Importance 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. Objective 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. Exposures Initiation of pulmonary rehabilitation within 90 days of hospital discharge. Main Outcomes and Measures 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. Results 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). Conclusions and Relevance 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.

中文翻译：

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慢性阻塞性肺病住院后开始肺康复与医疗保险受益人 1 年生存率之间的关联

重要性 荟萃分析表明，在慢性阻塞性肺病 (COPD) 恶化后开始肺康复与提高生存率相关，尽管研究的患者数量很少且异质性很高。目前的指南建议患者在出院后参加肺康复。目的 确定出院 90 天内开始肺康复与 1 年生存率之间的关联。设计、设置和患者 这项回顾性、初始队列研究使用了 2014 年在美国 4446 家急症护理医院因慢性阻塞性肺病住院的按服务收费的医疗保险受益人的索赔数据。最终随访日期为 2015 年 12 月 31 日。暴露 出院后 90 天内开始肺康复。主要结果和测量 主要结果是 1 年的全因死亡率。使用 Cox 回归对从出院到死亡的时间进行建模，并使用随时间变化的肺康复暴露，调整死亡率和不平衡的特征以及开始肺康复的倾向。其他分析评估了肺康复时间与死亡率之间以及完成的疗程数与死亡率之间的关系。结果 在 197 376 名患者（平均年龄 76.9 岁；115 690 名 [58.6%] 女性）中，2721 名（1.5%）患者在出院后 90 天内开始了肺康复治疗。共有 38 302 人（19.4%）在出院 1 年内死亡，其中 7.3% 的患者在 90 天内开始肺康复和 19 天。6% 的患者在 90 天后开始或根本不开始肺康复。90 天内开始用药与 1 年内较低的死亡风险显着相关（绝对风险差异 [ARD]，-6.7% [95% CI，-7.9% 至 -5.6%]；风险比 [HR]，0.63 [95% CI，0.57 至 0.69]；P < .001)。开始肺康复与在 30 天或更短的开始日期内降低死亡率显着相关（ARD，-4.6% [95% CI，-5.9% 至 -3.2%]；HR，0.74 [95% CI，0.67 至 0.82 ]；P < .001) 至出院后 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 < . 001)。每增加 3 个疗程与较低的死亡风险显着相关（HR，0.91 [95% CI，0.85 至 0.98]；P = .01）。结论和相关性 在因慢性阻塞性肺病住院的按服务付费医疗保险受益人中，出院后 3 个月内开始肺康复与 1 年死亡率风险降低显着相关。这些发现支持目前关于 COPD 住院后肺康复的指南建议，尽管存在残留混杂的可能性，需要进一步研究。