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

Educational Objective
To learn the association between initiating pulmonary rehabilitation and the risk of subsequent mortality among patients recently discharged after hospitalization for COPD.
1 Credit CME
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.

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Article Information

Corresponding Author: Peter K. Lindenauer, MD, MSc, Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School—Baystate, 3601 Main St, Springfield, MA 01199 (peter.lindenauer@baystatehealth.org).

Accepted for Publication: March 16, 2020.

Author Contributions: Drs Lindenauer and Pekow had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Lindenauer, Stefan, Pekow, Mazor, Lagu, ZuWallack.

Acquisition, analysis, or interpretation of data: Lindenauer, Stefan, Pekow, Priya, Spitzer, Pack, Pinto-Plata, ZuWallack.

Drafting of the manuscript: Lindenauer, Pekow, Priya.

Critical revision of the manuscript for important intellectual content: Stefan, Pekow, Mazor, Priya, Spitzer, Lagu, Pack, Pinto-Plata, ZuWallack.

Statistical analysis: Pekow, Priya.

Obtained funding: Lindenauer.

Administrative, technical, or material support: Lindenauer, Spitzer, Lagu.

Supervision: Lindenauer, Pekow, Lagu, Pinto-Plata.

Conflict of Interest Disclosures: Dr Lagu reported serving as a consultant for the Yale Center for Outcomes Research and Evaluation, under contract to the Centers for Medicare & Medicaid Services. Dr Pack reported receiving a grant from the National Heart, Lung, and Blood Institute (K23HL135440-01A1). No other disclosures were reported.

Funding/Support: The research was supported by the National Heart, Lung, and Blood Institute of the National Institutes of Health under grants K24 HL132008-01 and 5R01HL133046-02.

Role of the Funder/Sponsor: The National Heart, Lung, and Blood Institute had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

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