Virtual Pulmonary Rehabilitation in COPD: Who Enrolls After Referral?

Although pulmonary rehabilitation can improve exercise capacity, symptoms, quality of life, and decrease acute care utilization in patients with chronic obstructive pulmonary disease (COPD), participation remains low. And while virtual pulmonary rehabilitation (VPR) may remove some practical barriers to traditional in-person programs, it’s still unclear whether it broadens access across geographic and social vulnerability.

To help address this knowledge gap, a recent retrospective study examined who enrolled in a commercial VPR program after referral, why some patients declined, and how clinical outcomes changed among those who completed the program.

Enrollment Remains a Key Hurdle

Investigators evaluated 278 patients referred to the Kivo Health VPR program between July 2023 and August 2025. The 8-week program included twice-weekly, 90-minute virtual sessions that combined individualized aerobic and resistance exercise, education, and real-time heart rate and oxygen saturation monitoring.

At the time of data collection, 50 patients had completed the program, 13 remained active, and 45 patients declined enrollment. The most common reported reason for declining was that the program was out of network.

It’s important to note that there were no statistically significant differences in demographic characteristics, including Social Vulnerability Index (SVI), between patients who were active in or had completed VPR and those who never enrolled. Participants who were active in or completed the VPR program were predominantly White, female, English-speaking, with an average age of 76.7 years.

Virtual Delivery Reached Patients Farther from In-Person Care

Geography was one area where VPR appeared to offer practical reach. Patients who participated in or completed VPR lived an average of 12.6 miles from the nearest in-person pulmonary rehabilitation center, with 22% living more than 20 miles away.

VPR participation also extended across levels of social vulnerability as the average SVI among active or completed participants was 0.53 and ranged from 0.36 to 0.97. Because race, primary language, and SVI didn’t differ significantly between participants and nonparticipants, the findings suggest that these measured characteristics weren’t major determinants of enrollment within this cohort.

Clinical Measures Improved After Program Completion

Among patients completing VPR, all measured clinical outcomes showed statistically significant pre- to post-program changes, including:

• Mean 1-minute sit-to-stand (1-MSTS) performance changed from 10.9 before the program to 16.5 afterward.
• Mean COPD Assessment Test (CAT) scores decreased from 21.4 to 15.6.
• Modified Medical Research Council Scale (mMRC) scores declined from 2.2 to 1.7.
• Patient Health Questionnaire-9 (PHQ-9) scores decreased from 6.6 to 4.0.

These improvements generally extended across SVI categories, although a post-hoc analysis found significantly worse CAT outcomes in the high-SVI group compared with the low-to-medium-SVI group (P=0.026).

In terms of safety, one adverse event was reported and required no additional workup or treatment.

What the Findings Can and Cannot Establish

These results support VPR as a feasible option for patients across geographic distances and levels of social vulnerability. However, the study cannot establish that virtual delivery itself caused the observed improvements or increased access because it involved referrals from a single academic institution and lacked a control group for pre- and post-program outcomes. It also could not compare VPR directly with the institution’s in-person program, as that center had closed.

Other key limitations were that distance was estimated using zip codes rather than individual addresses, and SVI reflects community-level rather than individual vulnerability. Physician discretion in referring patients may also have introduced selection bias, and the cohort’s limited diversity further constrains interpretation of any enrollment patterns.

Still, the findings identify an important distinction: VPR may reduce the burden of distance, but it doesn’t eliminate barriers to participation, such as lack of in-network insurance coverage.

Reference:
Schultz EA, Frank M, Eppler SL, et al. Who enrolls after referral to virtual pulmonary rehabilitation? A descriptive comparison. Chronic Obstr Pulm Dis. 2026; 13(4): 275-283.