilitation.Membersofthetaskforceareasfollows:SALLYJ.SINGH,PH.D.AuthorDisclosures:C.L.R.servedonanadvisorycommitteeofGlaxoSmithKline.S.C.L.CAROLYNL.ROCHESTER,M.D.(Co-Chair)RICHARDCASABURI,PH.D.,M.D.servedonanadvisorycommitteeofBoehringerIOANNISVOGIATZIS,PH.D.(Co-Chair)CHRISGARVEY,F.N.P.,M.S.N.,M.P.A.Ingelheim.D.D.M.isaboardmemberoftheRICHARDL.ZUWALLACK,M.D.BARBARAP.YAWN,M.D.,MSC.LungHealthInstituteofCanada.M.A.S.MILOA.PUHAN,M.D.,PH.D.FABIOPITTA,P.T.,PH.D.receivedrelevantfinancialsupportfromCIRO1DARCYD.MARCINIUK,M.D.KYLIEHILL,B.SC.(PHYSIOTHERAPY),PH.D.intheNetherlandsandREVAL/BIOMEDinANNEE.HOLLAND,B.SC.(PHYSIOTHERAPY),PH.D.REBECCACROUCH,P.T.,D.P.T.,M.S.Belgium.M.M.istheNationalClinicalDirectorforRespiratoryServicesforNHSEngland.SUZANNEC.LAREAU,R.N.,M.S.JUDITHGARCIA-AYMERICH,M.D.,PH.D.P.J.W.servedasaspeakerforPhilips/MARTIJNA.SPRUIT,P.T.,PH.D.PETERJ.WIJKSTRA,M.D.,PH.D.Respironics,ResMed,andVIVISOLandANDREWL.RIES,M.D.,M.P.H.SARAHMASEFIELD(ELF)receivedresearchsupportpaidtohis1institutionfromResMed,VIVISOL,andMICHAELMORGAN,M.D.,PH.D.PIPPAPOWELL(ELF)B1VitalAire-AirLiquide.I.V.,A.E.H.,M.A.P.,S.M.,ROGERS.GOLDSTEIN,M.B.CHB.JORNSTAHLBERG,M.D.R.Casaburi,E.M.C.,R.Crouch,J.G.-A.,C.G.,ENRICOM.CLINI,M.D.1TheseindividualsweremembersofthetaskR.S.G.,K.H.,L.N.,F.P.,A.L.R.,S.J.S.,T.T.,LINDANICI,M.D.forcebutwerenotmembersofthewritingB.P.Y.,andR.L.Z.reportednorelevantTHIERRYTROOSTERS,P.T.,PH.D.committee.commercialrelationships.References5.MarciniukDD,BrooksD,ButcherS,DebigareR,DechmanG,FordG,PepinV,ReidD,SheelAW,SticklandMK,etal.Optimizingpulmonary1.SpruitMA,SinghSJ,GarveyC,ZuWallackR,NiciL,RochesterC,HillK,rehabilitationinchronicobstructivepulmonarydisease–practicalHollandAE,LareauSC,ManWD,etal.;ATS/ERSTaskForceonissues:aCanadianThoracicSocietyClinicalPracticeGuideline.CanPulmonaryRehabilitation.AnofficialAmericanThoracicSociety/RespirJ2010;17:159–168.EuropeanRespiratorySocietystatement:keyconceptsandadvancesin6.MarciniukDD,GoodridgeD,HernandezP,RockerG,BalterM,BaileyP,Fordpulmonaryrehabilitation.AmJRespirCritCareMed2013;188:e13–e64.G,BourbeauJ,O’DonnellDE,MaltaisF,etal.Managingdyspneain2.AmericanAssociationofCardiovascularandPulmonaryRehabilitation.patientswithadvancedchronicobstructivepulmonarydisease:aCanadianGuidelinesforcardiacrehabilitationandsecondarypreventionThoracicSocietyClinicalPracticeGuideline.CanRespirJ2011;18:69–78.programs.Champaign,IL,HumanKinetics;7.NiciL,DonnerC,WoutersE,ZuwallackR,AmbrosinoN,BourbeauJ,CaroneM,CelliB,EngelenM,FahyB,etal.;ATS/ERSPulmonary2011.RehabilitationWritingCommittee.AmericanThoracicSociety/3.BoltonCE,Bevan-SmithEF,BlakeyJD,CroweP,ElkinSL,GarrodR,EuropeanRespiratoryS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