Abstract
PURPOSE: This study evaluated pulmonary rehabilitation as practiced in the general California medical community to determine its effectiveness in improving dyspnea and health-related quality of life and reducing the use of healthcare resources.
METHODS: For this study, 10 established pulmonary rehabilitation programs agreed to collect common clinical health outcome data on consecutive patients over 2 years. The following three self-administered questionnaires were obtained before and after rehabilitation, then at 3-, 6-, 12-, and 18-month follow-up assessments: Medical Outcomes Survey Short Form (SF-36), University of California, San Diego Shortness of Breath Questionnaire (SOBQ), and Health Care Utilization in the preceding 3 months. Information also was collected on patient demographics, diagnostic categories, use of supplemental oxygen, and available spirometry and 6-minute walk tests.
RESULTS: Nine centers enrolled 647 patients that met prespecified inclusion criteria. Of these, 521 completed the rehabilitation program and both the pre- and the postprogram assessment. At least two of the four follow-up assessments were completed by 415 patients in eight centers. The mean age of the patients was 68 years, and 42% were men. Overall, the forced expiratory volume in 1 second was 44% of the predicted value. There were few significant differences between the centers. The baseline outcome measures demonstrated marked symptoms, as evidenced by the mean SOBQ score (56.8) and the mean impaired quality of life results (SF-36 physical component score, 31.2; SF-36 mental component score, 47.5). These measures also showed high utilization of healthcare services over the preceding 3 months in terms of mean hospital stay (2.4 days), urgent care visits (0.4), physician visits (4.4), and telephone calls (2.7). After rehabilitation, there were significant improvements in symptoms and quality of life in all the centers, as evidence by mean changes of -6.8 for the SOBQ, 7.5 for the physical component score, and 3.9 for the mental component score). Over 18 months, benefits gradually declined, but levels remained above baseline values. There also were significant reductions in all measures of healthcare utilization.
CONCLUSIONS: Pulmonary rehabilitation was effective in improving symptoms and quality of life and reducing the utilization of healthcare resources over 18 months. The results were consistent across participating centers despite variations in practice settings, patient referral patterns, and program structure.
Pulmonary diseases have become increasingly important causes of morbidity and mortality in the modern world. They also are associated with large expenditures of healthcare resources in an aging population. 1,2
Pulmonary rehabilitation has been well established as a means of enhancing standard therapy to control and alleviate symptoms, optimize functional capacity, and reduce the medical and economic burdens of disabling lung disease. 3-10 A growing body of scientific evidence demonstrates important benefits including improved exercise tolerance, symptoms, and quality of life as well as a decrease in healthcare expenditures. 3,4,6,10,11 Most clinical trials establishing the efficacy of comprehensive pulmonary rehabilitation have been conducted in single, well-established centers under research conditions.
As the practice of pulmonary rehabilitation has grown in recent years, questions have arisen about the effectiveness of pulmonary rehabilitation as practiced in the general medical community. Also, despite the established benefits, there continue to be questions about the cost effectiveness of pulmonary rehabilitation. Much of the published data about reduction in the use of healthcare resources was collected before the dramatic changes in medical practice patterns in the United States during recent years involving more stringent criteria for hospital admission. There is thus a need for contemporary data about the effects of pulmonary rehabilitation on the use of healthcare resources.
To address these important questions, 10 pulmonary rehabilitation centers in California joined to collect clinical health outcome data about pulmonary rehabilitation using common evaluation methods.