Pulmonary rehabilitation as a mechanism to reduce hospitalizations for acute exacerbations of chronic obstructive pulmonary disease: A systematic review and meta-analysis.

BACKGROUND: Acute exacerbations of COPD (AECOPD) have a significant impact on healthcare utilization, including physician visits and hospitalizations. Previous studies and reviews have shown that pulmonary rehabilitation 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 pulmonary rehabilitation on AECOPD, defined as unscheduled or emergency hospitalizations and emergency room (ER) visits. Cohort studies and randomised controlled trials (RCTs) reporting hospitalizations for AECOPD as an outcome were included. Meta-analyses compared hospitalization rates between eligible pulmonary rehabilitation recipients and non-recipients, before and after rehabilitation. RESULTS: 18 studies were included in the meta-analysis. Results from ten RCTs showed that the control groups had a higher overall rate of hospitalizations than the pulmonary rehabilitation groups (0.97 hospitalizations/patient-year, 95% Confidence Intervals (CIs) 0.67, 1.40; 0.62 hospitalizations/patient-year, 95% CI 0.33, 1.16 respectively). Five studies compared admission numbers in the 12 months before and after rehabilitation, finding a significantly higher admission rate before compared to after (1.24 hospitalizations/patient-year, 95% CIs 0.66, 2.34; 0.47 hospitalizations/patient-year, 95% CIs 0.28, 0.79 respectively). The pooled result of three cohort studies found the reference group had a lower admission rate compared to the pulmonary rehabilitation group (0.18 hospitalizations/patient-year, 95% CI 0.11, 0.32 for reference group versus 0.28 hospitalizations/patient-year, 95% CI 0.25, 0.32 for pulmonary rehabilitation). CONCLUSIONS: Although results from RCTs suggested that pulmonary rehabilitation 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 pulmonary rehabilitation programmes.