Although pulmonary rehabilitation for chronic obstructive pulmonary disease (COPD) is linked to better survival, a large study of fee-for-service (FFS) Medicare patients show it is underused, with less than 2% of those studied taking part in a 3-month program.
Pulmonary rehabilitation significantly lowers the risk of death after hospitalization for chronic obstructive pulmonary disease (COPD), but it is rarely used, according to a large study and an accompanying editorial released Tuesday.
The retrospective study, published in JAMA, examined a large dataset of patients enrolled in fee-for-service Medicare in 4446 hospitals across the United States in 2014.1 Investigators looked at the association between the start of pulmonary rehabilitation within 90 days of hospital discharge and 1-year survival rates. They noted the severity of the problem: one study said that between 2008 and 2014, mortality for Medicare patients within 1 year of discharge for COPD was estimated at 26%.
In their study of 197,376 patients (mean age, 76.9 years; 115,690 [58.6%] women), just 2721 patients (1.5%) initiated pulmonary rehabilitation within 90 days of discharge. Patients completed a median of 9 sessions (interquartile range, 4-14) during the 90-day period.
Initiation of pulmonary rehabilitation within 90 days was associated with a lower risk of death over 1 year, with 198 deaths (7.3%) among patients who began pulmonary rehabilitation within 90 days. Patients who started rehabilitation after the 90 days or did not begin at all had higher mortality, with 38,104 deaths (19.6%).
Lower mortality was seen when pulmonary rehabilitation was initiated early, within 30 days of discharge (ARD, −4.6%; hazard ratio [HR], 0.74; 95% CI, 0.67-0.82) or 61 to 90 days after discharge (ARD, −11.1%; HR, 0.40; 95% CI, 0.30-0.54).
Participation in every 3 additional pulmonary rehabilitation sessions in the first 90 days after discharge was associated with a lower hazard ratio for death (HR, 0.91; 95% CI, 0.85 to 0.98; P = .01).
Noting the low rates of participation, the authors wrote that “the results of this study reinforce the importance of developing more effective strategies for increasing participation in rehabilitation.” Pulmonary rehabilitation is particularly important for women, those with lower socioeconomic status, and members of minority groups.
COPD is the fourth leading cause of death in the United States and is estimated to affect more than 16 million people. Current guidelines, such as the 2015 ATS/ERS joint policy statement, recommend pulmonary rehabilitation after acute COPD exacerbations.
In an accompanying editorial, the authors noted several reasons for the underuse of pulmonary rehabilitation.2 Health care providers often do not recommend the service due to a lack of incentives, such as financial reimbursement linked to patient outcomes, or national care quality metrics. In addition, pulmonary rehabilitation programs are “typically underfunded and underresourced” while the use of bronchodilators are endorsed, they wrote.
Even patients who are referred do not follow through on a program; this may be due to barriers to access such as transportation issues, geography, or comorbidities. Indeed, in this study, patients who attended rehabilitation were more likely to be younger, live close to a program, to be white men, and healthier.
The study had several limitations: there may have been residual bias due to confounders that could not be measured. And although the study included proxies for disease severity, such as the use of home oxygen, pulmonary function tests or other physiologic measures were not available. In addition, the claims data did not include other components of rehabilitation delivered during the sessons, such as patient and caregiver education, exercise training, or smoking cessation.
1. Lindenauer PK, Stefan MS, Pekow PS, et al. Association between initiation of pulmonary rehabilitation after hospitalization for COPD and 1-year survival among Medicare beneficiaries [published online May 12, 2020]. JAMA. doi:10.1001/jama.2020.4437
2. Rochester CL, Holland AE. Pulmonary rehabilitation and improved survival for patients with COPD [published online May 12, 2020]. JAMA. doi:10.1001/jama.2020.4436