Initiating pulmonary rehabilitation within 90 days of discharge may improve one-year survival in older patients with chronic obstructive pulmonary disease (COPD), a retrospective cohort study found.
Researchers used claims data from Medicare fee-for-service beneficiaries hospitalized for COPD in 2014 at 4,446 U.S. hospitals, with follow-up through Dec. 31, 2015. The primary outcome was all-cause mortality at one year. The researchers modeled time from discharge to death using Cox regression with time-varying exposure to pulmonary rehabilitation, adjusting for mortality and for unbalanced characteristics and propensity to initiate pulmonary rehabilitation. In additional analyses, they evaluated the associations between mortality and timing of pulmonary rehabilitation and number of sessions completed. Results were published by JAMA on May 12.
Of 197,376 patients (mean age, 76.9 years; 58.6% women), 2,721 (1.5%) initiated pulmonary rehabilitation within 90 days of discharge and completed a median of nine sessions (interquartile range, 4 to 14) during that time. Overall, 38,302 (19.4%) patients died within one year of discharge, including 198 (7.3%) patients who initiated pulmonary rehabilitation within 90 days and 38,104 (19.6%) patients who started after 90 days or not at all. Initiation within 90 days was associated with lower risk of death over one year (absolute risk difference, −6.7% [95% CI, −7.9% to −5.6%]; hazard ratio [HR], 0.63 [95% CI, 0.57 to 0.69]; P<0.001) compared to initiation after 90 days or none at all. Early pulmonary rehabilitation initiation was associated with lower mortality across start dates, ranging from 30 days or fewer (absolute risk difference, −4.6% [95% CI, −5.9% to −3.2%]; HR, 0.74 [95% CI, 0.67 to 0.82]; P<0.001) to 61 to 90 days after discharge (absolute risk difference, −11.1% [95% CI, −13.2% to −8.4%]; HR, 0.40 [95% CI, 0.30 to 0.54]; P<0.001). For 31 to 60 days, the absolute risk difference was −10.6% (95% CI, −12.4% to −8.4%), and the HR was 0.43 (95% CI, 0.34 to 0.54) (P<0.001). In the first 90 days, every three additional sessions (a suggested weekly dose) was associated with lower risk of death (HR, 0.91 [95% CI, 0.85 to 0.98]; P=0.01).
Among other limitations, treatment assignment was not random, and information about the individual components of pulmonary rehabilitation (e.g., education, exercise training, nutrition counseling, smoking cessation) were unavailable in the claims data, the study authors noted. “These findings support current guideline recommendations for pulmonary rehabilitation after hospitalization for COPD, although the potential for residual confounding exists and further research is needed,” they concluded.
Despite the benefits and recommendations for its use, pulmonary rehabilitation is underutilized for many reasons, including a dearth of referrals from health care professionals, an accompanying editorial noted. “In the US, there are no health care system-driven incentives for physicians to refer patients to pulmonary rehabilitation, no relevant required national care quality metrics, and financial reimbursement of clinicians does not depend on whether their patients undertake pulmonary rehabilitation,” the editorialists wrote.
The study findings should encourage health systems to increase funding for and use of pulmonary rehabilitation services, as well as encourage CMS and other payers to require referrals of suitable patients as part of national care quality metrics, they added. “It is time that one of the most effective treatments for patients with COPD and other chronic respiratory diseases be used routinely and proactively,” they wrote.