Pulmonary rehabilitation in Switzerland

Pulmonary rehabilitation is a form of therapy for patients with chronic lung disease that is evidence based, which ameliorates performance and endurance of the patient and improves quality of life significantly. Pulmonary rehabilitation also diminishes the amount of hospitalisations and the duration of stay in hospitals. It can improve capacity of work and diminishes the absenteeism. Motivated patients who have stopped or intend to stop smoking are the best candidates for a pulmonary rehabilitation programme.


Chronic obstructive pulmonary disease
Chronic obstructive pulmonary disease (COPD) is a disease that is increasing world-wide.Hospital costs in Switzerland amount to 100 million SFr and consecutive costs are at least three times as much per year.As the Swiss Study on Air Pollution and Lung Diseases in Adults (SAPAL-DIA) showed, 3% of the adult population suffers from COPD [4,5].

What is pulmonary rehabilitation?
Pulmonary rehabilitation is a multidisciplinary programme with the following goals: -increasing patient's endurance and performance (evidence A) -increasing quality of life (evidence A) -increasing survival (evidence C) -decreasing the amount of hospitalisations and the duration of hospital stay (evidence B) -decreasing exacerbations (evidence B) [6][7][8][9] One of the goals of pulmonary rehabilitation is increasing the exercise tolerance and endurance capacity.In the United States 10% of the male population is suffering from COPD and half of these patients are limited in their daily activities [10].25% of these patients suffer from a decreased working capacity.
Pulmonary rehabilitation is a multidisciplinary programme, which engages a team of therapists that addresses the whole personality of the ill patient.The team consists of -medical doctors; -physiotherapists/ergo therapists; -dieticians; -social workers; -psychologists.
The programme includes medical training therapy (MTT), information on the disease and its prevention, information about behavioural changes in smoking habits and other risk factors, physiotherapy for respiration and relaxation, and information on how to cope with wellness [11].
There are 4 to 6 hours of daily activities in the inpatient programme.In the outpatient programmes 2 to 3 hours per day twice a week are usual.The patients are classified into different endurance-groups, in order to maximize individual performance.

When is a pulmonary rehabilitation indicated?
Pulmonary rehabilitation should be offered to all patients with COPD with an impairment of daily life or capacity of work.Pulmonary rehabilitation is the only therapy to break the vicious circle from dyspnoea to anxiety, inactivity, reconditioning to isolation.Most studies examined patients in a stable condition of lung function [reference?].Pulmonary rehabilitation in these circumstances can lift the patient from a low activity level to a higher activity level.There are almost no studies that have examined the early rehabilitation just after an exacerbation.Based on our experience we state that pulmonary rehabilitation under this condition is also very efficient.There is a multicentre study planned in Switzerland to learn more about this problem, which is very important because a lot of rehabilitation programmes get their patients from hospitals or pulmonologists soon after an exacerbation.
Motivation is a very important factor to achieve good results.A patient who is motivated to improve his/her quality of life is also a better candidate to give up smoking, which is the most com-mune cause of chronic bronchitis.A patient's motivation can be improved by information about his/her disease and its sequels as well as the prognosis and the possibilities of treatment.Communicating information to the patient by physicians, nurses and physiotherapists engaged in a pulmonary rehabilitation programme is essential.Motivation can also be improved by a written schedule of daily activities in the programme.It informs the patient on what to expect the next day or week, which enables him/her to cope better with the programme.The patient should also be able to discuss the programme with the different therapists to bring in his/her own wishes and capabilities.Group activities are important for the "group feeling", which itself stimulates the patient to bring the best performance.Positive feedbacks like diplomas for a completed rehabilitation programme may also reinforce the patient.We suggest that a low level activity like a "lung group" should follow a pulmonary rehabilitation programme."Lung groups" are patient organised and exist in different areas of the country.

How should pulmonary rehabilitation be performed?
Pulmonary rehabilitation is based on the ICF code of functioning, activity and participation [12].
Functioning requires an exact diagnosis and treatment of the disease.It includes psychological therapy to treat the patient in all his/her dimensions as well as to recognise the different sensitivities in regard to his/her culture, language and mobility.Language problems with foreign patients may be a handicap for successful rehabilitation.In addition, patients who are not sufficiently mobile cannot be treated in an outpatient programme and should therefore be addressed to an inpatient programme.
Activity involves activity of daily life and communication with the team as well as with other patients.The patients must be able to learn and have to be encouraged for their daily activities.The family and the social environment are partners in this regard.
Participation has to be promoted before the programme ends, in order to build up a social network and organise help at home.Communication with the family doctor is very important and the patient should preferably be addressed to a patient organised "lung group" to continue the programme on a patient organised basis.An economic participation for this follow-up programme is important.Social activities after the in-or outpatient rehabilitation programme should be paid by the patient, which can improve the patient's motivation to cope with the directions he learned during the rehabilitation programme.

Which pulmonary rehabilitation programme is appropriate?
In Switzerland there are 10 inpatient and 40 outpatient programmes accredited by the Swiss Respiratory Society and their commission for pulmonary rehabilitation and patient education.The accreditation guarantees quality.The quality criteria have been elaborated in a working group (Arbeitsgemeinschaft Leistungserbringer -Versicherer für wirtschaftliche und qualitätsgerechte Rehabilitation ALVR) together with the insurance companies [13][14][15].Based on various criteria a patient is assigned to an in-or an outpatient programme.Patients with severe co-morbidity, impaired mobility, or elderly patients who are not able to take part in an outpatient programme 2-3 times a week have to be addressed to inpatient programmes.Younger patients on the other hand who are mobile and go to work can be rehabilitated in an outpatient programme.
Out-patient programmes are directed by a respiratory physician.The rehabilitation consists of all the specialists mentioned before, who work together and are coordinated by the programme director.Often the programme is based on the local lungteam, which can offer the infrastructure for training and instruction.
The duration of the inpatient programme is

Costs
For inpatient programmes the costs are 8000 SFr.Outpatient programmes are 50% of this amount.In Switzerland, the costs of inpatient programmes are covered by the insurance companies and the state (50% each).As of 2005 outpatient programmes are only paid by insurance companies.Pulmonary rehabilitation was accepted as an efficient therapy by the Federal Office of Public Health and by the insurance companies.Cost effectiveness has been proved [19].Criteria for in-and outpatient pulmonary rehabilitation.

Expectations
In Switzerland only a very small percentage of pulmonary patients are addressed to a rehabilitation programme.We think that not more than 10% of the possible candidates get to a pulmonary rehabilitation programme.In order to diminish costs of hospitalisation and absenteeism the im-portance of rehabilitation programmes should be emphasized more.The pulmonary rehabilitation programmes are of good quality and evidence based.Almost all regions of Switzerland offer such a programme and quality control is guaranteed.usually 3 weeks, whereas the outpatient programme takes 3 to 6 months, with activities twice a week (table 2).Scientific data on the outcome of in-and outpatient programmes for pulmonary rehabilitation are not available.However for rheumatologic rehabilitation it has been shown that intensive inpatient programmes show a quicker success than outpatient programmes [16].

Unterägeri
In addition, other studies have shown that both forms of rehabilitation, the in-and the outpatient rehabilitation are successful [17,18].
Non-smoking is compulsory and essential for a successful rehabilitation.Stop smoking programmes should be integrated in every pulmonary rehabilitation programme despite its low degree of success.The medical doctor and the therapist have a lot of possibilities to help the willing patient to quit smoking by nicotine replacement medication, psychological help and medication [20,21].
The non-smoking policy is coordinated with other institutions that work for smoking prevention as well as with the anti-smoking campaign of the Swiss Federal Office of Public Health.

Non smoking
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The many reasons why you should choose SMW to publish your research Co-Morbidity (cardiovascular disease, diabetes) Unhealthy environment (working place, air pollution, passive smoking) Distance to next rehabilitation centre Additional therapy (Long time oxygen therapy, mechanical ventilation, transtracheal catheter) Table 2 Med Wochenschr (1871-2000) Swiss Med Wkly (continues Schweiz Med Wochenschr from 2001) Editores Medicorum Helveticorum