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

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

Peter K. Lindenauer, MD, MSc1,2,3Mihaela S. Stefan, MD, PhD1,2Penelope S. Pekow, PhD1,4; et alKathleen M. Mazor, EdD5Aruna Priya, MA, MSc1,4Kerry A. Spitzer, PhD, MPA1Tara C. Lagu, MD, MPH1,2Quinn R. Pack, MD, MSc1,2,6Victor M. Pinto-Plata, MD2,7Richard ZuWallack, MD8

Author Affiliations

JAMA. 2020;323(18):1813-1823. doi:10.1001/jama.2020.4437

 

 

Key Points

Question  Is initiation of pulmonary rehabilitation after hospitalization for chronic obstructive pulmonary disease (COPD) associated with better survival?

Findings  In this retrospective observational study that included 197 376 Medicare beneficiaries discharged after hospitalization for COPD, initiation of pulmonary rehabilitation within 3 months of discharge, compared with later or no initiation of pulmonary rehabilitation, was significantly associated with lower risk of mortality at 1 year (hazard ratio, 0.63).

Meaning  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.

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.

Editor’s Note: Pulmonary Rehabilitation has tended to publish results related to improved functional capacity, improved quality of life and reduced hospitalizations. This article points out a significant mortality benefit. All of these outcomes are extremely important and the mortality benefit is very important to the physician community.

The referral rate for PR continues to be around 10% of eligible patients, most of whom have severe or highly severe lung function. We need to examine ways to recruit patients at a stage of the disease where there is a greater rehab potential. We also need to encourage physicians to include simple spirometry as a part of the physical exam especially in older patients and patients who have a significant history of smoking.

Review of the article “Effect of Initiating Cardiac Rehabilitation After Myocardial Infarction on Subsequent Hospitalization in Older Adults”

by Mary Ann Compton

An article in The Journal of Cardiovascular and Pulmonary Rehabilitation caught my eye recently both because of the subject matter and because I recognized several of the investigators and their ties to UNC.  The lead investigator, Montika Bush, PhD, surveyed program directors in our state last year and will soon be submitting information from that survey for publication.

The article reviewed here is the “Effect of Initiating Cardiac Rehabilitation after Myocardial Infarction on Subsequent Hospitalization in Older Adults.”

As we all know, there is a gradual shift in our country from fee-for-service care towards value-based care.  If value-based care comes to fruition, providers and hospitals will be financially compensated for keeping patients well and out of the hospital. In addition, hospitals and providers would pay a penalty for exceeding “standard” costs to care for a patient.  We all know that Cardiac Rehabilitation helps to not only decrease mortality, but also helps to keep our patients well.  But knowing something is not always enough.  If scientific studies show that participation in Cardiac Rehab will improve the health of our patients while also saving the hospital money (i.e. keeping patients out of the hospital), then the value of Cardiac Rehab increases and the support we will get in our larger organizations should be immense.

This study looked back at 32,851 Medicare beneficiaries in 2008 and compared those patients who initiated CR within 60 days post-discharge with those patients who did not.  The study was limited to those patients age 65-88 years of age who were hospitalized with an AMI, had a revascularization, and had not previously experienced an MI.  It is one of the few studies to look at readmissions after cardiac rehabilitation in an older population.

While the article is dense with statistical analysis, the conclusions are fairly succinct.  The authors were primarily looking to see if there was a difference between the two groups (CR initiators vs CR noninitiators) in admission for AMI in the year following discharge.  There was not a substantial difference for AMI admission between the two groups, but there was a difference for all-cause hospital admissions.  The CR initiators had a lower risk of hospital admission for a major cardiac event (MACE) and for all-causes compared to the CR noninitiators.  Of note, the older beneficiaries (>75 years) had a greater reduction in all-cause hospitalization risk than MACE risk.

The authors made several references in the paper regarding the need for more information on the effects of cardiac rehab, or exercise therapy, on nonmortality outcomes.   This study noted, that “the risk of each study outcome for CR initiators with 1 to 2 medications at day 60 is similar to the risk of that same outcome in CR noninitiators with 3 to 4 medications at day 60” and that since older patients are not always able to tolerate medication therapy, the exercise therapy could be even more important.  This finding, if repeated in other studies, could greatly enhance the value of cardiac rehabilitation.

Similar to other studies, the mortality rate was lower for initiators than noninitiators, and the participation rate for cardiac rehab was 21%.  This low percentage of participation has got to improve, and should be a focus of our programs.  I suspect, also, it will be a focus as we learn from changes we have all had to implement in our programs due to the COVID pandemic.

Effect of Initiating Cardiac Rehabilitation After Myocardial Infarction on Subsequent Hospitalization in Older Adults

Bush, Montika; Kucharska-Newton, Anna; Simpson, Ross J. Jr; More

Bush, Montika; Kucharska-Newton, Anna; Simpson, Ross J. Jr; Fang, Gang; Stürmer, Til; Brookhart, M. Alan Less

Journal of Cardiopulmonary Rehabilitation and Prevention. 40(2):87-93, March 2020.

Legislative Updates: We need your help!

Cardiac and pulmonary rehab professionals – it is time to act!

In March, representatives from NCCRA joined AACVPR in their efforts in Washington, DC to gain support for the Sustaining Outpatient Services Act.  This Act has the potential to directly affect the ability of cardiopulmonary rehab departments from growing and in some cases, remaining open.

This bill will exempt certain hospital outpatient services from a drastic reimbursement reduction that are based solely on the location of the hospital outpatient service which is explained in depth in the Legislative Priority (https://www.aacvpr.org/Portals/0/DOTH/2020/Legislative%20Priority_AACVPR_2020_6-20.doc)

Now we need your help to get this included into legislation that will be considered by the legislation in July. 

Please support and assist in getting this legislation moved forward by taking part in the follow-up letter writing campaign. Template follow-up email letters requesting sponsorship (signature) of these bills will be posted on the DOTH advocacy web page. The virtual lobbying tool used this spring has been put on hold during this interim, so template letters and how to contact your US Congressional members are on the Advocacy web page and can also be found below.

How to find your U.S. House Representative: For the contact information of your House Representative, click here.

How to find your U.S. Senators: For the contact information of your two Senators, click here.

Letter to co-sponsor the Senate bill:

https://www.aacvpr.org/Portals/0/DOTH/2020/Introduction%20letter%20to%20co-sponsor%20Senate%20bill%20S.4151.docx

Letter to co-sponsor the House bill:

https://www.aacvpr.org/Portals/0/DOTH/2020/Introduction%20letter%20to%20co-sponsor%20US%20House%20bill%20HR4838.docx

The world of Cardiopulmonary Rehab in the days of COVID19

The NCCRA Board will be hosting a few online conversations that will allow our membership to hear about the current status of a few programs across the state and then engage in a round table discussion. We hope this will be helpful to our membership as they navigate this new landscape of the COVID19 pandemic.  The dates that are currently planned include:

Wed, May 27 at 1pm and Friday, May 29 at 2pm.

If you are interested in attending please rsvp to  info@nccraonline.org and let us know what date you are interested in participating in.

We look forward to a great discussion!

COVID19 resources

These are  great resources that can help support our programs and patients during this time:

http://www.aacvpr.org/covid19

https://www.henryford.com/services/cardiology/support/cardiac-rehab/home-based-cardiac-rehabilitation.

Cardiosmart videos https://www.cardiosmart.org/Videos

Heart failure:  https://www.cardiosmart.org/News-and-Events/2019/09/Learning-to-Live-With-Heart-Failure

https://www.cardiosmart.org/News-and-Events/2018/04/Managing-Heart-Failure

PAD https://www.cardiosmart.org/News-and-Events/2013/12/Video-Peripheral-Artery-Disease

LVAD

https://youtu.be/OQJfCUrvBBI

Coping with your emotions

Cardiac come back  https://shar.es/aHYdYw

Dealing you’re your emotions after a heart attack:  http://healthlibrary.vidanthealth.com/MultimediaRoom/AnimationsPlus/#vm_A_2314a147

Depression and CAD https://www.cardiosmart.org/News-and-Events/2013/12/Video-Depression-and-Heart-Disease

Cardiac curriculum

https://www.healtheuniversity.ca/EN/CardiacCollege/Pages/learn-online.aspx

Patient Education Resources

 

Send us others that you feel need to be added to this list!

 

NCCRA Board Updates

We hope you are all remaining healthy and well.  It seems that many programs are either closed or working at decreased capacity right now.  Since our state symposium was cancelled, we wanted to share the changes in our NCCRA Board as of today.  Usually when you agree to a position as a Regional Vice President our bylaws require you to serve in that capacity for three years.  During that time you host yearly fall meetings for your region. We are so very happy to announce Jeff Soukup will be taking on this roll for the coastal region!  Congratulations Jeff and welcome to our NCCRA Board.  Susanne Bice and Beth Ann Scott will remain as the Piedmont and Mountain Vice Presidents.

We also want to congratulate Kelly Forrest as she moves from the Coastal VP position into the Incoming President role, Jennifer Simmons is now in the role of President and Candace Langston is the Immediate Past President.

We look forward to a productive year for the NCCRA and we hope that our membership stays safe, healthy and well.

2020 NCCRA Symposium has been cancelled

In the wake of the COVID-19 outbreak, the UNC system has canceled all campus-based events including those at the Friday Center.  As a result, the NCCRA has to cancel our annual symposium, scheduled at that location for March 26th and 27thAlthough we are disappointed by this turn of events, the safety of our membership and the greater community obviously takes precedence.

As you know the work of the NCCRA and the benefits of membership extend beyond the symposium.  The organization supports its membership and the field of cardiopulmonary rehab through:

  • Support of the NCCRA website which provides information relevant to our membership and our field
  • Regular communication and support of our members through social media and email
  • Support of AACVPR Day on the Hill efforts and advocacy throughout the year
  • Regional meetings to provide membership education and networking opportunities
  • Promotion of cardiopulmonary rehabilitation services at all levels
  • Connectivity to AACVPR
  • Continuing education credits for the annual symposium as well as the regional meetings
  • Support of the NC speakers at the AACVPR national symposium

This work is made possible through the monies gained from membership fees and the annual symposium.  Despite the cancelation of the symposium, we ask that our membership consider allowing us to retain their membership dues and only requesting a refund for the symposium registration.  This would allow us to continue the work mentioned above and maintain the financial viability of our organization.  For those who typically pay for registration and membership at the symposium we hope you will consider proceeding with completing the membership process and just paying through the website or by mail.

Please direct correspondence about reimbursements to info@nccraonline.org.  If your organization/hospital was the one to pay for your symposium registration, please include information about the specific process at your facility when processing a refund.

We are already looking ahead to the 2021 Annual Symposium and hope that you will make plans to join us.  It is planned for March 4-5, 2021.

Take Action to support Cardiopulmonary Rehab

On March 2nd and 3rd Amy Birling and Stacey Greenway members of NCCRA will be attending the AACVPR Day on the Hill.  Don’t let their visits to all of our Congressman and Senators be the first time that these offices have heard about this issue.  Take Action Now!

Taken from AACVPR:

As AACVPR members prepare to take issues that are important to our profession to Congress in 2020, Pat Comoss provides a look back at how this organization began its presence in the political arena in Washington DC. It should be recognized that Pat, as AACVPR President, was instrumental in obtaining a federal grant for AACVPR to develop the first clinical practice guidelines for cardiac rehabilitation. AACVPR is grateful to Pat for her continued leadership in advocacy, over 14 years of DOTH, and for mentoring of so many of us today who strive to provide quality cardiac and pulmonary rehabilitation services.

Pat Comoss RN, BS, MAACVPR

Association – Government Collaboration: A 25 year AACVPR Legacy

Each year at this time, staff and volunteers at AACVPR begin planning for what has become a dynamic event affecting the future healthcare delivery and practice of cardiac and pulmonary rehabilitation (CR/PR). That event is the Association’s annual Day on the Hill (DOTH) in Washington DC.

The purpose of that advocacy visit to the nation’s capital is to inform and educate elected members of Congress about legislative and regulatory issues that impact rehab patients and CR/PR programs. And so it is in 2020 where the issue at hand is win support for U.S. House bill # 4838 – SOS (Sustaining Outpatient Services).

Approval of U.S. House bill # 4838, would enable rehab programs to expand or relocate offsite without suffering the currently imposed cut in Medicare reimbursement when such a move occurs away from hospital campus. Congressional support is essential to getting the bill passed this year. The proposed relief from the so-called “Section 603 rule” is the key to future growth of CR and PR rehab programs. But no movement on a bill happens unless/until our US Congressional members are made aware of the need for and importance of why they should vote in favor. Signatures of support only come when legislators understand what needs to be done and why. And that is our job – to explain the what and the why of the pending legislation, to advocate for change that benefits our patients and our CR/PR programs.

Such advocacy efforts through DOTH appear to be a recent development to some involved with AACVPR activities. But in fact, the seeds for such association – government education and collaboration efforts were planted 25 years ago. In 1995, the Agency for Health Care Policy and Research (AHCPR-now the Agency for Healthcare Research and Quality) published a landmark document in its growing collection of national healthcare guidelines – Clinical Practice Guideline #17, Cardiac Rehabilitation. That 200 page book was the product of 3 years of work done under a government contract awarded to AACVPR.

The work to collect, review, and synthesize available research on cardiac rehab involved several prestigious content experts in the field who were led by Nanette Wenger MD, Erika Froelicher RN, PhD, and L. Kent Smith MD, PhD. Support and guidance were offered by the Nationals Heart, Lung, and Blood Institute (NHLBI) throughout the project.

When completed, not only did the Guideline justify the use of cardiac rehabilitation as a standard component of contemporary cardiac care, it also established an enduring connection between professional interests and government activities. The collaboration of AACVPR, AHCPR and NHLBI produced advances and advantages that propelled the field forward. That connection, now deeply rooted as DOTH activities, remains an integral part of promoting and protecting cardiac and pulmonary rehab interests in the 21st century.

Now, in the current and often confusing political environment, each of us needs to be part of ongoing efforts to nurture our still young and evolving specialty. Involvement in advocacy efforts at the national (DOTH) level or locally via visits to your Congress member’s office makes a difference to your program and your practice. Collaborative efforts that began over 25 years ago continue to be essential to sustaining cardiac and pulmonary rehab for the next 25 years and beyond. Be part of that history starting in 2020!

https://www.aacvpr.org/Advocacy-Take-Action

 

 

Have you made your travel plans yet? The 41st Annual NCCRA symposium is 2 months away!

On March 26th and 27th the NCCRA is hosting the 41st annual symposium at the Friday Center in Chapel Hill. More details will be forthcoming as the brochure is completed and details are finalized.  We look forward to seeing everyone!

 

The Senate bill to support APPs supervising Cardiopulmonary Rehab has been introduced

We are excited to say that a companion bill to HB4838 has been introduced.  Please check back regarding the updates to the AACVPR Virtual Lobbying tool so you can take action with this important effort.

https://www.acc.org/latest-in-cardiology/articles/2019/11/12/16/22/bipartisan-legislation-expanding-access-to-cv-rehab-services-introduced-in-senate?utm_campaign=ncdrnews&utm_medium=email_newsletter&utm_source=ncdrnews&utm_content=20191218