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BackgroundGiven limited access to center-based, in-person pulmonary rehabilitation (PR), alternative delivery strategies are needed.Research QuestionWe compared a virtual PR program with a conventional center-based one with respect to safety, feasibility/acceptability, and geographic catchment (primary outcomes). We explored efficacy by examining changes in functional outcomes (secondary outcomes).Study Design and MethodsThis single-center, observational, real-world report included patients enrolled from July 30, 2020, through June 30, 2023, who attended one or more PR class. Patients in virtual PR exercised in their homes under direct supervision via two-way audiovisual teleconferencing. Baseline demographic information and adverse events were extracted from electronic medical records. Google Maps estimated distance and drive time from residential addresses to the PR center. Intake and exit evaluations for secondary (functional) outcomes and feedback questionnaires were completed in a subset.ResultsA total of 120 (52 in-person and 68 virtual) patient enrollments were examined; 84% had COPD. Mean age, FEV1 and FVC % predicted, and baseline 6-min walk test distance were similar between groups. For safety, the overall rate of PR-related adverse events was 1.2 per 1,000 person-days of observation, with no between-group differences. For feasibility, the average number of exercise classes completed (12.4 ± 6.2 vs 13.0 ± 6.1) and proportion completing ≥ 70% of classes (61.5% vs 67.6%) was comparable between in-person and virtual groups, respectively. For acceptability, among those who completed the virtual PR feedback questionnaire (n = 30), 100% felt safe exercising at home, 97% endorsed clear internet connection, and 90% agreed education sessions were easy to understand. For geographic catchment, patients in virtual PR lived farther (median, 34.1; interquartile range, 16.6-45.1 vs median, 10.3; interquartile range, 5.6-20.6 miles, P < .001) and had longer drive times (mean 86.0 ± 31.6 vs 51.4 ± 31.9 min, P < 0.001) than patients in in-person PR. In the subset with both intake and exit evaluations, similar improvements were observed in functional outcomes and dyspnea in both groups.InterpretationTwo-way audiovisual teleconferenced PR is safe, feasible/acceptable, and significantly expands geographic catchment. Given limited access to center-based, in-person pulmonary rehabilitation (PR), alternative delivery strategies are needed. We compared a virtual PR program with a conventional center-based one with respect to safety, feasibility/acceptability, and geographic catchment (primary outcomes). We explored efficacy by examining changes in functional outcomes (secondary outcomes). This single-center, observational, real-world report included patients enrolled from July 30, 2020, through June 30, 2023, who attended one or more PR class. Patients in virtual PR exercised in their homes under direct supervision via two-way audiovisual teleconferencing. Baseline demographic information and adverse events were extracted from electronic medical records. Google Maps estimated distance and drive time from residential addresses to the PR center. Intake and exit evaluations for secondary (functional) outcomes and feedback questionnaires were completed in a subset. A total of 120 (52 in-person and 68 virtual) patient enrollments were examined; 84% had COPD. Mean age, FEV1 and FVC % predicted, and baseline 6-min walk test distance were similar between groups. For safety, the overall rate of PR-related adverse events was 1.2 per 1,000 person-days of observation, with no between-group differences. For feasibility, the average number of exercise classes completed (12.4 ± 6.2 vs 13.0 ± 6.1) and proportion completing ≥ 70% of classes (61.5% vs 67.6%) was comparable between in-person and virtual groups, respectively. For acceptability, among those who completed the virtual PR feedback questionnaire (n = 30), 100% felt safe exercising at home, 97% endorsed clear internet connection, and 90% agreed education sessions were easy to understand. For geographic catchment, patients in virtual PR lived farther (median, 34.1; interquartile range, 16.6-45.1 vs median, 10.3; interquartile range, 5.6-20.6 miles, P < .001) and had longer drive times (mean 86.0 ± 31.6 vs 51.4 ± 31.9 min, P < 0.001) than patients in in-person PR. In the subset with both intake and exit evaluations, similar improvements were observed in functional outcomes and dyspnea in both groups. Two-way audiovisual teleconferenced PR is safe, feasible/acceptable, and significantly expands geographic catchment. Take-home PointsStudy Question: In this single-center, real-world observational cohort of patients enrolled in either virtual or traditional in-center pulmonary rehabilitation between July 30, 2020, and June 30, 2023, the total adverse event rate was low, with no significant differences by pulmonary rehabilitation modality (virtual vs in-person).Results: Individuals enrolled in the virtual pulmonary rehabilitation program lived significantly farther, with longer drive times, relative to those enrolled in the in-person program, supporting increased geographic catchment of the pulmonary rehabilitation program through the inclusion of a virtual option.Interpretation: Comparable rates of completing pulmonary rehabilitation and, in exploratory analyses, similar improvements in dyspnea and functional outcomes (6-min walk test, 30-s sit-to-stand) were observed in both virtual and in-person arms. Study Question: In this single-center, real-world observational cohort of patients enrolled in either virtual or traditional in-center pulmonary rehabilitation between July 30, 2020, and June 30, 2023, the total adverse event rate was low, with no significant differences by pulmonary rehabilitation modality (virtual vs in-person). Results: Individuals enrolled in the virtual pulmonary rehabilitation program lived significantly farther, with longer drive times, relative to those enrolled in the in-person program, supporting increased geographic catchment of the pulmonary rehabilitation program through the inclusion of a virtual option. Interpretation: Comparable rates of completing pulmonary rehabilitation and, in exploratory analyses, similar improvements in dyspnea and functional outcomes (6-min walk test, 30-s sit-to-stand) were observed in both virtual and in-person arms. Pulmonary rehabilitation (PR) provides supervised aerobic exercise training, strength training, and multidisciplinary self-management education for people with chronic lung diseases, including COPD.1Global Strategy for the Diagnosis, Management and Prevention of COPDGlobal Initiative for Chronic Obstructive Lung Disease (GOLD).2024Google Scholar, 2Rochester C.L. Alison J.A. Carlin B. et al.Pulmonary rehabilitation for adults with chronic respiratory disease: an official American Thoracic Society Clinical Practice Guideline.Am J Respir Crit Care Med. 2023; 208: e7-e26Crossref PubMed Scopus (46) Google Scholar, 3Spruit M.A. Singh S.J. Garvey C. et al.An official American Thoracic Society/European Respiratory Society statement: key concepts and advances in pulmonary rehabilitation.Am J Respir Crit Care Med. 2013; 188: e13-e64Crossref PubMed Scopus (2732) Google Scholar Center-based (in-person) PR has been studied extensively and improves exercise tolerance and health-related quality of life (HRQoL), reduces symptoms, and is associated with decreased risk for hospitalizations and death in people with COPD.4Lindenauer P.K. Stefan M.S. Pekow P.S. et al.Association between initiation of pulmonary rehabilitation after hospitalization for COPD and 1-year survival among Medicare beneficiaries.JAMA. 2020; 323: 1813-1823Crossref PubMed Scopus (143) Google Scholar,5McCarthy B. Casey D. Devane D. Murphy K. Murphy E. Lacasse Y. Pulmonary rehabilitation for chronic obstructive pulmonary disease.Cochrane Database Syst Rev. 2015; 2015CD003793Google Scholar Center-based PR is cost-effective6Mosher C.L. Nanna M.G. Jawitz O.K. et al.Cost-effectiveness of pulmonary rehabilitation among US adults with chronic obstructive pulmonary disease.JAMA Netw Open. 2022; 5e2218189Crossref PubMed Scopus (26) Google Scholar and is considered standard of care for symptomatic patients with COPD.1Global Strategy for the Diagnosis, Management and Prevention of COPDGlobal Initiative for Chronic Obstructive Lung Disease (GOLD).2024Google Scholar, 2Rochester C.L. Alison J.A. Carlin B. et al.Pulmonary rehabilitation for adults with chronic respiratory disease: an official American Thoracic Society Clinical Practice Guideline.Am J Respir Crit Care Med. 2023; 208: e7-e26Crossref PubMed Scopus (46) Google Scholar, 3Spruit M.A. Singh S.J. Garvey C. et al.An official American Thoracic Society/European Respiratory Society statement: key concepts and advances in pulmonary rehabilitation.Am J Respir Crit Care Med. 2013; 188: e13-e64Crossref PubMed Scopus (2732) Google Scholar,5McCarthy B. Casey D. Devane D. Murphy K. Murphy E. Lacasse Y. Pulmonary rehabilitation for chronic obstructive pulmonary disease.Cochrane Database Syst Rev. 2015; 2015CD003793Google Scholar Despite the benefits of PR, participation in conventional center-based programs remains limited, with only 1.5% to 3.7% of US Medicare and Veterans Health Administration beneficiaries using PR.7Nishi S.P. Zhang W. Kuo Y.F. Sharma G. Pulmonary rehabilitation utilization in older adults with chronic obstructive pulmonary disease, 2003 to 2012.J Cardiopulm Rehabil Prev. 2016; 36: 375-382Crossref PubMed Scopus (66) Google Scholar,8Vercammen-Grandjean C. Schopfer D.W. Zhang N. Whooley M.A. Participation in pulmonary rehabilitation by Veterans Health Administration and Medicare beneficiaries after hospitalization for chronic obstructive pulmonary disease.J Cardiopulm Rehabil Prev. 2018; 38: 406-410Crossref PubMed Scopus (23) Google Scholar Patients who are referred to center-based PR face significant barriers, including the need to travel long distances multiple times a week.9Bamonti P.M. Boyle J.T. Goodwin C.L. et al.Predictors of outpatient pulmonary rehabilitation uptake, adherence, completion, and treatment response among male U.S. veterans with chronic obstructive pulmonary disease.Arch Phys Med Rehabil. 2022; 103: 1113-1121.e1Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar,10Keating A. Lee A. Holland A.E. What prevents people with chronic obstructive pulmonary disease from attending pulmonary rehabilitation? A systematic review.Chron Respir Dis. 2011; 8: 89-99Crossref PubMed Scopus (416) Google Scholar Because most PR programs are located in urban areas, access for rural patients remains limited.11Moscovice I.S. Casey M.M. Wu Z. Disparities in geographic access to hospital outpatient pulmonary rehabilitation programs in the United States.Chest. 2019; 156: 308-315Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar,12Spitzer K.A. Stefan M.S. Priya A. et al.A geographic analysis of racial disparities in use of pulmonary rehabilitation after hospitalization for COPD Exacerbation.Chest. 2020; 157: 1130-1137Abstract Full Text Full Text PDF PubMed Google Scholar Among Medicare beneficiaries, two-fifths of older adults with COPD had poor access to PR, with markedly worse access for patients in rural areas.13Malla G. Bodduluri S. Sthanam V. Sharma G. Bhatt S.P. Access to pulmonary rehabilitation among Medicare beneficiaries with chronic obstructive pulmonary disease.Ann Am Thorac Soc. 2023; 20: 516-522Crossref PubMed Scopus (6) Google Scholar With center-based programs at risk for closure due to inadequate reimbursement14Garvey C. Pulmonary rehabilitation in persons with COPD.Respir Care. 2023; 68: 983-997Crossref PubMed Scopus (1) Google Scholar and disruptions from the COVID-19 pandemic, there is a need to identify alternative PR delivery strategies. Telerehabilitation, defined as "the delivery of medical or rehabilitative care to persons with rehabilitation needs via telecommunication or the internet"15TelerehabilitationPrinciples and Practice.2022Google Scholar holds promise to address the gap in PR access. Studies support that telerehabilitation for people with chronic respiratory disease achieves functional outcomes similar to those of center-based PR.16Cox N.S. Dal Corso S. Hansen H. et al.Telerehabilitation for chronic respiratory disease.Cochrane Database Syst Rev. 2021; 1CD013040PubMed Google Scholar, 17Cox N.S. McDonald C.F. Mahal A. et al.Telerehabilitation for chronic respiratory disease: a randomised controlled equivalence trial.Thorax. 2022; 77: 643-651Crossref PubMed Scopus (37) Google Scholar, 18Zanaboni P. Dinesen B. Hoaas H. et al.Long-term telerehabilitation or unsupervised training at home for patients with chronic obstructive pulmonary disease: a randomized controlled trial.Am J Respir Crit Care Med. 2023; 207: 865-875Crossref PubMed Scopus (16) Google Scholar However, in current telerehabilitation models, which have been developed mainly outside the United States, considerable heterogeneity with respect to asynchronous or unsupervised sessions, requirements for additional resources or staffing, or reliance on prerecorded or written educational materials exists.16Cox N.S. Dal Corso S. Hansen H. et al.Telerehabilitation for chronic respiratory disease.Cochrane Database Syst Rev. 2021; 1CD013040PubMed Google Scholar,19Nolan C.M. Kaliaraju D. Jones S.E. et al.Home versus outpatient pulmonary rehabilitation in COPD: a propensity-matched cohort study.Thorax. 2019; 74: 996-998Crossref PubMed Scopus (43) Google Scholar, 20Bondarenko J. Babic C. Burge A.T. Holland A.E. Home-based pulmonary rehabilitation: an implementation study using the RE-AIM framework.ERJ Open Res. 2021; 7Crossref PubMed Scopus (7) Google Scholar, 21Cox N.S. Bondarenko J. Chong M. Marceu T. Perryman J. Holland A.E. Rapid real-world implementation of pulmonary telerehabilitation: good fortune or COVID-19 luck?.ERJ Open Res. 2024; 10Crossref PubMed Scopus (0) Google Scholar There is substantial variation in the degree to which virtual PR programs maintain fidelity to the essential components (eg, comprehensive intake and exit evaluations, individualized exercise prescriptions and progression plan, aerobic exercise, strength training, education) of conventional center-based PR programs.2Rochester C.L. Alison J.A. Carlin B. et al.Pulmonary rehabilitation for adults with chronic respiratory disease: an official American Thoracic Society Clinical Practice Guideline.Am J Respir Crit Care Med. 2023; 208: e7-e26Crossref PubMed Scopus (46) Google Scholar,5McCarthy B. Casey D. Devane D. Murphy K. Murphy E. Lacasse Y. Pulmonary rehabilitation for chronic obstructive pulmonary disease.Cochrane Database Syst Rev. 2015; 2015CD003793Google Scholar,16Cox N.S. Dal Corso S. Hansen H. et al.Telerehabilitation for chronic respiratory disease.Cochrane Database Syst Rev. 2021; 1CD013040PubMed Google Scholar,22Holland A.E. Cox N.S. Houchen-Wolloff L. et al.Defining modern pulmonary rehabilitation. An Official American Thoracic Society Workshop Report.Ann Am Thorac Soc. 2021; 18: e12-e29Crossref PubMed Scopus (201) Google Scholar Finally, the impact of telerehabilitation on safety, patient engagement, and geographic catchment in real-world settings outside of research trials has been incompletely examined.16Cox N.S. Dal Corso S. Hansen H. et al.Telerehabilitation for chronic respiratory disease.Cochrane Database Syst Rev. 2021; 1CD013040PubMed Google Scholar,19Nolan C.M. Kaliaraju D. Jones S.E. et al.Home versus outpatient pulmonary rehabilitation in COPD: a propensity-matched cohort study.Thorax. 2019; 74: 996-998Crossref PubMed Scopus (43) Google Scholar, 20Bondarenko J. Babic C. Burge A.T. Holland A.E. Home-based pulmonary rehabilitation: an implementation study using the RE-AIM framework.ERJ Open Res. 2021; 7Crossref PubMed Scopus (7) Google Scholar, 21Cox N.S. Bondarenko J. Chong M. Marceu T. Perryman J. Holland A.E. Rapid real-world implementation of pulmonary telerehabilitation: good fortune or COVID-19 luck?.ERJ Open Res. 2024; 10Crossref PubMed Scopus (0) Google Scholar,23Candy S. Reeve J. Dobson R. et al.The impact of patient preference on attendance and completion rates at centre-based and mHealth pulmonary rehabilitation: a non-inferiority pragmatic clinical trial.Int J Chron Obstruct Pulmon Dis. 2023; 18: 1419-1429Crossref PubMed Scopus (2) Google Scholar,24Cox N.S. Khor Y.H. Telerehabilitation in pulmonary diseases.Curr Opin Pulm Med. 2023; 29: 313-321Crossref PubMed Scopus (5) Google Scholar The VA Boston center-based PR program, continuously certified by the American Association of Cardiovascular and Pulmonary Rehabilitation since 2013, leveraged existing infrastructure in 2020 to develop a synchronous virtual program in response to the COVID-19 pandemic. In this pragmatic, real-world report, we compare telerehabilitation via VA Video Connect (VVC), a secure two-way audiovisual communications technology platform, with conventional center-based, in-person PR with respect to primary outcomes of safety, feasibility/acceptability, and geographic catchment. Secondary (exploratory) outcomes included changes in dyspnea and functional measures both within and between the two groups. This single-center, observational, cohort study included all patients enrolled in PR at VA Boston Healthcare System from July 30, 2020, to June 30, 2023, who attended one or more PR class (inclusion criteria). Patients who attended PR classes using both face-to-face (F2F) and VVC modes during the same enrollment due to evolving COVID-19 policies were excluded from analysis (n = 3). Patients completed intake and exit evaluations which included questionnaires, a 6-min walk test (6MWT), a 30-s sit-to-stand (STS) test, and the Timed Up and Go (TUG) test. Intake and exit evaluations for both VVC and F2F patients were performed in-person whenever possible; during periods when in-person evaluations were not possible due to COVID-19, limited evaluations (medical history, STS test) were conducted using VVC and questionnaires were sent to patients by mail.25Holland A.E. Malaguti C. Hoffman M. et al.Home-based or remote exercise testing in chronic respiratory disease, during the COVID-19 pandemic and beyond: a rapid review.Chron Respir Dis. 2020; 171479973120952418Crossref Scopus (78) Google Scholar For this analysis, pulmonary diagnoses, demographics, smoking history, medications, spirometry, supplemental oxygen use, history of prior participation in PR (within 10 years), residential address, and adverse events (AEs) were extracted from the electronic medical records (EMRs). Analysis of clinical PR data was approved by the VA Boston Institutional Review Board (IRBNet No. 1578006) in 2019. Choice of delivery mode was based on shared decision-making between the patient and PR staff and prevailing infection control guidelines (see e-Appendix 1 for details). The PR program included a total of 16 to 18 sessions (two classes per week for 8 to 9 weeks), with exercise duration of 20 to 50 min per session. Education was delivered in real-time by PR, pharmacy, nutrition, and behavioral health staff. Conventional F2F PR was composed of supervised aerobic exercise training and strength training. Exercise prescriptions were targeted to achieve Borg dyspnea ratings ≤ 4 and heart rates between 60% and 80% of the maximum recorded on the 6MWT at the intake evaluation.3Spruit M.A. Singh S.J. Garvey C. et al.An official American Thoracic Society/European Respiratory Society statement: key concepts and advances in pulmonary rehabilitation.Am J Respir Crit Care Med. 2013; 188: e13-e64Crossref PubMed Scopus (2732) Google Scholar,26Garber C.E. Blissmer B. Deschenes M.R. et al.American College of Sports Medicine position stand. Quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults: guidance for prescribing exercise.Med Sci Sports Exerc. 2011; 43: 1334-1359Crossref PubMed Scopus (6767) Google Scholar The VVC-mediated, synchronous PR program mirrored the center-based program except that minimal equipment was used. Patients were provided with a tablet through the VA Digital Divide initiative and a pulse oximeter, as needed. Patients exercised in their homes in groups of ≤ 10 per class. PR staff connected to VVC in the PR gym via a large monitor and led activities comprised of circuits of aerobic exercises (marching in-place, squats, lunges) and strength training (soup cans, water bottles, resistance bands). Exercise prescriptions were created in the same manner as those for the F2F program except for those who did not perform a 6MWT at baseline. Progression was guided by Borg dyspnea ratings and the age-predicted maximum heart rate (220 − age).3Spruit M.A. Singh S.J. Garvey C. et al.An official American Thoracic Society/European Respiratory Society statement: key concepts and advances in pulmonary rehabilitation.Am J Respir Crit Care Med. 2013; 188: e13-e64Crossref PubMed Scopus (2732) Google Scholar,26Garber C.E. Blissmer B. Deschenes M.R. et al.American College of Sports Medicine position stand. Quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults: guidance for prescribing exercise.Med Sci Sports Exerc. 2011; 43: 1334-1359Crossref PubMed Scopus (6767) Google Scholar,27Centers for Disease Control and PreventionTarget heart rate and estimated maximum heart rate.https://www.cdc.gov/physicalactivity/basics/measuring/heartrate.htmDate accessed: February 15, 2024Google Scholar VVC patients also received a pedometer and were encouraged to walk daily. Since mid-February 2022, when both modalities have been available, the two programs have been integrated. VVC PR is held first; after cooldown, the VVC group is joined by the F2F group for a shared education session delivered in real-time. After education, the VVC group logs off and the F2F group begins warm-up and exercises. AEs, defined a priori as unexpected or worsening symptoms immediately before, during, or after class which required evaluation by medical staff, referral to urgent care/ED or dispatch of emergency medical services (for VVC patients), early termination of class, or request for additional monitoring, were captured by review of the EMR. All events were reviewed independently, in duplicate, by two pulmonologists (E. S. W. and M. L. M.) and were classified as respiratory, cardiac, musculoskeletal, or other types. Each AE was also adjudicated as PR-related or non-PR-related (eg, due to comorbidity or unrelated, intercurrent event/illness). Discordant adjudications were reviewed and discussed until agreement was achieved. The number of PR classes completed for each enrollment and the proportion of enrollments where ≥ 70% of classes were completed were recorded.28Lahham A. Holland A.E. The need for expanding pulmonary rehabilitation services.Life (Basel). 2021; 11PubMed Google Scholar All patients were asked to complete a feedback questionnaire at the exit evaluation. Both groups were asked (yes/no) if they were satisfied with the program and if they would recommend the program to others. The virtual group was asked additional questions related to connectivity, clarity, and subjective sense of safety with the virtual platform. Distance and drive time from the patient's residential address to the PR center were estimated using Google Maps' predictive travel time set to a standardized date and time (October 18, 2022, arrive by 9 am). If multiple routes were provided, the fastest route was selected. At the intake and exit evaluations, a 6MWT was conducted according to European Respiratory Society/American Thoracic Society29Holland A.E. Spruit M.A. Troosters T. et al.An official European Respiratory Society/American Thoracic Society technical standard: field walking tests in chronic respiratory disease.Eur Respir J. 2014; 44: 1428-1446Crossref PubMed Scopus (1625) Google Scholar guidelines, except a practice test was not performed. The STS test counts the number of times a patient can stand from the seated position without the use of their hands; higher numbers indicate greater lower body strength.30Jones C.J. Rikli R.E. Beam W.C. A 30-s chair-stand test as a measure of lower body strength in community-residing older adults.Res Q Exerc Sport. 1999; 70: 113-119Crossref PubMed Google Scholar,31Zanini A. Crisafulli E. D'Andria M. et al.Minimum clinically important difference in 30-s sit-to-stand test after pulmonary rehabilitation in subjects with COPD.Respir Care. 2019; 64: 1261-1269Crossref PubMed Scopus (43) Google Scholar The TUG test assessed the time (in seconds) for a patient to rise from the seated position, walk 10 ft, and return to the seated position; lower numbers indicate better functional mobility.32Podsiadlo D. Richardson S. The timed "Up 39: 142-148Crossref PubMed Google Scholar Dyspnea was self-reported using the modified Medical Research Council (mMRC) (range, 0-4) questionnaire, where higher numbers reflect greater dyspnea.33Bestall J.C. Paul E.A. Garrod R. Garnham R. Jones P.W. Wedzicha J.A. Usefulness of the Medical Research Council (MRC) dyspnoea scale as a measure of disability in patients with chronic obstructive pulmonary disease.Thorax. 1999; 54: 581-586Crossref PubMed Google Scholar If a patient enrolled in more than one course of PR, each enrollment was counted as a separate observation to properly account for time-at-risk for AEs, PR completion rates, and burden of travel (primary outcomes). For secondary outcomes (change in dyspnea and functional outcomes), data from the first enrollment only was used. Subgroup analyses examined change in functional outcomes in the subset who completed ≥ 70% of PR classes. For between-group comparisons and exploratory assessment of pre/post changes in functional outcomes, the χ2 or Fisher exact test (categorical) or unpaired t test or Wilcoxon rank sum (continuous) test was performed. Within-group changes in outcomes were assessed using paired t tests. Analyses were performed using R (version 4.2.1); a two-sided P value < .05 was considered significant. Geographic location represented by residential zip code was plotted using ArcGIS Pro (v3.1.0). Between July 30, 2020, and June 30, 2023, 174 referrals to the VA Boston PR program were received, of whom 120 observations (107 unique individuals) from patients enrolled in F2F (n = 52) or VVC (n = 68) PR and attended one or more exercise class were included in the analysis for primary outcomes (e-Fig 1). Thirteen (seven F2F and six VVC) individuals enrolled twice in PR during the observation period; the same modality was chosen for both enrollments. Seventeen (27.4%) of 62 unique VVC patients were provided a tablet and/or internet services through VA Digital Divide. Most patients (84%) had COPD as their primary or secondary diagnosis; among those without COPD, the most common diagnosis was interstitial lung disease (10%). The two groups were similar with respect to mean age, FEV1 and FVC % predicted, baseline dyspnea, and 6MWT distance (Table 1). The F2F PR group had more active tobacco users and higher average pack-years relative to the VVC group. A greater proportion of patients in F2F PR used supplemental oxygen (34.6% vs 8.8% in VVC, P = .001). At baseline, the F2F group achieved a higher average number of repetitions on the STS test and lower average time on the TUG test compared with the VVC group (Table 1).Table 1Baseline Characteristics of F2F and VVC Pulmonary Rehabilitation Patients (All Enrollments)CharacteristicF2F (n = 52)VVC (n = 68)P < .05Age, y72.8 ± 6.872.7 ± 7.3…Male sex50 (96.2)66 (97.1)…BMI, kg/m228.1 ± 6.929.4 ± 6.2…COPD diagnosis47 (90.4)54 (79.4)…GOLD spirometric grade (among those with COPD diagnosis and spirometry available; F2F: n = 46, VVC: n = 53)… I7 (15.2)13 (24.5) II20 (43.5)18 (34.0) III15 (32.6)14 (26.4) IV4 (8.7)8 (15.1)Smoking statusaDenotes P < .05 for significance testing between the F2F and VVC groups. Never0 (0)12 (17.6) Former42 (80.8)52 (76.5) Current10 (19.2)4 (5.9)Smoking history, pack-years48.5 (40.0-60.0)40.0 (18.0-60.0)aDenotes P < .05 for significance testing between the F2F and VVC groups.FEV1, L (F2F: n = 51, VVC: 64)1.72 ± 0.631.82 ± 0.81…FEV1 % predicted (F2F: n = 51, VVC: n = 66)59.4 ± 22.661.0 ± 26.3…FVC, L (F2F: n = 51, VVC: n = 64)3.19 ± 0.833.24 ± 0.87…FVC % predicted (F2F: n = 51, VVC: n = 66)82.9 ± 20.880.9 ± 19.5…Short-acting bronchodilator use47 (90.4)54 (79.4)…Long-acting beta-agonist use42 (80.8)51 (75.0)…Long-acting antimuscarinic use43 (82.7)48 (70.6)…Inhaled corticosteroid use35 (67.3)38 (55.9)…Home oxygen use18 (34.6)6 (8.8)aDenotes P < .05 for significance testing between the F2F and VVC groups.mMRC (F2F: n = 50, VVC: n = 53)1.92 ± 1.262.11 ± 1.03…6-min walk test distance, m (F2F: n = 52, VVC: n = 34)308 ± 102.9277.6 ± 103.6…30-s sit to stand, repetitions (F2F: n = 52, VVC: n = 65)10.0 ± 3.58.1 ± 4.2aDenotes P < .05 for significance testing between the F2F and VVC groups.Timed Up and Go, s (F2F: n = 52, VVC: n = 32)10.9 ± 314.0 ± 5.8aDenotes P < .05 for significance testing between the F2F and VVC groups.Previously attended pulmonary rehabilitation (within 10 y)19 (36.5)17 (25.0)…No. of classes competed12.4 ± 6.213.0 ± 6.1…Driving distance, miles10.3 (5.6-20.6)34.1 (16.6-45.1)aDenotes P < .05 for significance testing between the F2F and VVC groups.Driving time, min51.4 ± 31.986.0 ± 31.6aDenotes P < .05 for significance testing between the F2F and VVC groups.Values are as No. (%), mean ± SD, median (interquartile range), or as otherwise indicated. COPD diagnosis was considered present if listed as either the primary or secondary diagnosis for pulmonary rehabilitation. F2
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