Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School-Baystate, Springfield.
Department of Medicine, University of Massachusetts Medical School-Baystate, Springfield.
JAMA. 2020 May 12;323(18):1813-1823. doi: 10.1001/jama.2020.4437.
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.
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.
Initiation of pulmonary rehabilitation within 90 days of hospital discharge.
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.
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).
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.
荟萃分析表明，慢性阻塞性肺疾病（COPD）加重后开始肺康复与生存率提高相关，尽管研究的患者数量较少且异质性较高。目前的指南建议患者在出院后参加肺康复。
确定出院后 90 天内开始肺康复与 1 年生存率之间的关系。
设计、背景和患者：这是一项回顾性、起点队列研究，使用了美国 2014 年在 4446 家急性护理医院因 COPD 住院的医疗保险自付费患者的索赔数据。随访的最终日期为 2015 年 12 月 31 日。
出院后 90 天内开始肺康复。
主要结局是 1 年的全因死亡率。使用 Cox 回归模型，对出院后时间到死亡时间进行建模，调整了死亡率和不平衡的特征以及开始肺康复的倾向。额外的分析评估了肺康复时机与死亡率之间的关系以及完成的治疗次数与死亡率之间的关系。
在 197376 名患者（平均年龄 76.9 岁；115690[58.6%]名女性）中，2721 名（1.5%）在出院后 90 天内开始肺康复。共有 38302 名（19.4%）患者在出院后 1 年内死亡，其中 7.3%的患者在出院后 90 天内开始肺康复，19.6%的患者在出院后 90 天或根本没有开始肺康复。在 90 天内开始治疗与 1 年内死亡风险显著降低相关（绝对风险差异[ARD]，-6.7%[95%CI，-7.9%至-5.6%]；危险比[HR]，0.63[95%CI，0.57 至 0.69]；P < 0.001）。从 30 天或更短（ARD，-4.6%[95%CI，-5.9%至-3.2%]；HR，0.74[95%CI，0.67 至 0.82]；P < 0.001）到出院后 61 至 90 天（ARD，-11.1%[95%CI，-13.2%至-8.4%]；HR，0.40[95%CI，0.30 至 0.54]；P < 0.001）开始肺康复与死亡率显著降低相关。每增加 3 次治疗与死亡风险降低显著相关（HR，0.91[95%CI，0.85 至 0.98]；P = 0.01）。
在因 COPD 住院的医疗保险自付费患者中，出院后 3 个月内开始肺康复与 1 年死亡率显著降低相关。这些发现支持目前关于 COPD 患者住院后进行肺康复的指南建议，尽管存在潜在的残余混杂因素，仍需要进一步研究。
