Patient participates in VA’s telepulmonology program, which helps deliver care to rural veterans with COPD. VA photo
SEATTLE — Chronic obstructive pulmonary disease, a group of progressive and complex conditions that affect the lungs, require a comprehensive treatment approach. A new VA study found, however, that the majority of patients hospitalized for COPD—particularly those in rural areas—did not receive the recommended care after discharge. The findings highlight the need for systemic interventions to ensure equitable care for all veterans, regardless of their place of residence.
The study, published in Annals of the American Thoracic Society, was designed to explore whether living in rural areas affected the likelihood of receiving recommended COPD care after hospital discharge. Researchers analyzed data from 67,649 veterans who were discharged from VA medical centers between 2010 and 2019. Of these, 10.8% resided in rural areas, and 3.0% lived in highly rural regions, as defined by the Rural Urban Commuting Area classification.
The primary outcome was the proportion of recommended care—including smoking cessation therapy, appropriate management of supplemental oxygen, appropriate prescription of inhaled therapy and pulmonary rehabilitation—received within 90 days of hospital discharge. The researchers conducted multivariable linear regression between rural residence and the proportion of recommended care received, adjusting for factors such as age, sex, race, ethnicity, comorbidities and primary-care facility type. They also tested multivariable linear probability models for each of the recommended therapies.1
The study revealed that overall adherence to recommended COPD treatments was low, with veterans receiving only about 15% of the recommended care on average. More concerning, those living in rural and highly rural areas received even less care than their urban counterparts.
Two crucial aspects of COPD management—inhaled therapy escalation and referral to pulmonary rehabilitation—were notably less accessible to rural veterans, the study found.
Proper adjustment of inhaled medications is critical for controlling COPD symptoms and preventing flare-ups, the authors explained. The study found that rural veterans were 4.0% less likely to receive appropriate inhaled therapy escalation compared to urban veterans. Those in highly rural areas experienced a 3.0% lower likelihood.
Pulmonary rehabilitation programs are proven to improve lung function and overall quality of life for COPD patients. Yet, rural veterans were 0.2% less likely to be referred to pulmonary rehabilitation, with those in highly rural areas facing a 2.1% lower likelihood.
Interestingly, the study found that rural veterans were more likely to receive smoking cessation therapy compared to their urban peers. Specifically, rural veterans had a 5.4% higher likelihood of receiving this treatment, while those in highly rural areas had a 7.2% higher likelihood. This suggests that targeted public health initiatives focused on smoking cessation may be offered more in rural settings.
Unlike other aspects of COPD care, the study found no significant differences between rural and urban veterans in the management of supplemental oxygen, indicating that certain healthcare services may be more evenly distributed across geographic locations.
The study’s findings highlight the urgent need for systemic interventions to bridge the gap in COPD care for rural veterans. The researchers recommended several strategies, including the following:
- Targeted Outreach Programs. While smoking cessation programs are more accessible in rural areas, similar efforts should be made for other aspects of COPD care.
- Telemedicine Expansion. Telehealth services can improve access to pulmonologists, respiratory therapists, and rehabilitation programs, particularly for veterans in remote areas. Virtual consultations and remote monitoring could help ensure timely adjustments to inhaled therapies and rehabilitation support.
- Policy Changes to Improve Rural Healthcare Infrastructure. Increasing resources at VA facilities in rural areas—such as respiratory specialists and rehabilitation services—could help reduce disparities in COPD care.
- Enhanced Training for Rural Providers. Equipping rural healthcare providers with specialized COPD management training can improve the quality of care for veterans with COPD. This training could include best practices for inhaled therapy escalation and pulmonary rehabilitation referrals.
“Patients across the rural-urban spectrum received few recommended post-discharge COPD treatments,” the authors concluded. “Health systems approaches are needed to address widespread underutilization of evidence-based COPD care.”
- Picazo F, Duan KI, Hee Wai T, Hayes S, et al. Rural Residence Associated with Receipt of Recommended Post-Discharge COPD Care among a Cohort of U.S. Veterans. Ann Am Thorac Soc. 2024 Nov 8. doi: 10.1513/AnnalsATS.202405-493OC. Epub ahead of print. PMID: 39513986.
