Health-Care Utilization and Economic Analysis
Regarding changes in health-care utilization resulting from pulmonary rehabilitation, the previous panel concluded that there was B level strength of evidence supporting the recommendation that "pulmonary rehabilitation has reduced the number of hospitalizations and the number of days of hospitalization for patients with chronic obstructive pulmonary disease (COPD)."
In the current review, some additional information is available about changes in health-care utilization after pulmonary rehabilitation. In one study, over 1 year of follow-up the number of patients admitted to the hospital was similar in both the pulmonary rehabilitation group and the control group (40 of 99 vs 41 of 101 patients); however, the number of days
spent in the hospital was significantly lower in the rehabilitation patients (10.4 vs 21.0 days, respectively). In a subsequent cost-utility economic analysis of the results in this pulmonary rehabilitation trial, the authors found that the cost per quality-adjusted life-years indicated that pulmonary rehabilitation was, in fact, cost-effective and would likely result in financial benefits to the health-care system (quality-adjusted life-year is a measure of effectiveness that is commonly used in cost-effectiveness analyses, reflecting survival adjusted for quality of life, or the value that individuals place on expected years of life). In another reported trial, results indicated a significant decrease in yearly hospitalizations and exacerbations >2 years after pulmonary rehabilitation.
A cost analysis that was associated with a randomized controlled trial (RCT) of a 2-month inpatient pulmonary rehabilitation program (followed by 4 months of outpatient supervision) produced statistically and clinically significant improvements in measures of health-related quality of life (HRQOL) and exercise capacity. Although the cost analysis in this study was driven largely by the inpatient phase of the program and, as such, is not applicable to the large majority of outpatients programs, the authors found cost-effectiveness ratios for the chronic respiratory disease questionnaire (CRDQ) component measures to range from $19,011 to $35,142 (in Canadian dollars) per unit difference. Even with the added costs associated with the inpatient program, these cost/benefit ratios are within a range that has been typically considered to represent reasonable cost-effectiveness for other widely advocated health-care programs.
In a small randomized trial of early pulmonary rehabilitation after hospitalization for acute exacerbation, the trial authors reported a significant reduction in emergency department visits and a trend toward reduced numbers of hospital admissions and days spent in the hospital over the 3 months after hospital discharge in the pulmonary rehabilitation group compared to the usual-care group. Also, in a multicenter randomized trial of a self-management program of patients with severe COPD, the authors reported a significant reduction in the numbers of hospital admissions and days spent in the hospital in the year following the intervention compared to the usual-care control group.
In a multicenter, observational evaluation of the effectiveness of pulmonary rehabilitation in centers throughout California, self-reported measures of health-care utilization were found to decrease substantially over 18 months of observation after the rehabilitation intervention. In the 3-month period prior to pulmonary rehabilitation, 522 patients reported 1,357 hospital days (2.4 per patient), 209 urgent care visits (0.4 per patient), 2,297 physician office visits (4.4 per patient), and 1,514 telephone calls to physicians (2.7 per patient). Over the 18 months after rehabilitation, the average per patient reported health-care utilization (in the past 3 months) was reduced approximately 60% for hospital days, 40% for urgent care visits, 25% for physician office visits, and 30% for telephone calls. It should be recognized that the results of an observational, noncontrolled study like this may be influenced by the selection of patients for pulmonary rehabilitation shortly after an exacerbation or episode of increased health-care utilization.