Argument for Early Post-COPD Exacerbation PR: Lower 1-year Mortality
By Gerene Bauldoff, PhD, RN, MAACVPR
The impact of post-COPD exacerbation pulmonary rehabilitation (PR) has stimulated interest as the effectiveness of PR related to outcomes has moved to the forefront. In a recent article published in JAMA, Dr. Peter Lindenauer and colleagues report the findings of a retrospective cohort study using claims data from fee-for-service Medicare beneficiaries hospitalized in 2014. The data period was through December 31, 2015.
In this study, all-cause mortality at 1-year served as the primary outcome. A Cox regression was conducted evaluating time from discharge to death with the time to pulmonary rehabilitation and varying exposure to PR. This study used the Medicare outpatient and carrier files to identify PR recipients where the G0424 (COPD specific PR code), G0237, G0238 and G0239 non-specific PR codes) were used. The sample included 197,376 Medicare beneficiaries from 4,446 hospitals who were hospitalized with a COPD or acute respiratory failure diagnosis in 2014. Patients who had previous PR experience within the prior year were excluded to generate an inception cohort.
PR initiation within 90 days of discharge was seen in 2,721 (1.5% of the sample). Another 3,161 (1.6% of the sample) initiated PR more than 90 days after discharge. There were 191,494 who did not initiate PR. Propensity matching was conducted between the within 90-day PR vs > 90-day PR initiation to account for patient clusters within hospitals. Patients who were discharged from hospitals with no PR program were excluded. Dr. Lindenauer and colleagues also explored if timing of PR initiation moderated survival. They also explored the impact of the number of PR sessions completed on survival.
In the group who started PR within 90 days, they were noted to be younger (74.5 vs 77 years of age), men (47.6% vs. 41.3% women), non-Hispanic white (92.6% vs. 85.1%) and closer to a PR site (5.8 miles vs. 9.8 miles). Additionally this group has less co-morbidities, lower frailty risk and fewer prior year hospitalizations. However, they were more likely to have in-home oxygen pre-hospitalization (39.4% vs. 31.7%).
The primary outcome of this study, survival at one year, was found to be higher in the group who started PR within 90 days when compared to those who started PR after 90 days or never started a program (Hazard ratio 0.63). In other words, 7.3% of patients who started PR within 90 days died within 1-year vs. 19.6% of patients who started PR later or not at all. Lower mortality was also seen whether patients started PR within 30 days, 31-60 days or 61-90 days vs. later or not at all. Additionally, every 3 additional PR sessions were associated with a significantly lower risk of death (Hazard ratio 0.91).
The authors noted limitations including non-randomization to treatment assignment, use of proxies for disease severity (as PFT data was not available), limitations of claims data (lack of information regarding PR program components, patient-centered outcomes, and use of physical therapy or cardiac rehabilitation alternative use). The data used was for 70% of Medicare beneficiaries who are fee-for-service.
What does this mean for the PR Professional?
This paper is one of the most important PR papers published recently. While very dense, with use of sophisticated statistical procedures, Dr. Lindenauer and colleagues provide critically important evidence of the importance of PR on the actual survival of our patients. The difference in survival between those who start PR within 90 days vs. others is a major point in our armamentarium of arguments supporting PR. Additionally, this is one of the rare papers that uses such a large data set to describe PR utilization. While not a focus of this paper, the reality that barely 3% of patients who qualify for PR in this specific cohort actually initiated a program continues to be major roadblock to patients with lung disease participating in a program that can enhance their lives.
Lindenauer, PK, Stefan MS, Pekow PS, Mazor KM, Priya A, Spitzer KA, Lagu TC, Pack QR, Pinto-Plata-VM, ZuWallack R. (2020). Association between initiation of pulmonary rehabilitation after hospitalization for COPD and 1-year survival among Medicare beneficiaries. JAMA 323 (18): 1813-1823. doi: 10.1001/jama.2020.4437
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