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, MSc1,2,3; Mihaela S. Stefan, MD, PhD1,2; Penelope S. Pekow, PhD1,4; et alKathleen M. Mazor, EdD5; Aruna Priya, MA, MSc1,4; Kerry A. Spitzer, PhD, MPA1; Tara C. Lagu, MD, MPH1,2; Quinn R. Pack, MD, MSc1,2,6; Victor M. Pinto-Plata, MD2,7; Richard 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.