Pulmonary rehabilitation within 3 months of hospital discharge was associated with a significant reduction in deaths at 1 year in a study involving 197,376 Medicare beneficiaries hospitalized for chronic obstructive pulmonary disease (COPD) exacerbations.
Peter Lindenauer, MD, of the University of Massachusetts Medical School in Springfield, and co-researchers reported that fewer than 2% of patients included in the study initiated pulmonary rehabilitation within 90 days of discharge, and these patients completed a median of nine sessions (interquartile range 4-14) within 3 months of leaving the hospital.
The death rate 1 year post-discharge among these patients was 7.3%, compared with 19.6% among patients who started pulmonary rehabilitation therapy after 90 days or did not participate in rehabilitation at all (absolute risk difference [ARD] -6.7%, 95% CI -7.9% to -5.6%; hazard ratio [HR] 0.63, 95% CI 0.57-0.69).
Participation in every three additional rehabilitation sessions within 3 months of hospital discharge was significantly associated with a lower risk of death (HR 0.91, 95% CI 0.85-0.98, P=0.01), the results showed.
The findings, published online in JAMA, support guidelines from the American Thoracic Society/European Respiratory Society and others recommending that patients begin pulmonary rehabilitation within 3 to 4 weeks of experiencing a COPD exacerbation.
But utilization of post-exacerbation rehabilitation remains rare, the researchers noted. “To put this into broader context, noninvasive ventilation and long-term oxygen therapy are the only treatments shown to improve survival for patients requiring hospitalization for COPD.”
The study findings “reinforce the importance of developing more effective strategies for increasing participation in rehabilitation,” the team wrote.
In an interview with MedPage Today, the co-author of an accompanying editorial, Carolyn Rochester, MD, of Yale University School of Medicine in New Haven, Connecticut, said the availability and utilization of pulmonary rehabilitation for patients with COPD varies across the country and across health systems, but remains low nationwide.
Analysis of Medicare beneficiaries data suggest that just 3-4% of patients with COPD receive pulmonary rehabilitation, she said. “The evidence for the efficacy of this therapy is now overwhelming — on par with and across more outcome areas than even bronchodilator use. It is also one of the most cost-effective COPD therapies.”
“In recent years it has also become clear that pulmonary rehabilitation benefits patients with other chronic lung disorders, including asthma and interstitial lung diseases,” she added. “This is really a very important therapy whose benefits are underrecognized.”
Rochester said lack of education and reimbursement, along with lack of access, are significant barriers to utilization of pulmonary rehabilitation in the COPD setting.
She noted that pulmonary specialists often receive little to no training in the therapy, which incorporates lung exercise training, patient education, and behavioral changes. There is also no system in place to reimburse healthcare providers for referring patients to receive it.
In the editorial, Rochester and her co-author, Anne E. Holland, PT, PhD, of Monash University in Melbourne, called for the Centers for Medicare & Medicaid Services and other insurance payers “to require referrals of suitable patients to pulmonary rehabilitation as part of national health care quality metrics,” as well as increased training for medical professionals.
For the study, Lindenauer and co-authors used Medicare data from patients hospitalized across the nation for COPD in 2014; patients were a mean age of 76.9, and 58.6% were women.
Just 2,721 (1.5%) patients initiated pulmonary rehabilitation within 90 days of hospital discharge, and 38,302 (19.4%) died within a year of discharge.
Initiation of pulmonary rehabilitation was significantly associated with lower death rates across start dates, ranging from 30 days or less (ARD -4.6%, 95% CI -5.9% to -3.2%; HR 0.74, 95% CI 0.67-0.82, P<0.001) to 61 to 90 days after hospital discharge (ARD -11.1%, 95% CI -13.2% to -8.4%; HR o.40, 95% CI 0.30-0.54, P<0.001).
In an exploratory analysis evaluating the number of sessions as a continuous factor after adjusting for confounders including age, comorbidities, prior home oxygen use, and frailty score, the suggested weekly dose of every three additional sessions in the first 90 days following hospital discharge was significantly associated with lower morality, the researchers reported.
They noted that prior studies have shown pulmonary rehabilitation to be especially efficacious in vulnerable subpopulations of patients with COPD, including women, racial and ethnic minorities, and those living in poverty.
Rochester said the findings should be considered a mandate for greater access and utilization of pulmonary rehabilitation in the treatment of patients with COPD: “It should drive healthcare systems to offer this, and patients to advocate more for it,” she said.
The research was funded by the National Heart, Lung, and Blood Institute (NHLBI).
Lindenauer reported no relevant disclosures; one co-author reported serving as a consultant for the Yale Center for Outcomes Research and Evaluation, under contract to CMS, and another co-author reported receiving a grant from the NHLBI.
Rochester reported serving as chair of the American Thoracic Society (ATS) Assembly on Pulmonary Rehabilitation from 2015-2017, serving as co-chair of the ATS/European Respiratory Society (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, participating in the development of the livebetter.org website to increase public awareness of pulmonary rehabilitation developed by the ATS and the Gawlicki Family Foundation; participating in clinical research in COPD funded by AstraZeneca; and previously serving on COPD-related scientific advisory boards for GlaxoSmithKline and Boehringer Ingelheim. Holland reported currently serving as an ATS board director and as chair of the Pulmonary Rehabilitation Assembly and that she was a co-author on the ATS/ERS Policy Statement on Pulmonary Rehabilitation and was senior author for the Australian and New Zealand Pulmonary Rehabilitation Guidelines.