Association Between Initiation of Pulmonary Rehabilitation After Hospitalization for COPD and 1-Year Survival Among Medicare Beneficiaries

Abstract

IMPORTANCE Meta-analyses have suggested that initiating pulmonary rehabilitation after an exacerbation of chronic obstructive pulmonary disease (COPD) was associated with improved survival, although the number of patients studied was small and heterogeneity was high. Current guidelines recommend that patients enroll in pulmonary rehabilitation after hospital discharge. OBJECTIVE To determine the association between the initiation of pulmonary rehabilitation within 90 days of hospital discharge and 1-year survival. DESIGN, SETTING, AND PATIENTS This retrospective, inception cohort study used claims data from fee-for-service Medicare beneficiaries hospitalized for COPD in 2014, at 4446 acute care hospitals in the US. The final date of follow-up was December 31, 2015. EXPOSURES Initiation of pulmonary rehabilitation within 90 days of hospital discharge. MAIN OUTCOMES AND MEASURES The primary outcome was all-cause mortality at 1 year. Time from discharge to death was modeled using Cox regression with time-varying exposure to pulmonary rehabilitation, adjusting for mortality and for unbalanced characteristics and propensity to initiate pulmonary rehabilitation. Additional analyses evaluated the association between timing of pulmonary rehabilitation and mortality and between number of sessions completed and mortality. RESULTS Of 197 376 patients (mean age, 76.9 years; 115 690 [58.6%] women), 2721 (1.5%) initiated pulmonary rehabilitation within 90 days of discharge. A total of 38 302 (19.4%) died within 1 year of discharge, including 7.3% of patients who initiated pulmonary rehabilitation within 90 days and 19.6% of patients who initiated pulmonary rehabilitation after 90 days or not at all. Initiation within 90 days was significantly associated with lower risk of death over 1 year (absolute risk difference [ARD],-6.7% [95% CI,-7.9% to-5.6%]; hazard ratio [HR], 0.63 [95% CI, 0.57 to 0.69]; P < .001). Initiation of pulmonary rehabilitation was significantly associated with lower mortality across start dates ranging from 30 days or less (ARD,-4.6% [95% CI,-5.9% to-3.2%]; HR, 0.74 [95% CI, 0.67 to 0.82]; P < .001) to 61 to 90 days after discharge (ARD,-11.1% [95% CI,-13.2% to-8.4%]; HR, 0.40 [95% CI, 0.30 to 0.54]; P < .001). Every 3 additional sessions was significantly associated with lower risk of death (HR, 0.91 [95% CI, 0.85 to 0.98]; P = .01). CONCLUSIONS AND RELEVANCE Among fee-for-service Medicare beneficiaries hospitalized for COPD, initiation of pulmonary rehabilitation within 3 months of discharge was significantly associated with lower risk of mortality at 1 year. 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.

COVID-19: interim guidance on rehabilitation in the hospital and post-hospital phase from a European Respiratory Society- and American Thoracic Society-coordinated international task force

“…Likely, a fraction of patients not mechanically ventilated (also including patients on high-flow oxygen therapy) will need to be added, as some of these still have significant functional consequences of the hospital admission (Belli et al Under review ERJ; Paneroni et al Under review ERJ) . We strongly encourage countries to take action to organise rehabilitation for this influx of patients, on top of the many patients with chronic respiratory disease who already qualify for pulmonary rehabilitation [ 60 ].…”

Updated guidance on the management of COVID-19: from an American Thoracic Society/European Respiratory Society coordinated International Task Force (29 July 2020)

“…Pulmonary rehabilitation provides exercise training and education to improve the physical and psychological condition of individuals with chronic respiratory diseases [66,67]. While the strongest data exist for patients with COPD [68], pulmonary rehabilitation is also beneficial in other chronic respiratory conditions [69], including survivors of critical illness due to viral pneumonias [70][71][72]. Early experience with pulmonary rehabilitation in COVID-19 survivors from China indicates that a 6-week pulmonary rehabilitation programme can improve pulmonary function, quality of life measures and anxiety [73], although additional research is needed [73][74][75][76].…”

<p>Optimizing Supportive Care in COVID-19 Patients: A Multidisciplinary Approach</p>

“…Though there is limited data on the effects of early rehabilitation in COVID-19, recent studies on patients admitted with chronic lung disease showed that early pulmonary rehabilitation improved one year mortality rates. 15 Strategy 7: Use an Evidence-Based Approach to Prescribing Therapeutic Modalities…”