Cost-effectiveness of Pulmonary Rehabilitation Among US Adults With Chronic Obstructive Pulmonary Disease | Chronic Obstructive Pulmonary Disease | JAMA Network Open | JAMA Network
[Skip to Navigation]
Sign In
Figure 1.  Schematic of Decision Model
Schematic of Decision Model

HR indicates hazard ratio; M, Markov model state.

Figure 2.  Cost of Single Pulmonary Rehabilitation (PR) Session vs Incremental Cost-effectiveness Ratio
Cost of Single Pulmonary Rehabilitation (PR) Session vs Incremental Cost-effectiveness Ratio

At a willingness to pay of $50 000 per quality-adjusted life-year, cost of the PR session was $884; at $100 000 per quality-adjusted life-year, cost of the PR session was $1597.

Table 1.  Probability and Utility Parameters
Probability and Utility Parameters
Table 2.  Costs for COPD PR and COPD-Related Hospital Readmission in 2020 US Dollars
Costs for COPD PR and COPD-Related Hospital Readmission in 2020 US Dollars
Table 3.  Estimated Cost and Outcome Intervals
Estimated Cost and Outcome Intervals
1.
Mannino  DM, Homa  DM, Akinbami  LJ, Ford  ES, Redd  SC.  Chronic obstructive pulmonary disease surveillance--United States, 1971-2000.   MMWR Surveill Summ. 2002;51(6):1-16.PubMedGoogle Scholar
2.
National Center for Health Statistics.  Health, United States, 2015: With Special Feature on Racial and Ethnic Health Disparities. National Center for Health Statistics; 2016.
3.
Lozano  R, Naghavi  M, Foreman  K,  et al.  Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010.   Lancet. 2012;380(9859):2095-2128. Published correction in Lancet. 2013;381(9867):628. doi:10.1016/S0140-6736(12)61728-0 PubMedGoogle ScholarCrossref
4.
Zafari  Z, Li  S, Eakin  MN, Bellanger  M, Reed  RM.  Projecting long-term health and economic burden of COPD in the United States.   Chest. 2021;159(4):1400-1410. doi:10.1016/j.chest.2020.09.255 PubMedGoogle ScholarCrossref
5.
Shah  T, Press  VG, Huisingh-Scheetz  M, White  SR.  COPD readmissions: addressing COPD in the era of value-based health care.   Chest. 2016;150(4):916-926. doi:10.1016/j.chest.2016.05.002 PubMedGoogle ScholarCrossref
6.
Sullivan  J, Pravosud  V, Mannino  DM, Siegel  K, Choate  R, Sullivan  T.  National and state estimates of COPD morbidity and mortality—United States, 2014-2015.   Chronic Obstr Pulm Dis. 2018;5(4):324-333. doi:10.15326/jcopdf.5.4.2018.0157 PubMedGoogle ScholarCrossref
7.
Spruit  MA, Singh  SJ, Garvey  C,  et al; ATS/ERS Task Force on Pulmonary Rehabilitation.  An official American Thoracic Society/European Respiratory Society statement: key concepts and advances in pulmonary rehabilitation.   Am J Respir Crit Care Med. 2013;188(8):e13-e64. doi:10.1164/rccm.201309-1634ST PubMedGoogle ScholarCrossref
8.
Puhan  MA, Gimeno-Santos  E, Cates  CJ, Troosters  T.  Pulmonary rehabilitation following exacerbations of chronic obstructive pulmonary disease.   Cochrane Database Syst Rev. 2016;12:CD005305. doi:10.1002/14651858.CD005305.pub4 PubMedGoogle ScholarCrossref
9.
McCarthy  B, Casey  D, Devane  D, Murphy  K, Murphy  E, Lacasse  Y.  Pulmonary rehabilitation for chronic obstructive pulmonary disease.   Cochrane Database Syst Rev. 2015;(2):CD003793. doi:10.1002/14651858.CD003793.pub3 PubMedGoogle ScholarCrossref
10.
Lindenauer  PK, Stefan  MS, Pekow  PS,  et al.  Association between initiation of pulmonary rehabilitation after hospitalization for COPD and 1-year survival among Medicare beneficiaries.   JAMA. 2020;323(18):1813-1823. doi:10.1001/jama.2020.4437 PubMedGoogle ScholarCrossref
11.
Stefan  MS, Pekow  PS, Priya  A,  et al.  Association between initiation of pulmonary rehabilitation and rehospitalizations in patients hospitalized with chronic obstructive pulmonary disease.   Am J Respir Crit Care Med. 2021;204(9):1015-1023. doi:10.1164/rccm.202012-4389OC PubMedGoogle ScholarCrossref
12.
Nishi  SP, Zhang  W, Kuo  YF, Sharma  G.  Pulmonary rehabilitation utilization in older adults with chronic obstructive pulmonary disease, 2003 to 2012.   J Cardiopulm Rehabil Prev. 2016;36(5):375-382. doi:10.1097/HCR.0000000000000194 PubMedGoogle ScholarCrossref
13.
Keating  A, Lee  A, Holland  AE.  What prevents people with chronic obstructive pulmonary disease from attending pulmonary rehabilitation? a systematic review.   Chron Respir Dis. 2011;8(2):89-99. doi:10.1177/1479972310393756 PubMedGoogle ScholarCrossref
14.
Oates  GR, Niranjan  SJ, Ott  C,  et al.  Adherence to pulmonary rehabilitation in COPD: a qualitative exploration of patient perspectives on barriers and facilitators.   J Cardiopulm Rehabil Prev. 2019;39(5):344-349. doi:10.1097/HCR.0000000000000436 PubMedGoogle ScholarCrossref
15.
Garvey  C, Novitch  RS, Porte  P, Casaburi  R.  Healing pulmonary rehabilitation in the United States: a call to action for ATS members.   Am J Respir Crit Care Med. 2019;199(8):944-946. doi:10.1164/rccm.201809-1711ED PubMedGoogle ScholarCrossref
16.
Griffiths  TL, Phillips  CJ, Davies  S, Burr  ML, Campbell  IA.  Cost effectiveness of an outpatient multidisciplinary pulmonary rehabilitation programme.   Thorax. 2001;56(10):779-784. doi:10.1136/thorax.56.10.779 PubMedGoogle ScholarCrossref
17.
Hoogendoorn  M, van Wetering  CR, Schols  AM, Rutten-van Mölken  MP.  Is Interdisciplinary Community-Based COPD Management (INTERCOM) cost-effective?   Eur Respir J. 2010;35(1):79-87. doi:10.1183/09031936.00043309 PubMedGoogle ScholarCrossref
18.
Gillespie  P, O’Shea  E, Casey  D,  et al; PRINCE Study Team.  The cost-effectiveness of a structured education pulmonary rehabilitation programme for chronic obstructive pulmonary disease in primary care: the PRINCE cluster randomised trial.   BMJ Open. 2013;3(11):e003479. doi:10.1136/bmjopen-2013-003479 PubMedGoogle ScholarCrossref
19.
Golmohammadi  K, Jacobs  P, Sin  DD.  Economic evaluation of a community-based pulmonary rehabilitation program for chronic obstructive pulmonary disease.   Lung. 2004;182(3):187-196. doi:10.1007/s00408-004-3110-2 PubMedGoogle ScholarCrossref
20.
Shavelle  RM, Paculdo  DR, Kush  SJ, Mannino  DM, Strauss  DJ.  Life expectancy and years of life lost in chronic obstructive pulmonary disease: findings from the NHANES III follow-up study.   Int J Chron Obstruct Pulmon Dis. 2009;4:137-148. doi:10.2147/COPD.S5237 PubMedGoogle ScholarCrossref
21.
Fleurence  RL, Hollenbeak  CS.  Rates and probabilities in economic modelling: transformation, translation and appropriate application.   Pharmacoeconomics. 2007;25(1):3-6. doi:10.2165/00019053-200725010-00002 PubMedGoogle ScholarCrossref
22.
Rutten-van Mölken  MP, Oostenbrink  JB, Tashkin  DP, Burkhart  D, Monz  BU.  Does quality of life of COPD patients as measured by the generic EuroQol five-dimension questionnaire differentiate between COPD severity stages?   Chest. 2006;130(4):1117-1128. doi:10.1378/chest.130.4.1117 PubMedGoogle ScholarCrossref
23.
Huijsmans  RJ, de Haan  A, ten Hacken  NN, Straver  RV, van’t Hul  AJ.  The clinical utility of the GOLD classification of COPD disease severity in pulmonary rehabilitation.   Respir Med. 2008;102(1):162-171. doi:10.1016/j.rmed.2007.07.008 PubMedGoogle ScholarCrossref
24.
Nolan  CM, Longworth  L, Lord  J,  et al.  The EQ-5D-5L health status questionnaire in COPD: validity, responsiveness and minimum important difference.   Thorax. 2016;71(6):493-500. doi:10.1136/thoraxjnl-2015-207782 PubMedGoogle ScholarCrossref
25.
Esquinas  C, Ramon  MA, Nuñez  A,  et al.  Correlation between disease severity factors and EQ-5D utilities in chronic obstructive pulmonary disease.   Qual Life Res. 2020;29(3):607-617. doi:10.1007/s11136-019-02340-4 PubMedGoogle ScholarCrossref
26.
US Bureau of Labor Statistics. Databases, tables, & calculators by subject. Accessed August 10, 2021. https://data.bls.gov/timeseries/CUUR0000SAM?output_view=data
27.
American Association of Cardiovascular and Pulmonary Rehabilitation. Hospital Policy & Reimbursement Update. January 6, 2021. Accessed August 24, 2021. https://www.aacvpr.org/Portals/0/Docs/Advocacy/Reimbursement%20Updates/2021/1.06.21%20AACVPR%20Reimbursement%20Update.pdf?ver=2021-01-19-101211-627
28.
Agency for Healthcare Research and Quality. HCUPnet Healthcare Cost and Utilization Project. May 2021. Accessed September 7, 2021. https://hcupnet.ahrq.gov/
29.
Dalal  AA, Shah  M, D’Souza  AO, Rane  P.  Costs of COPD exacerbations in the emergency department and inpatient setting.   Respir Med. 2011;105(3):454-460. doi:10.1016/j.rmed.2010.09.003 PubMedGoogle ScholarCrossref
30.
Genworth. Cost of care survey: median cost data tables. Updated January 31, 2022. Accessed September 9, 2021. https://pro.genworth.com/riiproweb/productinfo/pdf/282102.pdf
31.
Fitzsimmons  K, Pechter  E, Sparer-Fine  E.  Chronic obstructive pulmonary disease and employment among Massachusetts adults.   Prev Chronic Dis. 2020;17:E144. doi:10.5888/pcd17.200116 PubMedGoogle ScholarCrossref
32.
DiBonaventura  MD, Paulose-Ram  R, Su  J,  et al.  The burden of chronic obstructive pulmonary disease among employed adults.   Int J Chron Obstruct Pulmon Dis. 2012;7:211-219. doi:10.2147/COPD.S29280 PubMedGoogle ScholarCrossref
33.
Liu  S, Zhao  Q, Li  W, Zhao  X, Li  K.  The cost-effectiveness of pulmonary rehabilitation for COPD in different settings: a systematic review.   Appl Health Econ Health Policy. 2021;19(3):313-324. doi:10.1007/s40258-020-00613-5 PubMedGoogle ScholarCrossref
34.
Yakutcan  U, Demir  E, Hurst  JR, Taylor  PC, Ridsdale  HA.  Operational modeling with health economics to support decision making for COPD patients.   Health Serv Res. 2021;56(6):1271-1280. doi:10.1111/1475-6773.13652 PubMedGoogle ScholarCrossref
35.
Centers for Medicare & Medicaid Services. Pulmonary rehabilitation standards and limitations. Accessed October 8, 2021. https://www.govinfo.gov/content/pkg/CFR-2010-title42-vol2/pdf/CFR-2010-title42-vol2-sec410-47.pdf
36.
Ritchey  MD, Maresh  S, McNeely  J,  et al.  Tracking cardiac rehabilitation participation and completion among Medicare beneficiaries to inform the efforts of a national initiative.   Circ Cardiovasc Qual Outcomes. 2020;13(1):e005902. doi:10.1161/CIRCOUTCOMES.119.005902 PubMedGoogle ScholarCrossref
37.
Centers for Medicare & Medicaid Services. CMS Manual System. Pub 100-02 Medicare Benefit Policy. March 24, 2021. Accessed October 26, 2021. https://www.cms.gov/files/document/r10573bp.pdf-0
38.
Spitzer  KA, Stefan  MS, Priya  A,  et al.  A geographic analysis of racial disparities in use of pulmonary rehabilitation after hospitalization for COPD exacerbation.   Chest. 2020;157(5):1130-1137. doi:10.1016/j.chest.2019.11.044 PubMedGoogle ScholarCrossref
Limit 200 characters
Limit 25 characters
Conflicts of Interest Disclosure

Identify all potential conflicts of interest that might be relevant to your comment.

Conflicts of interest comprise financial interests, activities, and relationships within the past 3 years including but not limited to employment, affiliation, grants or funding, consultancies, honoraria or payment, speaker's bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued.

Err on the side of full disclosure.

If you have no conflicts of interest, check "No potential conflicts of interest" in the box below. The information will be posted with your response.

Not all submitted comments are published. Please see our commenting policy for details.

Limit 140 characters
Limit 3600 characters or approximately 600 words
    1 Comment for this article
    EXPAND ALL
    Cost-effectiveness of Pulmonary Rehabilitation for Adults With COPD - How might we reimagine the post-COVID future?
    Ala Szczepura, BA, DPhil (Oxon) | Centre for Healthcare Research, Coventry University, Priory St, Coventry UK.
    This interesting article estimates that pulmonary rehabilitation (PR) after hospitalization for exacerbation of chronic obstructive pulmonary disease (COPD) in the United States (US) could provide large net cost savings and improved quality-adjusted life for patients at 12 months. However, although PR in this context is recognised as cost-effective, in Europe research indicates that effects may only be sustained for a few months.(1). This means that a supervised maintenance programme may be necessary to maintain PR benefits for patients discharged from hospital. A trial exploring this is currently underway in England which should provide evidence of cost-effectiveness.(2)

    Mosher et al
    also highlight the need for US policies to improve uptake of PR, citing as a major barrier patient access to transport for face-to-face sessions. In theory, such barriers might be addressed if cost-effective online-delivery can be developed. However, a recent systematic review of randomised controlled trials evaluating mobile devices to support COPD self-management reports a lack of evidence to date and inconsistencies in terms of reported impact on physical function and quality-of-life.(3). It may be that an improved evidence-base will emerge due to COVID-19.

    During the pandemic, many trials have had to modify conventional face-to-face provision to web-based support and, as a result, should be able to explore whether any advantages emerge through enabling patients to access remote provision as well as the impact on cost of delivery. The final cost-effectiveness of this form of support will be limited by two additional potential barriers: digital access and acceptance of a remote clinical model. A recent study comparing COPD patients over the course of the pandemic (2020 and 2021) has reported that, although confidence in remote non-face-to-face PR improved over time, there was no increased likelihood of patients choosing this option as their preferred service.(4). it will be important to consider the degree to which offering PR and long-term maintenance programmes online in future after hospitalisation, instead of face-to-face, leads to an increase in uptake and improved cost-effectiveness at national population levels in North America and Europe. Also, following an earlier economic evaluation demonstrating the cost-effectiveness of a similar COPD programme for patients with stable COPD managed in primary care, discussion could extend to such patients as well.(5)

    (1) Spruit MA et al. An official American Thoracic Society/European Respiratory Society statement: key concepts and advances in pulmonary rehabilitation. Am J Respir Crit Care Med. 2013;188(8):e13-64.
    (2) Alqahtani KA et al. SPACE FOR COPD delivered as a maintenance programme on pulmonary rehabilitation discharge: protocol of a randomised controlled trial evaluating the long-term effects on exercise tolerance and mental well-being. BMJ open. 2022;12(4):e055513.
    (3) Shaw G et al. Are COPD self-management mobile applications effective? A systematic review and meta-analysis. NPJ Prim Care Respir Med. 2020;30(1):11.
    (4) Polgar O et al. Digital habits of pulmonary rehabilitation service-users following the COVID-19 pandemic. Chron Respir Dis. 2022;19:14799731221075647.
    (5) Dritsaki M et al. An economic evaluation of a self-management programme of activity, coping and education for patients with chronic obstructive pulmonary disease. Chron Respir Dis. 2016;13(1):48-56.
    CONFLICT OF INTEREST: None Reported
    READ MORE
    Original Investigation
    Pulmonary Medicine
    June 22, 2022

    Cost-effectiveness of Pulmonary Rehabilitation Among US Adults With Chronic Obstructive Pulmonary Disease

    Author Affiliations
    • 1Division of Pulmonary, Allergy, and Critical Care Medicine, Duke University Medical Center, Durham, North Carolina
    • 2Duke Clinical Research Institute, Durham, North Carolina
    • 3Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut
    • 4Department of Surgery, Duke University Medical Center, Durham, North Carolina
    • 5Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina
    • 6Rehabilitation Clinical Trials Center, Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, California
    • 7Division of Women’s Community and Population Health, Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, North Carolina
    JAMA Netw Open. 2022;5(6):e2218189. doi:10.1001/jamanetworkopen.2022.18189
    Key Points

    Question  Among patients with chronic obstructive pulmonary disease (COPD), is pulmonary rehabilitation (PR) after COPD hospitalization cost-effective in the US health care system?

    Findings  In this economic evaluation using data from published literature, a Markov microsimulation model found that PR after COPD hospitalization resulted in net cost savings.

    Meaning  These findings provide evidence for stakeholders to use to support polices that will increase access and adherence to PR for patients with COPD.

    Abstract

    Importance  Pulmonary rehabilitation (PR) after exacerbation of chronic obstructive pulmonary disease (COPD) is effective in reducing COPD hospitalizations and mortality while improving health-related quality of life, yet use of PR remains low. Estimates of the cost-effectiveness of PR in this setting could inform policies to improve uptake.

    Objective  To estimate the cost-effectiveness of participation in PR after hospitalization for COPD.

    Design, Setting, and Participants  This economic evaluation estimated the cost-effectiveness of participation in PR compared with no PR after COPD hospitalization in the US using a societal perspective analysis. A Markov microsimulation model was developed to estimate the cost-effectiveness in the US health care system with a lifetime horizon, 1-year cycle length, and a discounted rate of 3% per year for both costs and outcomes. Data sources included published literature from October 1, 2001, to April 1, 2021, with the primary source being an analysis of Medicare beneficiaries living with COPD between January 1, 2014, and December 31, 2015. The analysis was designed and conducted from October 1, 2019, to December 15, 2021. A base case microsimulation, univariate analyses, and a probabilistic sensitivity analysis were performed.

    Interventions  Pulmonary rehabilitation compared with no PR after COPD hospitalization.

    Main Outcomes and Measures  Net cost in US dollars, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratio.

    Results  Among the hypothetical cohort with a mean age of 76.9 (age range, 60-92) years and 58.6% women, the base case microsimulation from a societal perspective demonstrated that PR resulted in net cost savings per patient of $5721 (95% prediction interval, $3307-$8388) and improved quality-adjusted life expectancy (QALE) (gain of 0.53 [95% prediction interval, 0.43-0.63] years). The findings of net cost savings and improved QALE with PR did not change in univariate analyses of patient age, the Global Initiative for Obstructive Lung Disease stage, or number of PR sessions. In a probabilistic sensitivity analysis, PR resulted in net cost savings and improved QALE in every one of 1000 samples and was the dominant strategy in 100% of simulations at any willingness-to-pay threshold. In a 1-way sensitivity analysis of total cost, assuming completion of 36 sessions, a single PR session would remain cost saving to $171 per session and had an incremental cost-effectiveness ratio of $884 per session for $50 000/QALY and $1597 per session for $100 000/QALY.

    Conclusions and Relevance  In this economic evaluation, PR after COPD hospitalization appeared to result in net cost savings along with improvement in QALE. These findings suggest that stakeholders should identify policies to increase access and adherence to PR for patients with COPD.

    Introduction

    Chronic obstructive pulmonary disease (COPD) is estimated to affect 24 million people in the US and is a leading cause of morbidity and mortality of adults in both the US and across the globe.1-3 There are significant direct health system costs associated with COPD, namely an estimated $800 billion during the next 20 years.4 More than 25% of these costs are attributable to hospitalization for acute exacerbation of COPD,5 with one-quarter of these patients readmitted within 30 days.6

    Pulmonary rehabilitation (PR) involves supervised instruction in exercise training, education, and behavioral change designed to improve physical function and change behavior.7 Participation in PR has been shown to relieve breathlessness, increase exercise capacity, and improve health-related quality of life in individuals with COPD.8,9 Furthermore, PR has been found to be associated with a significant reduction in hospital admissions and 1-year mortality after hospitalization.8,10 Despite consistent evidence of benefits in both randomized clinical trials8 and large observational studies,10,11 uptake of PR remains low.12 Lack of access to transport13 and copayments14 have been cited as major hurdles to uptake and adherence, whereas others have pointed to poor reimbursement as the critical barrier to broader use.15

    Although prior studies have demonstrated the cost-effectiveness of PR outside the US,16-19 to our knowledge no estimates of the cost-effectiveness of PR in the US health care system have been published.7 Evidence supporting the cost-effectiveness of PR within the US health care system would provide a strong justification to motivate the development of policies to improve use of PR. In this study, we compared the estimated effects of posthospitalization PR on cost and quality-adjusted life expectancy (QALE) measured in quality-adjusted life-years (QALYs) in the US.

    Methods

    In this economic evaluation, we constructed a Markov microsimulation model of outcomes after discharge for a COPD hospitalization and compared a strategy of universal PR with no PR in the US health care system (Figure 1). The Markov model itself has 3 states: alive during the first year after the index COPD hospitalization, alive during subsequent years, and dead. Although we used a lifetime time horizon, we assumed that (1) PR would only be performed within 90 days after the index admission; (2) PR would not continue beyond the first year; and (3) PR had no effects, either positive or negative, on cost or outcomes beyond the first year. During the first year, probabilities of readmission or death were conditioned on receipt of PR, as were costs associated with rehospitalization, emergency department (ED) visits, and skilled nursing facility (SNF) stays. Each individual “patient” during the microsimulation was subject to an annual probability of readmission or death. We assumed that PR had no effects after the first year, which meant that subsequent mortality after the first year was dependent only on age, sex, and COPD disease stage defined by the Global Initiative for Obstructive Lung Disease (GOLD) criteria.20 Data sources included published literature from October 1, 2001, to April 1, 2021, with the primary source being an analysis of Medicare beneficiaries living with COPD between January 1, 2014, and December 31, 2015 (mean age, 76.9 [range, 60-92] years; 58.6% women). The analysis was designed and conducted from October 1, 2019, to December 15, 2021. Markov cycles were 1 year in length, and costs and outcomes were discounted at a 3% annual rate. The analysis was performed using TreeAge Pro Healthcare, version 2022 (TreeAge Software, LLC). This study followed the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) reporting guideline. All data were publicly available, deidentified data from published studies and trials; therefore, informed consent was not required. Since the study used data from the published literature, the study was exempt from institutional review board review.

    Probability Parameters

    Most of the model parameters directly relevant to PR in the US were derived from 2 analyses of fee-for-service Medicare beneficiaries 65 years or older who were hospitalized for COPD in 2014.10,11 In these analyses, participants were stratified into those who started PR within 90 days of the index admission and those who either received no PR or started PR more than 90 days after the index admission, with propensity matching used to adjust for baseline differences. We used reported estimates from the propensity-matched cohorts for 1-year mortality,10 hospital readmission,11 and number of days per person-year in the hospital, ED, or SNF for each group11; outcomes reported as rates (such as mortality and readmission) were converted to probabilities using standard methods.21 Conservatively, we did not model a dose-response with PR, although Lindenauer et al10 reported a statistically significant association between the number of completed sessions and mortality reduction. 1 − Mortality HR for pulmonary rehabilitation

    To estimate QALE, we incorporated GOLD stage–specific utilities derived from a previously published large multinational study22 that reported EuroQoL-5D scores derived from a US value set stratified by GOLD stage22 (Table 1). To account for PR participation population differences in utilities by GOLD stage, we used a published distribution of 30% for GOLD stage 2 (moderate), 48% for GOLD stage 3 (severe), and 22% for GOLD stage 4 (very severe).23 To account for the expected improvement in health-related quality of life associated with PR,8 we used a reported change in utility.24 Although prior studies have shown a negative correlation between utility scores and number of hospitalizations,25 we conservatively did not account for this potential additional benefit. To avoid potential underestimation of net lifetime cost attributable to COPD resulting from increased survival after PR, we included life expectancy after the first year posthospitalization using annual all-cause mortality stratified by age, sex, and GOLD stage (Table 1).20

    Cost Parameters
    Pulmonary Rehabilitation

    All costs were converted to 2020 US dollars using the medical care component of the Consumer Price Index.26 We used Centers for Medicare & Medicaid Services reimbursement for COPD PR (billing code G0424) and assumed each PR session would last 2 hours at $44.52/h, and also included patient copayments of $22.28 for each 2-hour PR session (Table 2). For the societal perspective analysis, we added estimates for the costs of travel to and from each session based on previously published mean distance to the PR center.8,11 In the base case, we used the distribution of the number of PR sessions observed in the study by Lindenauer et al10; as a sensitivity analysis, we varied a fixed rate to 24 sessions to match guidelines of 3 weekly sessions for 8 weeks (Table 1).7 Although the comparator groups in both the studies of Lindenauer et al10 and Stefan et al11 included patients who received some PR starting more than 90 days after the index admission, we did not include any costs associated with these late sessions because only 1.6% of the total no PR group participated in PR after 90 days.

    We did not include potential time lost from work to attend PR sessions in the societal perspective analysis. First, workforce participation among patients living with COPD is low31 because of age and/or symptoms, and productivity losses due to absenteeism4 or presenteeism32 among those who are employed are common. Although estimating mean wages among employed patients with COPD based on age, sex, and employment sector is theoretically possible, using these data without adjusting for the effects of the disease on productivity would lead to an overestimate of the actual cost. Second, even among patients with COPD who were employed at the time of an index hospitalization, the timing of a postdischarge return to work relative to beginning a PR program is unclear. As a surrogate for potential productivity losses due to either attending PR sessions or postdischarge health care encounters due to exacerbations of disease, we present estimates of the number of days spent undergoing PR and in the hospital, ED, or SNF for each strategy (Table 1). We also did not include potential productivity losses for informal caregivers.

    Use of Health Care Resources

    We estimated the daily cost for a COPD-related hospital admission by identifying hospital discharges in the 2018 Nationwide Inpatient Sample within the diagnostic category of COPD and bronchiectasis28 and dividing the mean hospital charges by the mean length of stay (Table 2).10 Daily costs for a COPD-related ED visit29 were obtained from the literature. For skilled nursing care, we used the median daily cost for a semiprivate room in an SNF reported in the Genworth Survey for 2020 in the base case and varied daily cost using reported state-level medians.30 Total cost for each type of admission was estimated by multiplying these daily costs by estimated days. Annual costs after the first year were stratified by GOLD stage based on a recent projection of long-term cost (Table 2).4

    Statistical Analysis

    In the base case microsimulation, patient-level characteristics (age, sex, and GOLD stage) and outcomes (mortality, utilities, and rehospitalization, ED, and/or SNF days) without PR were drawn from the previously described distributions. The association of PR with outcomes was incorporated by either modifying mortality risk10 and utility24 based on reported effect estimates or using separate distributions for number of posthospitalization event days (Table 1).11

    We performed 1-way sensitivity analyses for age, sex, GOLD stage, and number and cost of PR sessions. In addition, we performed scenario analyses assuming (1) no incremental effect of PR on quality of life, (2) no incremental effect on quality of life or mortality, and (3) no incremental effect on quality of life or mortality while varying the hazard ratio for rehospitalization to 1 (ie, no effect). We also performed a 2-way probabilistic sensitivity analysis, using 1000 draws from the effect estimate distributions and 10 000 iterations of the underlying microsimulation.

    Results

    In the base case microsimulation from a societal perspective, PR resulted in net cost savings per patient of $5721 (95% prediction interval, $3307-$8388) and an improved QALE (gain of 0.53 [95% prediction interval, 0.43-0.63] years) (Table 3). Most of these savings were owing to reductions in the number of hospital and SNF days (Tables 1 and 3). Savings within the first year after the index hospitalization were $8226 (95% prediction interval, $5348-$10 873); the lower net savings over a lifetime of $5721 are due to higher survival with PR leading to greater longer-term COPD-related costs. From the health system perspective (eliminating patient travel costs), mean savings in the first year were $8667 per patient.

    Use of PR was dominant compared with no PR across sex, age, GOLD stage, and number of sessions (under the assumption of no dose-response with session number) (eTable 1 in the Supplement). If PR does not improve quality of life but only reduces rehospitalizations and mortality, incremental QALYs are 0.41 (vs 0.43). If PR does not improve quality of life or mortality but only prevents readmissions, there are no gains in QALYs, but PR remains cost saving (mean savings of $7607 per patient) unless the hazard ratio for readmission is less than 0.89 (approximately the upper bound of the 95% CI for the observed hazard ratio).

    In probabilistic sensitivity analysis, PR resulted in cost savings and improved QALE and unadjusted life expectancy in every one of 1000 samples of the effectiveness estimates: PR was the dominant strategy in 100% of simulations at any willingness-to-pay threshold (eFigure in the Supplement). As an additional sensitivity analysis, we estimated threshold values for total cost per PR session (2-hour session reimbursement [$89.04] + copay [$22.28] = $111.32/session current state) for a full 36 recommended sessions where PR would no longer be cost saving beginning at $171 per session. Thresholds for the incremental cost-effectiveness ratio of $50 000/QALY and $100 000/QALY were $884 per session and $1597 per session, respectively (Figure 2).

    Discussion

    In this model-based analysis, use of PR in the US health care system consistently resulted in net cost savings and improvement in QALE across the range of probability and cost parameters. However, as of 2012, the estimated utilization rate for PR among Medicare beneficiaries was only 4%.12 In 2018, there were approximately 393 000 hospitalizations for COPD among Medicare beneficiaries,28 with at least one-quarter of these representing readmissions within 30 days after a prior discharge.6 Assuming 200 000 patients per year (consistent with the Medicare studies10,11) and our estimated savings of $5700 per patient, universal utilization of PR could result in savings for Medicare of $1 to $1.25 billion annually.

    We were unable to identify any previously published cost-effectiveness analyses of PR for patients with COPD in the US health care system, although our findings are supported by numerous non-US studies (eTable 2 in the Supplement).16-19 A systematic review by Liu et al33 found that PR was cost-effective across a variety of settings, including outpatient and home-based rehabilitation and telerehabilitation.33 Although it is reassuring that these prior results are consistent with our present findings, our study has several important differences. In addition to including routinely reported costs of PR, rehospitalization, and ED use,17-19,34 we included the costs of SNF days, which to date have been reported infrequently (Table 1). In addition, we included data from multiple large data sources using clinical evidence,10,11 in contrast to most prior studies that used single-center clinical trial data.16,17,19

    Although Medicare will cover 1 lifetime PR program (36 sessions) as well as 1 additional program at the request of a physician (total of 72 lifetime sessions),35 only 4% of Medicare beneficiaries participate in PR,12 compared with 25% of patients with cardiac disease who participate in cardiac rehabilitation.36 Low reimbursement has been cited as one of the major barriers contributing toward low PR participation,15 and it is worth noting that reimbursement for PR ($44.52) is less than half that for cardiac rehabilitation ($92.84),15 despite comparable intensity of service and documentation.37 We estimate that the cost of PR per session would remain cost saving until the cost increased to $171 per session for 36 sessions. Furthermore, at a willingness-to-pay of $50 000/QALY, a standard for high-value interventions, PR would remain cost-effective until $884 per session (Figure 2). These findings illustrate the potential cost savings identified in our analysis, which could be used to address reported barriers to patient participation, such as higher reimbursement to support increasing PR building capacity in areas with low density of PR programs,38 facilitating patient transportation,13 and covering program copayments.14

    Limitations

    Our study has several limitations. As with any model-based analysis, our results depend on the validity of the model structure; the validity, precision, and applicability of the data used for parameters; and the extent to which all plausible values and scenarios are explored in sensitivity analyses. Most of our estimates of resource utilization come from a large observational study of Medicare beneficiaries that used propensity weighting to account for differences between patients who did and did not use PR.11 Major exceptions were for estimates of the distribution of GOLD stages among PR participants23 and effect of PR on health-related quality of life,24 which came from European studies and may not be generalizable to the US population. We used probabilistic analysis to account for the precision of the estimate of reduction in rehospitalization using Medicare claims data,11 which itself was lower than the estimate in a recent Cochrane review based on predominantly Asian and European randomized clinical trials.8 In our base case analysis, we used the distribution of attended PR visits (mean of 9) rather than assuming universal completion of a full course of PR. Although this may underestimate cost compared with a full 36 sessions, it may also underestimate effectiveness, because there was a significant correlation between the number of sessions completed and survival.10 Whether the estimated cost savings or improvement in health-related quality of life and life expectancy would apply to younger patients, especially if productivity costs were included, is unclear. To the extent that PR reduces posthospitalization use of health care resources among younger patients who may be employed, it seems unlikely that any impact of PR on time away from work would not be mitigated by reductions in ED visits and rehospitalization. We used the most recent Centers for Medicare & Medicaid Services pricing data available to generate national estimates, but because costs vary somewhat by region,27 we may have underestimated the cost of PR in specific locations. We did not validate our results because we are not aware of a readily available data set that would allow validation.

    Conclusions

    The findings of this economic evaluation suggest that PR after hospitalization for a COPD exacerbation among US patients may result in net cost savings and improvements in QALE. Given these findings, payers—particularly Medicare—should identify policies that would increase access and adherence to PR programs for patients living with COPD.

    Back to top
    Article Information

    Accepted for Publication: May 4, 2022.

    Published: June 22, 2022. doi:10.1001/jamanetworkopen.2022.18189

    Correction: This article was corrected on July 14, 2022, to correct an error that appeared in Table 2. The base case cost for a 2-hour pulmonary rehabilitation session had been inadvertently listed as not applicable; it should have been listed as $89.04.

    Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2022 Mosher CL et al. JAMA Network Open.

    Corresponding Author: Christopher L. Mosher, MD, MHS, Duke Clinical Research Institute, 300 W Morgan St, Office Number 521, Durham, NC 27701 (christopher.mosher@duke.edu).

    Author Contributions: Dr Myers had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

    Concept and design: Mosher, Nanna, Jawitz, Farrow, Aleem, Casaburi, MacIntyre, Palmer, Myers.

    Acquisition, analysis, or interpretation of data: Mosher, Nanna, Jawitz, Raman, Aleem, Casaburi, MacIntyre, Myers.

    Drafting of the manuscript: Mosher, Nanna, Jawitz, Raman, Farrow.

    Critical revision of the manuscript for important intellectual content: All authors.

    Statistical analysis: Myers.

    Obtained funding: MacIntyre.

    Administrative, technical, or material support: Mosher, Nanna, Raman, MacIntyre.

    Supervision: Nanna, MacIntyre, Palmer, Myers.

    Conflict of Interest Disclosures: Dr Mosher reported receiving training grant support from the National Institutes of Health (NIH) and research grant funding from CHEST Foundation and AstraZeneca outside the submitted work. Dr Nanna reported receiving prior training grant support from the NIH and current research support from the American College of Cardiology Foundation supported by the George F. and Ann Harris Bellows Foundation and from the National Institute on Aging, NIH (Grants for Early Medical/Surgical Specialists’ Transition to Aging Research award). Dr Jawitz reported receiving prior training grant support from the NIH. Dr Raman reported receiving prior training grant support from the NIH. Dr Farrow reported receiving prior training grant support from the NIH. Dr Casaburi reported stock ownership from Inogen during the conduct of the study. Dr MacIntyre reported consulting for InspiRx, Hill-Rom Holdings, Inc, Ventec Life Systems, and Inogen outside the submitted work. Dr Palmer reported receiving grants from Boehringer Ingelheim and Bristol Myers Squibb and personal fees from Altavant outside the submitted work. Dr Myers reported consulting for Merck & Co, Inc (human papillomavirus vaccination), Moderna, Inc (cytomegalovirus vaccination), and AbbVie (uterine fibroids) and event adjudication for Novo Nordisk A/S outside the submitted work. No other disclosures were reported.

    Disclaimer: The NIH was not involved in the research study or in the presentation of these findings.

    References
    1.
    Mannino  DM, Homa  DM, Akinbami  LJ, Ford  ES, Redd  SC.  Chronic obstructive pulmonary disease surveillance--United States, 1971-2000.   MMWR Surveill Summ. 2002;51(6):1-16.PubMedGoogle Scholar
    2.
    National Center for Health Statistics.  Health, United States, 2015: With Special Feature on Racial and Ethnic Health Disparities. National Center for Health Statistics; 2016.
    3.
    Lozano  R, Naghavi  M, Foreman  K,  et al.  Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010.   Lancet. 2012;380(9859):2095-2128. Published correction in Lancet. 2013;381(9867):628. doi:10.1016/S0140-6736(12)61728-0 PubMedGoogle ScholarCrossref
    4.
    Zafari  Z, Li  S, Eakin  MN, Bellanger  M, Reed  RM.  Projecting long-term health and economic burden of COPD in the United States.   Chest. 2021;159(4):1400-1410. doi:10.1016/j.chest.2020.09.255 PubMedGoogle ScholarCrossref
    5.
    Shah  T, Press  VG, Huisingh-Scheetz  M, White  SR.  COPD readmissions: addressing COPD in the era of value-based health care.   Chest. 2016;150(4):916-926. doi:10.1016/j.chest.2016.05.002 PubMedGoogle ScholarCrossref
    6.
    Sullivan  J, Pravosud  V, Mannino  DM, Siegel  K, Choate  R, Sullivan  T.  National and state estimates of COPD morbidity and mortality—United States, 2014-2015.   Chronic Obstr Pulm Dis. 2018;5(4):324-333. doi:10.15326/jcopdf.5.4.2018.0157 PubMedGoogle ScholarCrossref
    7.
    Spruit  MA, Singh  SJ, Garvey  C,  et al; ATS/ERS Task Force on Pulmonary Rehabilitation.  An official American Thoracic Society/European Respiratory Society statement: key concepts and advances in pulmonary rehabilitation.   Am J Respir Crit Care Med. 2013;188(8):e13-e64. doi:10.1164/rccm.201309-1634ST PubMedGoogle ScholarCrossref
    8.
    Puhan  MA, Gimeno-Santos  E, Cates  CJ, Troosters  T.  Pulmonary rehabilitation following exacerbations of chronic obstructive pulmonary disease.   Cochrane Database Syst Rev. 2016;12:CD005305. doi:10.1002/14651858.CD005305.pub4 PubMedGoogle ScholarCrossref
    9.
    McCarthy  B, Casey  D, Devane  D, Murphy  K, Murphy  E, Lacasse  Y.  Pulmonary rehabilitation for chronic obstructive pulmonary disease.   Cochrane Database Syst Rev. 2015;(2):CD003793. doi:10.1002/14651858.CD003793.pub3 PubMedGoogle ScholarCrossref
    10.
    Lindenauer  PK, Stefan  MS, Pekow  PS,  et al.  Association between initiation of pulmonary rehabilitation after hospitalization for COPD and 1-year survival among Medicare beneficiaries.   JAMA. 2020;323(18):1813-1823. doi:10.1001/jama.2020.4437 PubMedGoogle ScholarCrossref
    11.
    Stefan  MS, Pekow  PS, Priya  A,  et al.  Association between initiation of pulmonary rehabilitation and rehospitalizations in patients hospitalized with chronic obstructive pulmonary disease.   Am J Respir Crit Care Med. 2021;204(9):1015-1023. doi:10.1164/rccm.202012-4389OC PubMedGoogle ScholarCrossref
    12.
    Nishi  SP, Zhang  W, Kuo  YF, Sharma  G.  Pulmonary rehabilitation utilization in older adults with chronic obstructive pulmonary disease, 2003 to 2012.   J Cardiopulm Rehabil Prev. 2016;36(5):375-382. doi:10.1097/HCR.0000000000000194 PubMedGoogle ScholarCrossref
    13.
    Keating  A, Lee  A, Holland  AE.  What prevents people with chronic obstructive pulmonary disease from attending pulmonary rehabilitation? a systematic review.   Chron Respir Dis. 2011;8(2):89-99. doi:10.1177/1479972310393756 PubMedGoogle ScholarCrossref
    14.
    Oates  GR, Niranjan  SJ, Ott  C,  et al.  Adherence to pulmonary rehabilitation in COPD: a qualitative exploration of patient perspectives on barriers and facilitators.   J Cardiopulm Rehabil Prev. 2019;39(5):344-349. doi:10.1097/HCR.0000000000000436 PubMedGoogle ScholarCrossref
    15.
    Garvey  C, Novitch  RS, Porte  P, Casaburi  R.  Healing pulmonary rehabilitation in the United States: a call to action for ATS members.   Am J Respir Crit Care Med. 2019;199(8):944-946. doi:10.1164/rccm.201809-1711ED PubMedGoogle ScholarCrossref
    16.
    Griffiths  TL, Phillips  CJ, Davies  S, Burr  ML, Campbell  IA.  Cost effectiveness of an outpatient multidisciplinary pulmonary rehabilitation programme.   Thorax. 2001;56(10):779-784. doi:10.1136/thorax.56.10.779 PubMedGoogle ScholarCrossref
    17.
    Hoogendoorn  M, van Wetering  CR, Schols  AM, Rutten-van Mölken  MP.  Is Interdisciplinary Community-Based COPD Management (INTERCOM) cost-effective?   Eur Respir J. 2010;35(1):79-87. doi:10.1183/09031936.00043309 PubMedGoogle ScholarCrossref
    18.
    Gillespie  P, O’Shea  E, Casey  D,  et al; PRINCE Study Team.  The cost-effectiveness of a structured education pulmonary rehabilitation programme for chronic obstructive pulmonary disease in primary care: the PRINCE cluster randomised trial.   BMJ Open. 2013;3(11):e003479. doi:10.1136/bmjopen-2013-003479 PubMedGoogle ScholarCrossref
    19.
    Golmohammadi  K, Jacobs  P, Sin  DD.  Economic evaluation of a community-based pulmonary rehabilitation program for chronic obstructive pulmonary disease.   Lung. 2004;182(3):187-196. doi:10.1007/s00408-004-3110-2 PubMedGoogle ScholarCrossref
    20.
    Shavelle  RM, Paculdo  DR, Kush  SJ, Mannino  DM, Strauss  DJ.  Life expectancy and years of life lost in chronic obstructive pulmonary disease: findings from the NHANES III follow-up study.   Int J Chron Obstruct Pulmon Dis. 2009;4:137-148. doi:10.2147/COPD.S5237 PubMedGoogle ScholarCrossref
    21.
    Fleurence  RL, Hollenbeak  CS.  Rates and probabilities in economic modelling: transformation, translation and appropriate application.   Pharmacoeconomics. 2007;25(1):3-6. doi:10.2165/00019053-200725010-00002 PubMedGoogle ScholarCrossref
    22.
    Rutten-van Mölken  MP, Oostenbrink  JB, Tashkin  DP, Burkhart  D, Monz  BU.  Does quality of life of COPD patients as measured by the generic EuroQol five-dimension questionnaire differentiate between COPD severity stages?   Chest. 2006;130(4):1117-1128. doi:10.1378/chest.130.4.1117 PubMedGoogle ScholarCrossref
    23.
    Huijsmans  RJ, de Haan  A, ten Hacken  NN, Straver  RV, van’t Hul  AJ.  The clinical utility of the GOLD classification of COPD disease severity in pulmonary rehabilitation.   Respir Med. 2008;102(1):162-171. doi:10.1016/j.rmed.2007.07.008 PubMedGoogle ScholarCrossref
    24.
    Nolan  CM, Longworth  L, Lord  J,  et al.  The EQ-5D-5L health status questionnaire in COPD: validity, responsiveness and minimum important difference.   Thorax. 2016;71(6):493-500. doi:10.1136/thoraxjnl-2015-207782 PubMedGoogle ScholarCrossref
    25.
    Esquinas  C, Ramon  MA, Nuñez  A,  et al.  Correlation between disease severity factors and EQ-5D utilities in chronic obstructive pulmonary disease.   Qual Life Res. 2020;29(3):607-617. doi:10.1007/s11136-019-02340-4 PubMedGoogle ScholarCrossref
    26.
    US Bureau of Labor Statistics. Databases, tables, & calculators by subject. Accessed August 10, 2021. https://data.bls.gov/timeseries/CUUR0000SAM?output_view=data
    27.
    American Association of Cardiovascular and Pulmonary Rehabilitation. Hospital Policy & Reimbursement Update. January 6, 2021. Accessed August 24, 2021. https://www.aacvpr.org/Portals/0/Docs/Advocacy/Reimbursement%20Updates/2021/1.06.21%20AACVPR%20Reimbursement%20Update.pdf?ver=2021-01-19-101211-627
    28.
    Agency for Healthcare Research and Quality. HCUPnet Healthcare Cost and Utilization Project. May 2021. Accessed September 7, 2021. https://hcupnet.ahrq.gov/
    29.
    Dalal  AA, Shah  M, D’Souza  AO, Rane  P.  Costs of COPD exacerbations in the emergency department and inpatient setting.   Respir Med. 2011;105(3):454-460. doi:10.1016/j.rmed.2010.09.003 PubMedGoogle ScholarCrossref
    30.
    Genworth. Cost of care survey: median cost data tables. Updated January 31, 2022. Accessed September 9, 2021. https://pro.genworth.com/riiproweb/productinfo/pdf/282102.pdf
    31.
    Fitzsimmons  K, Pechter  E, Sparer-Fine  E.  Chronic obstructive pulmonary disease and employment among Massachusetts adults.   Prev Chronic Dis. 2020;17:E144. doi:10.5888/pcd17.200116 PubMedGoogle ScholarCrossref
    32.
    DiBonaventura  MD, Paulose-Ram  R, Su  J,  et al.  The burden of chronic obstructive pulmonary disease among employed adults.   Int J Chron Obstruct Pulmon Dis. 2012;7:211-219. doi:10.2147/COPD.S29280 PubMedGoogle ScholarCrossref
    33.
    Liu  S, Zhao  Q, Li  W, Zhao  X, Li  K.  The cost-effectiveness of pulmonary rehabilitation for COPD in different settings: a systematic review.   Appl Health Econ Health Policy. 2021;19(3):313-324. doi:10.1007/s40258-020-00613-5 PubMedGoogle ScholarCrossref
    34.
    Yakutcan  U, Demir  E, Hurst  JR, Taylor  PC, Ridsdale  HA.  Operational modeling with health economics to support decision making for COPD patients.   Health Serv Res. 2021;56(6):1271-1280. doi:10.1111/1475-6773.13652 PubMedGoogle ScholarCrossref
    35.
    Centers for Medicare & Medicaid Services. Pulmonary rehabilitation standards and limitations. Accessed October 8, 2021. https://www.govinfo.gov/content/pkg/CFR-2010-title42-vol2/pdf/CFR-2010-title42-vol2-sec410-47.pdf
    36.
    Ritchey  MD, Maresh  S, McNeely  J,  et al.  Tracking cardiac rehabilitation participation and completion among Medicare beneficiaries to inform the efforts of a national initiative.   Circ Cardiovasc Qual Outcomes. 2020;13(1):e005902. doi:10.1161/CIRCOUTCOMES.119.005902 PubMedGoogle ScholarCrossref
    37.
    Centers for Medicare & Medicaid Services. CMS Manual System. Pub 100-02 Medicare Benefit Policy. March 24, 2021. Accessed October 26, 2021. https://www.cms.gov/files/document/r10573bp.pdf-0
    38.
    Spitzer  KA, Stefan  MS, Priya  A,  et al.  A geographic analysis of racial disparities in use of pulmonary rehabilitation after hospitalization for COPD exacerbation.   Chest. 2020;157(5):1130-1137. doi:10.1016/j.chest.2019.11.044 PubMedGoogle ScholarCrossref
    ×