Effectiveness and Economic Evaluation of Hospital-Outreach Pulmonary Rehabilitation for Patients with Chronic Obstructive Pulmonary Disease

Figures & data

Table 1 Contents of the 3-Month Intensive Intervention

	Content	Frequency	Interventionist
Physical exercise*	Upper-limb exercise: elastic band–resistance exercise and breathe training Lower-limb exercise: bicycle ergometer, treadmill Modified tai chi exercise	Twice aweek for  40–55 minutes each time	Physiotherapist Tai chi mentor Respiratory nurse
Smoking cessation	Group and individual intervention	Two sessions	Psychologist Respiratory nurse
Self-management education	COPD knowledge Physical exercise at home Symptom management Medication-taking instruction and adherence Lifestyle change Nutrition support Long-term oxygen therapy	Every 2 weeks	Physician Respiratory nurse Nutritionist
Psychosocial support	Group activity to facilitate communication among patients Education on emotional coping strategies	Two sessions	Psychologist Respiratory nurse

Notes: *Exercise intensity based on target heart rate (65%–75% [220 – age]) and BORG fatigue scale. During each supervised training, participants' heart rate, SPO², and symptoms of dyspnea were monitored. Oxygen supplementation would be provided if SPO² fell below 90%, and exercise would be stopped immediately if there were any chest pain, cardiac arrhythmia, dizziness, or nausea, or if participants couldnot continue due to fatigue or shortness of breath.

Table 2 Unit Cost Schema for Hospital-Outreach PR Intervention

Cost Elements	Unit Cost
3-month intensive intervention
Physical exercise	CN¥40/session
Educational session	¥20/session
Smoking cessation session	¥20/session
Psychosocial support session	¥20/session
transport^a	Individualized
Follow-up after intensive intervention
Telephone
Communication cost	¥0.19/minute
Human -esource cost^b	¥40/hour
Home visits
Human-resource cost^b	¥40/hour
transport^a	Individualized

Notes: ^aTransport cost for the intensive intervention included that for physical exercise, since education sessions and cessation sessions were conducted after exercise; transport costs for follow-up were costs of a respiratory nurse for home visits. Transport costs were calculated by actual individualized cost per session. ^bAverage annual salary for health-care providers for 2014–2016 was ¥8,491,⁵⁶ 8 hours' workper day, 258 days annually (except holidays). Cost of health providers was ¥40 per hour.

Table 3 Calculation of the net benefits

	Before intervention	After intervention	Difference based on time
Intervention group	β0+β1+ε (I=1, T=0)	β0+β1+β2+β3+ε (I=1, T=1)	Δγt1=β2+β3
Usual-care group	β0+ε (I=0, T=0)	β0+β2+β3+ε (I=0, T=1)	Δγt2=β2
Difference based on group	Δγi1=β1	Δγi2=β1+β3	ΔΔγ=β3

Table 4 Baseline Characteristics of Participants (n=174)

	Control	Intervention
Sex
Male, n (%)	67 (75.3)	65 (76.5)
Female, n (%)	22 (24.7)	20 (23.5)
Age, years	66.31±7.91	65.53±6.64
Education
Primary or lower, n (%)	33 (37.1)	29 (34.1)
Middle school, n (%)	36 (40.4)	34 (40.0)
High school or higher, n (%)	22 (25.9)	20 (22.5)
Smoking Status
Current smoker, n (%)	20 (22.5)	20 (23.5)
Ex-smoker, n (%)	35 (39.3)	39 (45.9)
Nonsmoker, n (%)	34 (38.2)	26 (30.6)
COPD length (years)	6.97±4.23	7.46±5.03
Stage of COPD
2	30	33
3	36	36
4	20	19
Comorbidities
None	16	15
1–2	48	48
3 or above	25	22
mMRC	2.21±0.67	2.05±0.63
CAT	23.96±3.58	24.05±3.82
6MWD	382.49±42.27	372.55±41.57
FEV1	1.15±0.47	1.29±0.44
FVC	1.82±0.56	1.89±0.57
FEV1% predicted	44.05±12.71	46.37±10.69
Self-management	125.81±16,967.54	122.92±20.34
Admission times	2 (1–2)	2 (1–2)
Admission days	16 (11–24)	16 (11–22. 5)
ED visits	0 (0–2)	1 (0–2)
Admission costs	12,897.50 (9,953.00–20,020.43)	11,585.50 (8,347.25–20,930.50)
ED-visit costs	0 (0–723.50)	524.00 (0–928.00)
Outpatient costs	700.00 (178.95–1,816.55)	673.90 (200.00–1,858.00)
Total medical costs	15,162.00 (10,297.36–22,183.10)	14,106.54 (9,475.00–23,269.05)

Table 5 Medication-Taking Comparisons Between the Groups

	Intervention (n=104)	Control (n=104)
Pharmacological therapy
Inhaled	37 (35.6%)	29 (27.9%)
Oral	47 (45.2%)	46 (44.2%)
Inhaled + oral	3 (2.9%)	5 (4.8%)
None	27 (16.3%)	24 (23.1%)
Nonpharmacological therapy
Long-term oxygen therapy (LTOT)	9 (8.7%)	16 (15.4%)
Exercise	45 (43.3%)	55 (52.9%)
LTOT + exercise	19 (18.3%)	5 (4.8%)
None	31 (29.8%)	28 (26.9%)

Figure 1 Participant flowchart.

Table 6 Health-Care Utilization of Patients Participating in Hospital-Outreach PR Versus Usual Care (n=174)

	Intervention (n=85)	Control (n=89)	Z/χ^2
Admission rates, n (%)
12 months before intervention	85 (100%)	89 (100%)
3 months	10 (11.8%)	18 (20.2%)	2.305
6 months	31 (36.5%)	48 (53.9%)	5.348*
12 months	47 (55.3%)	72 (80.9%)	13.185***
12–24 months	44 (51.8%)	69 (77.5%)	12.675***
Admission times, median (IQR)
12 months before intervention	2 (1–2)	2 (1–2)	−0.08
3 months	0 (0–1)	0 (0–0)	1.59
6 months	0 (0–1)	1 (0–1)	2.57*
12 months	1 (0–2)	2 (1–2.5)	3.26**
12–24 months	1 (0–2)	1 (1–2)	3.25**
Admission days, median (IQR)
12 months before intervention	16 (11–22)	16 (11–24)	0.52
3 months	0 (0–0)	0 (0–0)	1.64
6 months	0 (0–9)	8 (0–12)	2.85**
12 months	8 (0–20)	17 (8.5–31)	4.30***
12–24 months	7 (0–13)	13 (7–22)	4.39***
ED-visit times, median (IQR)
12 months before intervention	1 (0–2)	0 (0–2)	−1.89
3 months	0 (0–0)	0 (0–0)	1.28
6 months	0 (0–1)	0 (0–1)	1.04
12 months	0 (0–2)	1 (0–2)	3.14***
12–24 months	1 (0–2)	1 (0–2)	0.55

Notes: *p<0.05; **p<0.01; ***p<0.001.

Table 7 Costs of Different Groups at Different Times (n=174)

	Intervention	Control	Z
Total medical costs, median (IQR)
Baseline	14,106.54 (9,475.00–23,269.05)	15,162.00 (10,297.36–22,183.10)	0.778
12 months	10,370.00 (2,354.70–27,410.50)	14,736.51 (10,837.20–27,410.50)	3.476**
12–24 months	8049.00 (2,669.00–16,595.20)	12,941.00 (8,159.95–17,834.92)	2.327*
Inpatient costs, median (IQR)
Baseline	11,585.50 (8,347.25–20,930.50)	12,897.50 (9,953.00–20,020.43)	0.917
12 months	8,392.50 (0–12,905.25)	12,122.50 (8,696.73–26,235.42)	4.245***
12–24 months	1,372.60 (0–11,902.60)	10,600.20 (5,137.35–14,930.02)	3.617***
ED-visit costs, median (IQR)
Baseline	524.00 (0–928.00)	0 (0–723.50)	−2.082*
12 months	0 (0–585.70)	490.00 (0–998.50)	3.067**
12–24 months	422.50 (0–1,179.50)	567.00 (0–1,455.50)	0.945
Outpatient costs, median (IQR)
Baseline	673.90 (200.00–1,858.00)	700.00 (178.95–1,816.55)	−0.05
12 months	2,089.00 (1,259.20–2,790.00)	1,250.00 (583.50–1,909.00)	–4.67***
12–24 months	1,979.00 (922.30–3,837.55)	717.50 (422.00–1,163.00)	−6.57***

Notes: *p<0.05; **p<0.01; ***p<0.001.

Table 8 Changes to Health-Care Utilization and Costs in Hospital-Outreach PR Program Compared with Control Group (n=174)

	First-Year Postintervention  Per Patient Per Year (95% CI)		Second-Year Postintervention Per Patient Per Year (95% CI)		Two Years Postintervention Per Patient Per Year (95% CI)
	Savings	Ratio	Savings	Ratio	Savings	Ratio
Total medical cost	−4,927.94 (−9,265.93 to −589.95)*	2.71	−1,418.05 (−5,722.20 to 2,936.11)	3.56	−3,655.94 (−7,462.39 to 150.50)	3.29
Inpatient cost	−5,332.275 (−9,597.60 to −1,066.95)*	2.93	−2,478.67 (−6,638.91 to 1,681.58)	6.22	−4,296.45 (−8,008.77 to −584.14)*	3.87
ED visit cost	−465.30 (−801.13 to −129.48)**	0.26	−524.40 (−904.68 to −144.12)**	1.42	−494.67 (−815.60 to −173.73)**	0.45
Outpatient cost	869.64 (390.18– 1,349.09)***	0.48	1,585.02 (952.98– 2,217.07)***	3.98	1,124.08 (654.43– 593.72)***	1.01
Admission times	−0.61** (−1.03 to −0.18)	3,009.34	−0.65 (−1.07 to −0.23)**	614.18	−0.63 (−0.97 to −0.28)**	1,775.40
Admission days	−7.21 (−11.50 to −2.92)**	252.59	−6.56 (−11.20 to −1.93)**	60.73	−6.97 (−10.61 to −0.28)***	159.31
ED-visit times	−0.81 (−1.33 to −0.28)**	2,258.87	−0.55 (−1.15 to 0.04)	722.11	−0.68 (−1.17 to −0.19)**	1,624.64

Notes: *p<0.05; **p<0.01; ***p<0.001.

Table 9 Health-Outcome Scores of the Two Groups (n=174)

	Intervention	Control	t
FEV1% predicted
Baseline	46.4±10.7	44.1±12.7	1.31
3 months	49.4±10.6	43.7±13.2	3.13**
6 months	49.4±10.3	42.5±12.5	3.96***
12 months	49.5±10.2	42.0±13.0	4.25***
24 months	48.3±10.1	40.5±11.8	4.67***
FVC
Baseline	1.89±0.57	1.82±0.56	0.81
3 months	1.91±0.51	1.80±0.57	1.36
6 months	1.98±0.48	1.77±0.52	2.77*
12 months	1.99±0.45	1.79±0.50	2.78*
24 months	1.96±0.46	1.80±0.48	2.12*
FEV1
Baseline	1.29±0.44	1.15±0.47	1.96
3 months	1.36±0.42	1.15±0.45	3.12***
6 months	1.46±0.45	1.15±0.46	4.44*
12 months	1.46±0.47	1.15±0.40	4.71***
24 months	1.45±0.43	1.13±0.42	4.82***
6MWD
Baseline	372.6±41.6	382.5±43.3	−1.54
3 months	493.6±70.3	388.7±53.9	11.01***
6 months	486.5±60.6	390.7±58.9	10.58***
12 months	474.8± 52.8	389.1±60.8	9.90***
24 months	458.7±51.0	390.3±58.5	8.21***
mMRC
Baseline 3 months	2.1±0.6 1.3±0.6	2.2±0.7 2.0±0.7	−1.69 –7.34***
6 months	1.2±0.4	2.0±0.7	−9.38***
12months	1.3±0.5	2.0±0.8	−7.56***
24 months	1.5±0.6	2.1±0.8	−5.88***
CAT
Baseline	24.1±3.8	24.0±3.6	0.16
3 months	18.7±3.5	22.5±3.5	−7.26***
6 months	17.8±3.5	22.1±4.6	−6.97***
12 months	17.5±4.0	22.0±3.7	−7.80***
24 months	17.8±4.6	22.0±4.1	−6.66***
Self-management
Baseline	123.0±20.3	125.8±17.0	−1.02
3 months	171.7±24.2	136.1±21.0	10.36***
6 months	171.7±24.2	134.9±19.0	14.81***
12 months	173.0±19.3	134.2±17.9	13.75***
24 months	170.2±18.2	134.9±18.7	12.60***

Notes: Independent-sample t-tests used. *p<0.05; **p<0.01; ***p<0.001.

Table 10 Changes in Health Outcomes in Hospital-Outreach PR Program Compared with Usual Care (n=174)

	β (95% CI), 3 months	β (95% CI), 6 months	β (95% CI), 12 months	β (95% CI), 24 months
mMRC	−0.908 (−1.091 to −0.704)***	−1.013 (−1.178 to −0.849)***	−0.943 (−1.119 to −0.767)***	−0.731 (−0.925 to −0.537)***
6MWD	111.129 (93.785–128.473)***	104.063 (88.378–119.748)***	92.313 (78.009–106.618)***	76.242 (62.237–90.246)***
FEV1	0.212 (0.081–0.343)**	0.305 (0.170–0.440)***	0.311 (0.173–0.449)***	0.279 (0.164–0.429)***
FVC	0.092 (−0.066  to 0.250)	0.160 (0.006–0.314)*	0.174 (0.024–0.324)*	0.136 (−0.015 to 0.287)
FEV1% predicted	5.352 (1.906–8.798)**	5.347 (1.933–8.762)***	5.405 (2.010–8.800)**	4.202 (0.815–7.590)*
CAT	−5.308 (−6.349 to −4.267)***	−6.155 (−7.198 to −5.112)***	−6.508 (−7.629 to −5.387)***	−6.167 (−7.384 to −4.950)***
Self-management	45.885 (39.678–52.092)***	47.956 (43.179–52.732)***	47.129 (41.800–52.559)***	44.403 (39.132–49.613)***

Notes: *p<0.05; **p<0.01; ***p<0.001.

Statistical Yearbook of Zunyi. Available from: http://www.zunyi.gov.cn/zwgk/jcxxgk/tjxx/tjnj/201711/t20171116_721918.html.

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