Efficacy of supervised maintenance exercise following pulmonary rehabilitation on health care use: a systematic review and meta-analysis

Abstract

Introduction

The clinical benefit of continued supervised maintenance exercise programs following pulmonary rehabilitation in COPD remains unclear. This systematic review aimed to synthesize the available evidence on the efficacy of supervised maintenance exercise programs compared to usual care following pulmonary rehabilitation completion on health care use and mortality.

Methods

Electronic databases (MEDLINE, Embase, CINAHL, Cochrane Central Register of Controlled Trials, Web of Science, and PEDro) and trial registers (ClinicalTrials.gov and Current Controlled Trials) were searched for randomized trials comparing supervised maintenance exercise programs with usual care following pulmonary rehabilitation completion. Primary outcomes were respiratory-cause hospital admissions, exacerbations requiring treatment with antibiotics and/or systemic corticosteroids, and mortality.

Results

Eight trials (790 COPD patients) met the inclusion criteria, six providing data for meta-analysis. Continued supervised maintenance exercise compared to usual care following pulmonary rehabilitation completion significantly reduced the risk of experiencing at least one respiratory-cause hospital admission (risk ratio 0.62, 95% confidence interval [CI] 0.47–0.81, P<0.001). Meta-analyses also suggested that supervised maintenance exercise leads to a clinically important reduction in the rate of respiratory-cause hospital admissions (rate ratio 0.72, 95% CI 0.50–1.05, P=0.09), overall risk of an exacerbation (risk ratio 0.79, 95% CI 0.52–1.19, P=0.25), and mortality (risk ratio 0.57, 95% CI 0.17–1.92, P=0.37).

Conclusion

In the first systematic review of the area, current evidence demonstrates that continued supervised maintenance exercise compared to usual care following pulmonary rehabilitation reduces health care use in COPD. The variance in the quality of the evidence included in this review highlights the need for this evidence to be followed up with further high-quality randomized trials.

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Keywords:

• pulmonary rehabilitation
• health outcomes
• supervised maintenance programs
• hospitalization
• exacerbations

Supplementary materials

Methods

Data extraction

The following study characteristics were extracted: methods of the study (date/title of the study, aim of study, study design, unit of allocation, duration of study, duration of intervention, primary outcome, secondary outcomes, and funding source), participants (population description, demographics, inclusion criteria, exclusion criteria, method of recruitment of participants, total number randomized, clusters, baseline imbalances, withdrawal and exclusions, and subgroups reported), intervention and where relevant comparator (group name, number randomized to group-sample size, description, venue numbers/locations, duration and frequency of maintenance exercise training period, delivery, providers, co-interventions, compliance/adherence, and defined parameters of usual care), and outcomes (outcome name, outcome type, outcome definition, person measuring/reporting, unit of measurement, scales [upper and lower limits], outcome tool validation, imputation of missing data, assumed risk estimate, and level of power).

Figure S1 Trial-level data, effect estimates, and forest plot of comparison for the risk of all-cause hospital admission.

Abbreviations: CI, confidence interval; IV, inverse variance.

Figure S2 Trial-level data, effect estimates, and forest plot of comparison for the risk of GP visits.

Abbreviations: CI, confidence interval; GP, general practitioner; IV, inverse variance.

Table S1 Example search strategy of a bibliographic database (CINAHL)

Table S2 Characteristics of excluded studies

Table S3 Ongoing studies

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Acknowledgments

We acknowledge the cooperation of authors (Rosa Guell, Pilar Cejudo Ramos, Lissa Spencer, Miguel Roman, Magdalena Esteva, Thomas Ringbaek, Ed Wilson, and Greg Moullec) of the included studies in this review for providing data in a format appropriate for analyses. We also thank Marilyn Moy, Laura Desveaux, and Dina Brooks for providing updates on their current ongoing trials related to this review. This review was conducted during Alex R Jenkins’ PhD studentship, which was part of the Doctoral Training Alliance Applied Biosciences for Health Programme.

Disclosure

The authors report no conflicts of interest in this work.