Faster initiation tied to better survival after hospitalization

Starting pulmonary rehabilitation within 3 months of hospitalization discharge was linked with a lower risk of mortality at 1 year in Medicare patients with chronic obstructive pulmonary disorder (COPD), researchers reported.

In a retrospective, inception-cohort study, initiation of pulmonary rehab was significantly associated with lower mortality across start dates ranging from ≤30 days (absolute risk difference −4.6%, 95% CI −5.9% to −3.2%, hazard 0.74, 95% CI 0.67-0.82, P<0.001) to 61 to 90 days after discharge (ARD −11.1%, 95% CI −13.2% to −8.4%, HR 0.40, 95% CI 0.30-0.54, P<0.001), according to Peter K. Lindenauer, MD, MSc, of the University of Massachusetts Medical School-Baystate in Springfield, and co-authors.

Also, among nearly 200,000 patients, 19.4% died within 1 year of discharge, including 7.3% of patients who began pulmonary rehab within 90 days and 19.6% of patients who initiated pulmonary rehab after 90 days or not at all, they wrote in JAMA.

The authors also found that additional sessions of pulmonary rehab were significantly associated with lower risk of death, and they concluded that “These findings support current guideline recommendations for pulmonary rehabilitation after hospitalization for COPD.”

However, they also cautioned that “this study adjusted for numerous potential confounders… there is likely residual bias due to unmeasured confounding.”

Nonetheless, “Pulmonary rehabilitation is one of the most effective treatments for COPD and other chronic respiratory diseases” and is backed by international recommendations,” noted Carolyn L. Rochester, MD, of the Yale University School of Medicine in New Haven, Conn., and Anne E. Holland, PT, PhD, of Monash University in Melbourne, Australia, in an editorial accompanying the study.

Unfortunately, pulmonary rehab continues to be underused, they pointed out, and known reasons include failure to refer patients, poor understanding among patients on its benefits, and patient-related barriers such as comorbidities or transportation issues.

Also, the current healthcare system does not give clinicians incentive to refer patients to pulmonary rehab, as “financial reimbursement of clinicians does not depend on whether their patients undertake pulmonary rehabilitation,” nor does it properly support pulmonary rehab programs, Rochester and Holland explained.

Hopefully, the findings from Lindenauer’s group that highlight survival benefits of pulmonary rehab, but also call attention to health disparities in terms of access, will “encourage health care systems to increase funding for, and use of, pulmonary rehabilitation services for patients with COPD,” they wrote.

Pulmonary rehabilitation involves exercise training and self-management education to improve physical and psychological well-being,” the authors explained, noting that current guidelines from the American Thoracic Society/European Respiratory Society (ATS/ERS), and the American College of Chest Physicians, recommend that patients begin pulmonary rehab within 3 to 4 weeks of a COPD exacerbation.

Despite the guidelines, they found that out of 197,376 patients only 1.5% initiated pulmonary rehab within 90 days of discharge and 1.6% initiated within 91 and 365 days. Those who started within 90 days of discharge were:

  • Younger: mean 74.5 versus 77 years versus patients who never participated in pulmonary rehab or who started it after 90 days of discharge (ASD 0.36).
  • Men: 47.6% versus 41.3% (ASD 0.13).
  • Non-Hispanic white: 92.6% versus 85.1% (ASD 0.24).
  • Lived closer to a pulmonary rehab facility: mean 5.8 versus 9.8 miles (ASD 0.35).
  • Lower score on weighted Charlson Comorbidity Index: mean 3.5 versus 4.2 (ASD, 0.25).
  • Lower risk of frailty: mean 13% versus 20% (ASD 0.51).
  • No prior-year admissions: 61.9% versus 52.4% (ASD 0.24).
  • More likely to receive home oxygen before hospitalization: 39.4% versus 31.7% (ASD, 0.16).

In terms of the number of sessions completed, 98.8% of patients initiated pulmonary rehab within 90 days of the index hospitalization and completed a median of nine sessions during the 90-day period from their most recent COPD discharge, Lindenauer’s group reported. They found that every three additional sessions — “a suggested weekly dose” — in the first 90 days was significantly associated with lower mortality (HR 0.91, 95% CI 0.85-0.98, P=0.01).

Study limitations included the lack of randomization to treatment, the potential for “healthy user bias,” and a patient population that was ages ≥65 years, so the results may not apply to younger people. Also, “more patient-centered outcomes, such as exercise capacity or quality of life, were not available [and] receipt of physical therapy or cardiac rehabilitation as an alternative to pulmonary rehabilitation was not assessed,” the authors said.

Several studies in the U.S. and Europe are currently recruiting patients for studies on COPD and pulmonary rehab.

  1. Initiation of pulmonary rehabilitation within 3 months of discharge, compared with later or no initiation of pulmonary rehab, was significantly associated with lower risk of mortality at 1 year in hospitalized patients with chronic obstructive pulmonary disease (COPD).

  2. The results support current American and European guidelines for pulmonary rehab after hospitalization for COPD.

Shalmali Pal, Contributing Writer, BreakingMED™

The study was supported by the National Heart, Lung, and Blood Institute (NHLBI).

Lindenauer reported no relationships relevant to the contents of this paper to disclose. Co-authors reported relationships with the Yale Center for Outcomes Research and Evaluation/Centers for Medicare & Medicaid Services and support from NHLBI.

Rochester reported serving as chair of the ATS Assembly on Pulmonary Rehabilitation from 2015-2017, serving as co-chair of the ATS/ERS Task Force on Policy in Pulmonary Rehabilitation, holding other leadership positions in the ATS Pulmonary Rehabilitation Assembly, and currently serving on the Planning and Evaluation Committee of the ATS, as well as relationships with livebetter.org/American Thoracic Society/Gawlicki Family Foundation, AstraZeneca, GlaxoSmithKline, and Boehringer Ingelheim.

Holland reported serving as an ATS board director and as chair of the Pulmonary Rehabilitation Assembly, co-authoring the ATS/ERS Policy Statement on Pulmonary Rehabilitation, and serving as the senior author for the Australian and New Zealand Pulmonary Rehabilitation Guidelines.

Cat ID: 154

Topic ID: 89,154,730,143,192,154,195,925