# Impact of a pulmonary rehabilitation maintenance program on long-term healthcare resource utilization and costs in COPD patients: ancillary analysis from a real-life post-rehabilitation cohort

Fares Gouzi, Thomas Espie, Steven Lopes, Hélène Forthin, Elise Galmes, Léo

Blervaque, Christian Préfaut, François Carbonnel

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## ► To cite this version:

Fares Gouzi, Thomas Espie, Steven Lopes, Hélène Forthin, Elise Galmes, et al.. Impact of a pulmonary rehabilitation maintenance program on long-term healthcare resource utilization and costs in COPD patients: ancillary analysis from a real-life post-rehabilitation cohort. Respiratory Medicine and Research, 2025, 89, pp.101243. 10.1016/j.resmer.2025.101243. hal-05414505

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# Impact of a pulmonary rehabilitation maintenance program on long-term healthcare resource utilization and costs in COPD patients: ancillary analysis from a real-life post-rehabilitation cohort

Fares Gouzi¹, Thomas Espie², Steven Lopes², Hélène Forthin³, Elise Galmes³, Léo Blervaque⁴, Christian Préfaut⁵, François Carbonnel⁶

¹ PhyMedExp INSERM-U1046 - CNRS - UMR 9214, CHRU Montpellier, Université de Montpellier, France; Occitan'Air Healthcare network, France. Electronic address: f-gouzi@chu-montpellier.fr.

² Faculty of Medicine of Montpellier-Nîmes, University of Montpellier, Montpellier, France.

³ Occitan'Air Healthcare network, France.

⁴ Clinical research Department, Centre Hospitalier Métropole Savoie, Chambéry, France.

⁵ Occitan'Air Healthcare network, France; Faculty of Medicine of Montpellier-Nîmes, University of Montpellier, Montpellier, France.

⁶ University of Montpellier, UMR UA11 INSERM - UM IDESP Institut Desbrest d'Épidémiologie et de Santé Publique Campus Santé, IURC, Montpellier, France.

**Keywords:**

Healthcare costs; Maintenance program; Rehabilitation.

**\*Corresponding author at:**

UMRCNRS9214
INSERM
U-1046
PHYMEDEXP,
Montpellier
University Hospital, University of Montpellier, F-34295 Montpellier, France.

E-mail address:

f-gouzi@chu-montpellier.fr

(F. Gouzi).
# Abstract

**Rational:**

Chronic Obstructive Pulmonary Disease (COPD) is a major cause of healthcare system use and related cost. While pulmonary rehabilitation (PR) is efficient, maintenance programs (PR-MA) can maintain the benefits over time. Yet, the long-term impact (>36 months) of PR-MA on healthcare resource and cost has never been assessed. Recently, a PR-MA program based on self-help associations has shown a clinical efficacy beyond 36 months, Thus, we aimed to assess the effect of this PR-MA program on long-term hospitalizations and costs versus usual care (PR-UC).

**Methods:**

We performed an ancillary analysis of the post-rehabilitation LTAir+R cohort study, which compared a PR-MA group (n=144) to a matched PR-UC group (n=137) of COPD patients. Data were collected in 82 PR-MA and 93 PR-UC patients, from the Montpellier University Hospital database and patient records over 60 months, including hospitalizations, consultations, emergency visits, and associated costs.

**Results:**

In PR-AM vs. PR-UC group, the hospitalization probability reduction almost reached significance (hazard ratio: 1.68; p=0.05). The costs of each hospitalization day (867±116 vs. 1213±138 euros/day; p<0.05), emergency visits (8±5 euros/year vs. 12±3 euros/year) and medical consultations (110±3 vs. 174±3 euros/year; p<0.01) were significantly lower in the PR-AM vs. PR-UC group. Last, PR-MA mitigated the increase in total hospitalizations (p<0.001) associated with the follow-up duration.

**Conclusion:**

In addition to its long-term clinical efficacy, this PR-MA program showed a positive impact on hospitalization and healthcare use costs. The effect on hospitalization number and costs could be larger in patients with the longest PR-MA adherence.
# Introduction

Chronic Obstructive Pulmonary Disease (COPD) ranks as the third leading cause of death globally, affecting over 390 million individuals in 2019 [1,2]). In France, >3.5 million people are impacted, with the disease accounting for over 100,000 hospitalizations annually [3]. Comobities and exacerbations constitute a major issue in COPD, as its leads to a significant pressure on health care systems, with a considerable burden on non health care expenditure, mostly due to patient's hospitalisations [4-7]. In a context of health care system crisis, COPD represents >5% of the total health care costs in France. Direct and indirect costs have been estimated to 4882 euros per patient and per year in France, with 54% related to hospitalisations [8].

Several strategies have been implemented to reduce this burden, including Pulmonary Rehabilitation (PR) [9,10]. Pulmonary Rehabilitation is defined as a "comprehensive intervention based on a thorough patient assessment followed by the patient tailored therapies that include, but are not limited to, exercise training, education, and behavior change, designed to improve the physical and psychological condition of people with chronic respiratory disease" [10]. There is strong evidence supporting the benefits of pulmonary rehabilitation for people with COPD [11,12], with effects on symptoms, exercise capacity and health-related quality of life [13,14]. In addition, PR has demonstrated beneficial effects on health care costs [15] and in the context of the French health care system in particular [16]. Yet, despite its recognized benefits, the effects of primary in patients PR often decline within 9 to 12 months post-intervention [17]. Thus, the maintenance in patients PR benefits after discharge constitutes a major issue in PR [18,19]. Maintenance programs (PR-MA are structured physical activity, and educational sessions that are efficient to maintain the PR benefits [20]. However, if one study showed a reduction of hospitalizations after a 6-months PA-MA program [21], there was a large heterogeneity among PR-MA programs and no data regarding health care costs. In addition, no study has ever assessed the impact of longer (>36month) PR-MA programs [20] on hospitalization and costs.

The Occitan'Air program, provides an original and feasible PR maintenance strategy based on supervised self-help associations. This model has shown short term [22] and long-term clinical benefits, with persistent effects beyond 36 months [23]. However, the implementation of this PR-MA in the French health care system requires to assess its long-term impact on hospitalization and costs. Because patients of this PR-MA showed an improved survival versus matched patients receiving usual care (PR-UC) after 60 months [23], we hypothesized that these PR-MA patients would have less health care system utilization (hospitalizations) and reduced costs during this long-term follow-up.

Thus, this study aimed to compare the health care system utilization (hospitalization, consultations, emergency admissions) and related costs between COPD patients included in a PR-MA program and COPD patients treated with usual care (PR-UC), after a short-term in patient PR program. In addition, we aimed to assess the potential determinants of hospitalizations and associated costs.
# Methods

## Study design

The study was a nonrandomized comparative, retrospective cohort study. The study was conducted as an ancillary investigation to the LT-Air+R project, a longitudinal evaluation of Occitan'Air PR-MA and PR-UC programs [23]. Ethical approval was granted by the CHU Montpellier Ethics Committee (2018_IRB-MTP_09-02). Informed consent was obtained from each patient, and study protocol was pre-published on Clinical trial : https://clinicaltrials.gov/ct2/show/NCT03704935.The data base was screened from January 2011 to December 2018 and data were extracted in December 2018.

## Participants

Inclusion criteria were the following: 1) a COPD diagnosis reported by a lung specialist and based on the association of compatible symptoms (dyspnea, chronic cough or sputum production) and/or a history of exposure to risk factors and a post-bronchodilator forced expiratory volume in 1s (FEV1)/forced vital capacity ratio<70%,2) completion of a short-term in patient PR program,3) completion of 1 to 5 years in the maintenance program,4) at least two 6 min walking distance (6MWD) values during their follow-up. Regarding this ancillary study, the presence of PMSI data from the Montpellier University hospital constituted an additional inclusion criterion. For the eligible COPD patients, the “zero-time” point (T0) was set at the end of the impatient PR program date. Two groups of COPD patients were included in the study: a group of patients who completed primary PR followed by 1 to 5 years of pulmonary rehabilitation maintenance program (PR-MA), and a group of patients who completed primary PR without subsequent maintenance follow-up (PR-UC).

## Pulmonary rehabilitation maintenance

Patients of the PR-MA group were included in the Occitan'Air health-care network in the context of 12 local self-help patient associations: (for further information please see https://www.occitanair.fr/). Occitan'Air health care network offers multidisciplinary PR maintenance programs comprising supervised and individualized exercise training session (~42sessions/year), health education classes (6hr/session; 2sessions/year) and psychological support (~2.5sessions/year), as previously described [24]. Session attendance was monitored yearly. Adherence (%) was calculated as: (sessions attendance/scheduled)\* 100. The adherence decline was calculated as the difference between adherence at 36 months after the1st year.

## Usual care

Patients included in the PR-UC group we screened from two main PR centres in the study region, both of which are recruitment sources for the Occitan'Air health care network. Inclusion criteria were similar as those of the PR-MA group except that these patients did not participate in a maintenance program after completion of the short-term PR program. After screening, a random subset of eligible patients was obtained. The absence of overlap between the PR-UC and PR-MA groups was verified, with patients present in both groups being excluded. Last, the comparability between groups was ensured using clinically relevant factors, i.e. age, gender, 6 MWD and FEV1 values.
## Data collection and study outcomes

Health care utilization data were collected retrospectively from June 2022 to April 2023. Patients were identified using first name, last name, and date of birth, and medical information verified by the investigator (FG) using the Montpellier university hospital software program DxCare® (MEDASYS, Le Plessis-Robinson, France), in which all patient files are digitized and recorded. Data were extracted by the Medical Information Department from the Montpellier University Hospital data base (Programme de médicalisation des systèmes d'information, PMSI). In addition, hospitalization data were completed by medical records obtained blindly from patient's general practitioners, by 2 investigators (TE and SL, medical doctors), using phone-calls, mail and e-mails, in order to include hospitalizations outside the Montpellier university hospital. Hospitalization was defined as an unplanned stay in a hospital or clinic occurring following an acute event leading to the need for care. Hospitalizations in medicine and surgery were included, as well as those in intensive care units. Planned hospitalizations in follow-up and rehabilitation were also collected. Each patient-stay was classified into a Groupe Homogène de Malade (GHM), which is similar to the diagnosis related group (DRG), according to the information documented by the physician. Variables included the number of hospitalizations, duration of hospital stays, consultations, emergency visits, and associated health care costs.

In addition, patient's vital status was extracted from the Institut national de la statistique et des études économiques (INSEE) database, as previously reported [23]. Briefly, deaths among patients were obtained using an automatic matching with the INSEE database based on date of birth and the first 10 digits of the social security number. To avoid misclassification, we performed two other matching methods, one with a combination of name and the first 10 numbers of the social security number and another with a combination of name and date of birth. The total number of deaths within each group was determined after rigorous comparison of these three datasets. To ensure completeness and accuracy, data from both the CHU database and external sources were cross-referenced.

Costs (in euros) were determined from the perspective of the French national health insurance data system and attributed from official French-national hospitalisation tariff in 2021. A national tariff was applied to each hospitalization based on GHM code attributed in the 2PMSI database in 2021. A GHM is coded according to the information documented by the physician and include main medical and related procedures, nursing care, treatments, drugs/devices used, food and accommodation, and investment costs for hospitalized patients. Additional costs per day of hospitalization in an intensive care unit were added to GHM tariffs, when appropriate. The main study outcome was the probability of hospitalization over the follow-up period (5years). Other outcomes were the following:-Mortality probability and 5 year-survival

PMSI database in 2021. A GHM is coded according to the information documented by the physician and include main medical and related procedures, nursing care, treatments, drugs/devices used, food and accommodation, and investment costs for hospitalized patients. Additional costs per day of hospitalization in an intensive care unit were added to GHM tariffs, when appropriate.
The main study outcome was the probability of hospitalization over the follow-up period (5years). Other outcomes were the following:

- Mortality probability and 5year-survival

- Admission rate was defined for each patient as the ratio between total admission reported during the follow-up and duration of the follow-up, all causes combined and by type (medicine and intensive care). This included both hospitalizations occurring within the hospital and those outside the hospital.

- Rate of hospitalization day (in days/year) was defined for each patient as the ratio between total hospitalization duration during the follow-up and duration of the follow-up.

- Rate of hospitalization costs (in euros/year) was defined for each patient as the ratio between total cost of hospitalization during the follow-up and duration of the follow-up.

- Rate of visits to the Montpellier University Hospital emergency room and associated costs

- Rate of non-urgent consultations in the Montpellier University Hospital and associated costs

## Statistical analysis

Values presented in the tables correspond to means±SD, if normally distributed and Median [IQR25-75] if not. Survival analysis from T0 was performed by producing Kaplan-Meier survival curves and COX uni-and multivariate regression analyses, fitted with the survival and survminer R packages [25] and allowing calculations of the adjusted hazard ratio (HR). Patients with a follow-up longer than 60 months or without events up to 31 December 2018 were right censored, because the event (death or hospitalization) did not occur during the study duration. Differences between groups were analysed using Student's't-tests for normally distributed data or Mann-Whitney U tests for non-parametric comparisons. Depending on the data distribution, Pearson or Spearman coefficients described the correlations. A Poisson regression was used to examine the association of follow-up duration and study group on total hospitalization, and a linear regression was used to examine these latter associations on hospitalization costs. Results are presented as standard estimates and (standard error). All analysis was performed using R3.5.0 software (www.r-project.org), and Graph Pad Prism version 5.05. Ap-value <0.05 was considered statistically significant.
# Results

## Population characteristics

Starting from the patients included in the LT-Air+R study (PR-MA group: n=144 and PR-UC group n=137), hospital data were obtained from the Montpellier University Hospital PMSI in 175 patients (PR-MA group : n=82 and PR-UC group: n=93). Among these patients, additional data from hospitalizations outside university hospital have been collected in 19 in the PR-MA group and 23 in the PR-UC group. The characteristics of the two groups of patients are presented in Table 1. No significant difference was observed regarding age (p=0.29), sex ratio (p=0.62), FEV1 (p=0.14) and 6MWD (p=0.65) between groups. Drop-out rate after 36 months was 13% in the PR-MA group.

<table><caption>**Table 1**
Baseline characteristics of study groups.</caption><thead><tr><th></th><th>PR-MA (n = 82)</th><th>PR-UC (n = 93)</th><th>p-value</th></tr></thead><tbody><tr><td>Age (year old)</td><td>66.1 ± 0.9</td><td>64.7 ± 1.0</td><td>0.29</td></tr><tr><td>Follow-up duration (days)</td><td>1910 ± 72</td><td>1487 ± 74</td><td>&lt;0.001</td></tr><tr><td>Gender (% male)</td><td>50.5 %</td><td>57.3 %</td><td>0.62</td></tr><tr><td>FEV<sub>1</sub> (% predicted)</td><td>67.8 ± 2.4</td><td>62.3 ± 3.0</td><td>0.14</td></tr><tr><td>6MWD (meters)</td><td>464 ± 15</td><td>454 ± 13</td><td>0.65</td></tr><tr><td>Patients with at least one hospitalization (n/ %)</td><td>28/40.8 %</td><td>38/34.1 %</td><td></td></tr><tr><td>Nb of hospitalization per patient with at least 1 hospitalization</td><td>2.0 [1.0–5.0]</td><td>2.0 [1.0–5.0]</td><td>0.87</td></tr><tr><td>Nb of hospitalization per patient</td><td>0.0 [0.0–2.0]</td><td>0.0 [0.0–2.0]</td><td>0.41</td></tr></tbody></table>

In these two groups, survival analysis showed a better 5-years survival rate in the PR-MA vs. PR-UC group (p=0.044). Over the follow-up period, the probability of death in the PR-UC group was significantly higher with a Hazard-Ratio (HR) of 8.02 (95%CI:1.02–63.30;p<0.05).

## Hospitalizations

Probability of hospitalizations over time in the two groups are depicted using Kaplan Meier analysis in Fig.1. There was a tendency of lower hospitalization probability in the PR-MA group vs ; PR-UC group (log-rank test: p=0.07). When adjusted on the 6MWD, HR for hospitalization was in the PR-MA group versus PR-UC group was 1.68 (95%CI 0.96–2.80) after 60 months of follow-up, which was close to reach statistical significance (p=0.05).
<figure><img src="image_3.png" /><figcaption>Fig. 1. Fiver-year hospitalization probability for the PR-MA and PR-UC groups. Curves: Kaplan-Meier analysis; pink line: PR-MA group; green line PR-UC group.</figcaption></figure>

<figure><img src="image_4.png" /><figcaption>Fig. 2. A/Daily hospitalization cost per COPD patient in Montpellier University hospital (in euro/patient/day). B/Rate of hospitalization cost per COPD patient in Montpellier University hospital (in euro/patient/year). PR-UC: Pulmonary Rehabilitation followed by usual care. PR-MA: Pulmonary Rehabilitation followed by maintenance program. \*: p < 0.05.</figcaption></figure>

During the patient's follow-up, theme an admission rate was not significantly lower in the PR-MA vs. PR-UC (0.00 [0.00-0.29] per year vs. 0.00 [0.00-0.39] per year, respectively; p=0.29). The hospitalization day rate was also not significantly lower in the PR-MA vs. PR-UC group (0.00 [0.00-0.88] per year vs. 0.00 [0.00-1.75] per year, respectively; p=0.48), regardless of the hospitalization type (intensive care unit: p=0.40 in rehabilitation units: p=0.24). When focusing on patients with at least one hospital admission during the follow-up, the duration of the hospital stay for each patient tended to be higher in the PR-MA vs. PR-UC group (12.1±2.2 vs. 21.2±4.7 days; p=0.06). However, the duration of the hospital stay for each admission was not different between PR-MA vs. PR(4.8±0.7 vs. 7.8±1.8; p=0.21). Nevertheless, in patients of the PR-MA group, the duration of the hospital stay was inversely correlated with the adherence decline during the first 36 months (r=-0.68; p<0.001).

## Emergency visits and medical consultations

Regarding visits at the emergency department, while there was no significant difference between groups for the rate of visits (0.04±0.01 vs. 0.09±0.02 per year, in the PR-MA and PR-MA vs. PR-UC groups).
UC groups, respectively; p=0.10). Also, there was less non-urgent medical consultation in the PR-MA group versus PR-UC group (1.03±0.26 versus 1.94±0.47 per year in the PR-MA versus PR-UC group, respectively; p<0.001). In the whole study population, hospitalizations were significantly correlated with emergency visits (r=0.35; p<0.0001) and medical consultations (r=0.54; p<0.001).

## Health care system costs

Costs were obtained in COPD with data from the Montpellier university hospital. The rate of hospitalization cost per year was not significantly reduced in PR-MA versus the PU-UC group (0.00[0.00–332] per year vs. 0.0[0.0–1015] per year; p=0.20, Fig.2.A/). Yet, in patients of the PR-MA group, total hospital cost was inversely correlated with the decline in PR-MA adherence during the first 36 months (r=-0.40; p<0.001). In addition, the average cost per hospital admission was lower in the PR-MA group, though not statistically significant (2548±1571 vs. 3241±2300 euros; p=0.18). Interestingly, the average cost for one day of hospitalization was lower in the PR-MA versus PR-UC group (867±116 euros/day vs. 1213±138 euros/day; p<0.05), meaning a difference of 346±194 euros/day saved for each patient's hospitalization (Fig.2.B/).

Regarding visits at the emergency department, there was a tendency for lower costs in the PR-UC group (8±5 euros/year versus 12±3 euros/year in the PR-MA versus PR-UC group, respectively; p=0.06). In addition, there were lower non-urgent medical consultation costs in the PR-MA versus PR-UC group (110±3 euros/year versus 174±3 euros/year, respectively; p<0.01).

<figure><img src="image_5.png" /><figcaption>Fig. 3. A/Poisson regression analysis showing the relation between follow-up duration and total hospitalisations in the PR-MA group (red line) and PR-UC group (green) at the Montpellier University hospital (Follow-up duration (days): 0.00071 (0.00002); *p* < 0.001 and Group: -0.59 (0.0029); *p* < 0.001). B/ Linear regression analysis showing the relation between follow-up duration and hospitalisation costs at the Montpellier University hospital, in the PR-MA group (red line) and PR-UC group (green). Follow-up duration (days): 2.16 (0.82); *p* < 0.001 and Group (-1861.2 (1173.1); *p* = 0.11).</figcaption></figure>

## Hospitalization and costs and follow-up duration

In patients undergoing usual care with pulmonary rehabilitation, cumulated hospitalization admissions (Spearmanr =0.41; p<0.001), and costs (Spearmanr =0.35; p<0.001) reported in the Montpellier University Hospital increased with the duration of the patient's follow-up in the PR-UC group. However, in PR-MA patients, cumulated hospitalization number (Spearmanp =0.17), and costs (Spearmanp =0.19) did not increase with the follow-up duration. Thus, using a Poisson regression analysis, we observed that total hospitalizations were significantly predicted by the follow-up duration (0.00063 (0.00009); p<0.001) and the group (-0.55 (0.14); p<0.001), as depicted in Fig.3A/. Also, hospitalization costs were
significantly predicted by the follow-up duration (0.2.16 (0.82); p<0.001) but not by the group
(-1861.2 (1173.1); p=0.11), as depicted in Fig.3B/.

Discussion

The Results of the present study showed that during the 5 years follow-up, COPD patient involved in a rehabilitation maintenance program showed a reduced probability of unplanned hospitalization versus matched patients benefiting from usual care. In addition, these PR-AM patients showed a reduction in cost related to each hospitalization day, consultations and emergency visits at a university hospital.

Pulmonary rehabilitation maintenance and hospitalizations

The reduction in hospitalization probability reported in our PR-MA group vs .PR-UC group
was in line with previous studies [18,21]. A meta-analysis has also suggested a reduction in
the hospitalization risk and duration with supervised maintenance exercise [26]. Noteworthy,
studies that did not report any benefit on hospitalizations did not show any significant clinical
benefit [27,28]. This contrasts with our LT Air + Air study, in which a long-term benefit has
been demonstrated [23], and in which a survival advantage for the PR-MA vs. PR-UC
subgroups occurred after 5 years. Last, the reduction in hospitalization probability in PR-MA
was associated with a reduction in medical consultations (p < 0.001).

Yet, there was a lack of significant reduction in hospitalization yearly rate in the maintenance
group. However, these rates may not be the most sensitive parameter to evaluate potential
differences in hospitalizations, because hospitalizations occurred in <40% of patients.
Conversely, in patients experiencing at least 1 hospitalization, there was a tendency for a
reduction in the hospital stay duration in the PR-MA vs. PR-UC group (p=0.06).

Last, the positive role of the maintenance program on hospitalizations is highlighted by the
significant correlation between the duration of the hospital stay and the program adherence
during the first 36 months (r=-0.68;p<0.001).

Pulmonary rehabilitation maintenance and costs

According to the best author's knowledge, the impact of a PR maintenance program on health care cost has been assessed previously in only one study, which showed a positive incremental QALY gain, meaning the intervention was dominant (less costly and more effective) versus usual care, in UK [29]. The impact of PR maintenance program on hospitalizations was prevented in the PR-MA group. Yet, during this long-term follow-up
(4.6±2.0 years), there was no decrease in hospitalization cost per year, as well as hospitalization cost per admission in the PR-MA versus PR-UC group. Nevertheless, when the hospital cost was assessed per hospitalization day, it was significantly lower in the PR-MA versus PR-UC group (867±116 euros/day vs. 1213±138 euros/day; p<0.05), meaning a difference of 346±194 euros/day saved for each hospitalization day. This difference could be explained by a lower “intensity” of the respiratory care provided in the PR-MA vs .PR-UC group. This could be explained by the positive impact of PR on comorbidities, on length and cost of hospitalizations during COPD exacerbation [30].

Because hospitalization events were not linked to their date, we could not assess the time
course of hospitalizations and associated costs. Nevertheless, in order to perform more
sensitive timed analysis, we performed regression analysis to test the relation between total
hospitalizations and hospitalizations costs with the duration of the follow-up and with the
study group. Follow-up duration and study group were significantly associated with
hospitalizations, meaning that being in the PR-MA group mitigated the increase in
hospitalizations and related costs during the time (Fig.3A/.) Even though PR-MA did not
significantly mitigate the increase in hospitalization-related costs (Group: p=0.11; Fig.3B/.),
these results suggests that the positive effect of the maintenance program could occur in
patients with the longest adherence.

From 2007 to 2012, the increase in COPD hospitalization in France has led to a 12.6% increase in hospitalization costs (from 602 to 678 million euros [7]). The mean cost per admission was 3667±1976 euros in 2012[7] which is consistent with the 3241±2300 euros per admission in our PR-UC patients included from 2011 to 2018. Thus, the economy of 346±194 euro/patient/year for each patient included in the Occitan' Air maintenance program represent 9% of the hospitalization cost reported in 2012 [7] and even 11% in our study. In addition, hospitalization cost savings could be larger considering the hospitalizations outside the Montpellier university hospital. Last, there was also savings related to hospital consultations (64±42 euros/year) and to emergency visits (4±5 euros/year). Altogether, if the cost assessment was limited to the costs recorded at the Montpellier University hospital, cost saving in the PR-MA (414±241 euros) group already balanced a large part of the Occitan' air's PR-MA cost, which was 901 euros/year/patient. These preliminary data suggest that the Occitan'Air maintenance program is cost-effective, which could eventually justify the reimbursement of this new PR modality by the social insurance. In line with experimentations of innovative and collaborative health care circuits that are currently tested in the frame of the 2018 Social Security Financing Act [31], the cost-effectiveness of such modality of rehabilitation maintenance program should be further tested in a large multicentric medico-economy study.

Limitations

This retrospective study has a non-randomized design. However, given the evidence provided
by meta-analysis [20,26], a randomized controlled trial would not be ethical. Nevertheless, to
limit potential confounding factor on hospitalization, we performed a strict matching of the
patients, based on main prognosis factors (age, gender, FEV1, 6MWD). Conversely, real-life
observational cohorts have shown their value to guide decisions regarding health care system
policy [32,33]. In addition, we have tried to limit as much as possible any potential selection
bias, by statistical adjustment of the hospitalization probability analysis on the patient's
exercise capacity (6MWD). Moreover, our data showed an internal consistency, with
significant and positive associations between hospitalization and adherence to the PR
maintenance program adherence. Thus, this study has the merit to provide deciders the most
valid evidence currently available. Another limit is the ancillary character of the LTAir+R
study, which could lead to a selection bias. However, table of characteristics did not reveal
any difference in the main prognosis parameters between groups. Altogether, it remains
nevertheless scientifically acceptable that in this sample of COPD patients benefiting from a
clinically efficient maintenance program, health care system use and costs were reduced
versus a matched sample of patients.

Conclusion

In this ancillary analysis, our rehabilitation maintenance program based on self-help association efficacy was associated with a reduction of the hospitalization probability, and in the cost of each hospitalization day. This effect was associated with the program adherence. This reduction of the daily hospital cost was associated with reductions in emergency visits and medical consultations costs reaching 414±241 euros/patient/year. While hospitalization number and cost rates per year did not differ between maintenance and usual care groups, regression analysis indicates that patients with the longest PR-MA adherence may have the largest reduction in hospitalizations. These results—that should be confirmed in a larger sample cost-effectiveness study—support the integration of maintenance programs into standard care in COPD patients. By reducing hospitalizations and associated costs, these programs can alleviate the economic burden on health care systems while improving patient outcomes.

Funding

This study received no specific grant from funding agencies. Ethics approval and consent
Ethical approval was obtained from the CHU Montpellier Ethics Committee (2018_IRB-
MTP_09-02). Informed consent was obtained from all participants.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Acknowledgments

The authors thank the Occitan'Air team and CHU Montpellier for their support. Pr. Nicolas Molinari is also acknowledged for its kind reviewing of the statistical analysis.
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