Association Between Initiation of Pulmonary Rehabilitation After Hospitalization for COPD and 1-Year Survival Among Medicare Beneficiaries
Authors: Peter K. Lindenauer, Mihaela S. Stefan, Penelope S. Pekow, Kathleen M. Mazor, Aruna Priya, Kerry A. Spitzer, Tara C. Lagu, Quinn R. Pack, Victor M. Pinto-Plata, Richard ZuWallack
Journal: JAMA (2020)

<h3>Importance</h3> 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. <h3>Objective</h3> To determine the association between the initiation of pulmonary rehabilitation within 90 days of hospital discharge and 1-year survival. <h3>Design, Setting, and Patients</h3> 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. <h3>Exposures</h3> Initiation of pulmonary rehabilitation within 90 days of hospital discharge. <h3>Main Outcomes and Measures</h3> 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. <h3>Results</h3> 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];<i>P</i> &lt; .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];<i>P</i> &lt; .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];<i>P</i> &lt; .001). Every 3 additional sessions was significantly associated with lower risk of death (HR, 0.91 [95% CI, 0.85 to 0.98];<i>P</i> = .01). <h3>Conclusions and Relevance</h3> 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.