Pulmonary rehabilitation in minimal versus high resource settings in COPD: a non-inferiority and economic evaluation

Abstract

Background: Comparison of results and associated costs of pulmonary rehabilitation (PR) conducted with minimal resources (MR) versus specialised centres (SC) for people with chronic obstructive pulmonary disease (COPD) remains uncertain.

Objectives: We assessed the effects, non-inferiority and associated costs in Portugal of PR with MR compared to PR in SC for COPD.

Methods: PR was conducted with MR and in SC. The functional assessment of chronic illness therapy-fatigue scale-FACIT-FS, hospital anxiety and depression scale-HADS, COPD assessment test-CAT, St. George's Respiratory Questionnaire-SGRQ, quadriceps maximum voluntary contraction-QMVC, Brief-Balance Evaluation Systems Test-Brief-BESTest, 6-min walk test-6MWT and 1-min sit-to-stand-test-1minSTS were assessed pre-post PR. Effects were explored with robust/linear mixed effects model. Costs of PR implementation and intervention were estimated.

Results: 158 people with COPD (69±8years; 79.7 % male; FEV₁ 49.0[40.0; 65.8]%predicted) participated, 72 in MR and 86 in SC. No Time∗Group interaction was observed, except for the SGRQ. Improvements were significant for all measures in both settings. Non-inferiority was demonstrated for FACIT-FS, HADS-D, QMVC, Brief-BESTest and 1minSTS but inconclusive for HADS-A, CAT, SGRQ and 6MWT. PR implementation costs were 8384€ with MR vs. 33,123€ in SC. Intervention costs were 5168€ and 9803€/program including non-emergency medical transportation (646€ vs. 1225€/person) in MR and SC, respectively.

Conclusion: PR with MR has multiple benefits for people with COPD at a lower cost than in SC. However, its non-inferiority compared to SC remains inconclusive for core outcomes. PR with MR could be an effective alternative to increase access to this essential intervention when SC are unavailable.

Keywords: Chronic obstructive pulmonary disease; Constraint settings; Low resources; Pulmonary rehabilitation; Value-based healthcare.