美国圣弗朗西斯医院医疗中心Richard ZuWallack联合马萨诸塞大学医学院Peter K. Lindenauer课题组取得一项新突破。他们分析了慢性阻塞性肺病患者出院后肺功能康复与1年生存率的关系。该成果于2020年5月13日发表在《美国医学会杂志》上。

荟萃分析表明，慢性阻塞性肺疾病（COPD）恶化后开始进行肺康复与生存率提高有关，尽管该研究样本少且异质性高。当前指南建议患者出院后便进行肺康复。

为了探讨出院后90天内开始肺功能康复与1年生存率的关系。研究组进行了一项回顾性初始队列研究，使用2014年美国4446家急性护理医院中慢性阻塞性肺病住院的按服务收费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。

197376名患者的平均年龄为76.9岁，58.6%为女性，2721名（1.5%）出院后90天内开始进行肺部康复。出院后1年内死亡38302例（19.4%），其中90天内开始肺功能康复的死亡率为7.3%，90天后开始或根本不开始肺功能康复的死亡率为19.6%。90天内开始康复治疗显著降低了1年内的死亡风险，风险比为0.63。从出院后30天以内至出院后61-90天开始肺部康复，均可显著降低死亡率。每3次额外治疗与较低的死亡风险显著相关，风险比为0.91。

总之，COPD住院患者在出院后3个月内开始肺功能康复可显著降低1年死亡率，该发现支持对COPD患者出院后的肺功能康复进行指导性建议。

附：英文原文

Title: Association Between Initiation of Pulmonary Rehabilitation After Hospitalization for COPD and 1-Year Survival Among Medicare Beneficiaries

Author: 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

Issue&Volume: 2020/05/12

Abstract: 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 197376 patients (mean age, 76.9 years; 115690 [58.6%] women), 2721 (1.5%) initiated pulmonary rehabilitation within 90 days of discharge. A total of 38302 (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.

DOI: 10.1001/jama.2020.4437

Source: https://jamanetwork.com/journals/jama/article-abstract/2765730