Pulmonary rehab after COPD hospitalization lowers mortality risk

Initiation of pulmonary rehabilitation within 90 days after hospitalization for COPD was associated with significantly lower mortality at 1 year, according to data published in JAMA.

In this retrospective cohort study, the researchers evaluated all fee-for-service Medicare beneficiaries older than 65 years who were hospitalized for COPD in 2014, with final follow-up at the end of 2015. Of the 197,376 patients from 4,446 hospitals included in the study, the mean age was 76.9 years and 58.6% were women.

Of those studied, 1.5% of patients initiated pulmonary rehabilitation within 90 days of hospital discharge. During 1 year, 19.4% of patients died, including 7.3% of those who initiated pulmonary rehabilitation within 90 days and 19.6% of patients who initiated pulmonary rehabilitation after 90 days or not at all.

When compared with patients who initiated pulmonary rehabilitation after 90 days or not at all, initiation of rehabilitation within 90 days was linked to a lower risk for death within 1 year of hospital discharge (HR = 0.63; 95% CI, 0.57-0.69).

Additionally, in an exploratory analysis evaluating mortality in the context of different start dates among patients who initiated pulmonary rehabilitation within 90 days, the researchers found that risk for death at 1 year was lower whether pulmonary rehabilitation was initiated within 30 days (HR = 0.74; 95% CI, 0.67-0.82), 31 to 60 days (HR = 0.43; 95% CI, 0.34-0.54) or 61 to 90 days after hospital discharge (HR = 0.4; 95% CI, 0.3-0.54), as compared with initiation after 90 days or no initiation.

Initiation of pulmonary rehabilitation within 90 days after hospitalization for COPD was associated with significantly lower mortality at 1 year.

In a second exploratory analysis that evaluated the number of pulmonary rehabilitation sessions as a continuous factor, every three additional sessions during the first 90 days were also associated with lower mortality after adjustment for age, comorbidity, prior home oxygen use and frailty (HR = 0.91; 95% CI, 0.85-0.98).

In looking at patients who initiated pulmonary rehabilitation within 90 days vs. after 90 days, the researchers found that those who initiated rehabilitation earlier were more likely to be younger (mean age, 74.5 vs. 77 year), men (47.6% vs. 41.3%) and white (92.6% vs. 85.1%) and likely lived closer to a pulmonary rehabilitation facility (mean distance, 5.8 vs. 9.8 miles). Patients who initiated pulmonary rehabilitation earlier also had less comorbidity and a lower risk for frailty and were less likely to have been admitted to the hospital during the prior year. However, they were also more likely to receive home oxygen before hospitalization, according to the data.

The researchers concluded that their findings support guidelines recommending pulmonary rehabilitation after COPD hospitalization, but they noted that further research is necessary to overcome some of the study’s inherent limitations.

In an accompanying editorial, Carolyn L. Rochester, MD, from the section of pulmonary, critical care and sleep medicine and the department of internal medicine at the Yale University School of Medicine and the VA Connecticut Healthcare System in New Haven, and Anne E. Holland, PT, PhD, from the department of allergy, immunology and respiratory medicine at Monash University, the department of physiotherapy at Alfred Health and the Institute for Breathing and Sleep in Melbourne, Australia, noted that the reasons for underutilization of pulmonary rehabilitation, including lack of referrals, lack of awareness of its benefits and lack of funds or resources for these programs, are well understood. Nevertheless, these findings lend support to other research demonstrating the advantages of pulmonary rehabilitation for patients with respiratory diseases.

“It is time that one of the most effective treatments for patients with COPD and other chronic respiratory diseases be used routinely and proactively. In addition to improving exercise tolerance and quality of life and reducing symptoms, disease exacerbations, hospitalizations and readmissions, participation in pulmonary rehabilitation after hospitalization for COPD exacerbation, as the article by Lindenauer et al in this issue of JAMA suggests, is associated with lower all-cause mortality. These findings should serve to encourage health care systems to increase funding for, and use of, pulmonary rehabilitation services for patients with COPD,” they wrote. – by Melissa Foster

Disclosures: This study was supported by the National Heart, Lung, and Blood Institute of the NIH. Lindenauer reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures. Rochester reports she has served as chair of the American Thoracic Society Assembly on Pulmonary Rehabilitation from 2015 to 2017, and co-chair of the ATS/European Respiratory Society Task Force on Policy in Pulmonary Rehabilitation; she has held other leadership positions in the ATS Pulmonary Rehabilitation Assembly; she currently serves on the Planning and Evaluation Committee of the ATS; she has participated in the development of the livebetter.org website to increase public awareness of pulmonary rehabilitation developed by the ATS and the Gawlicki Family Foundation; she has participated in clinical research on COPD funded by AstraZeneca; and she has served on COPD-related scientific advisory boards for GlaxoSmithKline Pharmaceuticals and Boehringer Ingelheim. Holland reports she currently serves as an ATS board director and chair of the Pulmonary Rehabilitation Assembly; she was a co-author on the ATS/ERS Policy Statement on pulmonary Rehabilitation; and she was a senior author for the Australian and New Zealand Pulmonary Rehabilitation Guidelines.