Chest
Volume 150, Issue 4, October 2016, Pages 837-859
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Original Research: COPD
Pulmonary Rehabilitation as a Mechanism to Reduce Hospitalizations for Acute Exacerbations of COPD: A Systematic Review and Meta-Analysis

https://doi.org/10.1016/j.chest.2016.05.038Get rights and content

Background

Acute exacerbation of COPD (AECOPD) has a significant impact on health-care use, including physician visits and hospitalizations. Previous studies and reviews have shown that pulmonary rehabilitation (PR) has many benefits, but the effect on hospitalizations for AECOPD is inconclusive.

Methods

A literature search was carried out to find studies that might help determine, using a meta-analysis, the impact of PR on AECOPD, defined as unscheduled or emergency hospitalizations and ED visits. Cohort studies and randomized controlled trials (RCTs) reporting hospitalizations for AECOPD as an outcome were included. Meta-analyses compared hospitalization rates between eligible PR recipients and nonrecipients before and after rehabilitation.

Results

Eighteen studies were included in the meta-analysis. Results from 10 RCTs showed that the control groups had a higher overall rate of hospitalization than did the PR groups (control groups: 0.97 hospitalizations/patient-year; 95% CI, 0.67-1.40; PR groups: 0.62 hospitalizations/patient-year; 95% CI, 0.33-1.16). Five studies compared admission numbers in the 12 months before and after rehabilitation, finding a significantly higher admission rate before compared with after (before: 1.24 hospitalizations/patient-year; 95% CI, 0.66-2.34; after: 0.47 hospitalizations/patient-year; 95% CI, 0.28-0.79). The pooled result of three cohort studies found that the reference group had a lower admission rate compared with the PR group (0.18 hospitalizations/patient-year; 95% CI, 0.11-0.32 for reference group vs 0.28 hospitalizations/patient-year; 95% CI, 0.25-0.32 for the PR group).

Conclusions

Although results from RCTs suggested that PR reduces subsequent admissions, pooled results from the cohort studies did not, likely reflecting the heterogeneous nature of individuals included in observational research and the varying standard of PR programs.

Section snippets

Methods

We used methods as outlined in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement.12 A protocol was devised for the search strategy and is included in e-Appendix 1.

Results of the Searches

The searches yielded > 6,500 studies, and following screening of titles and abstracts, 181 full articles were reviewed. After the full review process, 21 studies were deemed eligible for inclusion. Of these, 18 reported outcomes that could be included in the meta-analysis, including 10 RCTs, three cohort studies, and five studies comparing admissions 1 year before and 1 year after PR (before/after studies). The three studies that were not included in the meta-analysis17, 18, 19 did not report

Discussion

The findings of these studies provide evidence that PR reduces hospitalizations for AECOPD in the short-term. Results from RCTs and cohort studies showed lower admission rates after rehabilitation compared with usual care. Additionally, studies that compared COPD hospital admission numbers before and after PR showed an overall reduction in admission rates. After a sensitivity analysis that included studies that looked at stable COPD, the same pattern was found.

Only one study did not favor PR

Conclusions

PR is an extremely valuable intervention for improving many aspects of the lives of patients with COPD. This review provides some evidence to suggest that providing rehabilitation is beneficial for reducing hospitalizations and therefore health-care consumption. Evidence has shown that hospital admissions after a course of PR are lower than before therapy. Also, when compared with usual care, admissions can be reduced with rehabilitation. However, pooled results from the cohort studies did not

Acknowledgments

Author contributions: M. A. S. and J. K. Q. conceived the study. E. M. and M. A. S. carried out searches, and articles were screened and reviewed by E. M., T. P., and M. A. S. R. N. performed the statistical analyses. E. M. and T. P. produced the first drafts, and all authors contributed to subsequent drafts. M. A. S. and J. K. Q. approved the final version.

Financial/nonfinancial disclosures: The authors have reported to CHEST the following: J. K. Q. reports grants from the Medical Research

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    FUNDING/SUPPORT: This study was funded by a research grant from the UK Chartered Society of Physiotherapy.

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