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

Alex R Jenkins, Holly Gowler, Ffion Curtis, Neil S Holden, Christopher Bridle, Arwel W Jones, Alex R Jenkins, Holly Gowler, Ffion Curtis, Neil S Holden, Christopher Bridle, Arwel W Jones

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.

Keywords: exacerbations; health outcomes; hospitalization; pulmonary rehabilitation; supervised maintenance programs.

Conflict of interest statement

Disclosure The authors report no conflicts of interest in this work.

Figures

Figure 1
Figure 1
Flow diagram of study selection. Note:aSome studies excluded for multiple reasons.
Figure 2
Figure 2
Trial-level data, effect estimates, and forest plot of comparison for the overall risk (of experiencing at least one event) (A) and incidence rates (B) of respiratory-cause hospitalization. Abbreviations: CI, confidence interval; IV, inverse variance; SE, standard error.
Figure 3
Figure 3
Trial-level data, effect estimates, and forest plot of comparison for the overall risk (of experiencing at least one event) (A) and incidence rates (B) of exacerbation requiring treatment with medication. Abbreviations: CI, confidence interval; IV, inverse variance; SE, standard error.
Figure 4
Figure 4
Trial-level data, effect estimates, and forest plot of comparison for the risk of mortality. Abbreviations: CI, confidence interval; IV, inverse variance.
Figure 5
Figure 5
Sensitivity analyses on trial-level data, effect estimates, and forest plot of comparison for the risk of hospital admission for a respiratory cause excluding Guell et al. Abbreviations: CI, confidence interval; IV, inverse variance.
Figure 6
Figure 6
Sensitivity analyses on trial-level data, effect estimates, and forest plot of comparison for the risk of hospital admission for a respiratory cause including 0–12 months follow-up of Guell et al. Abbreviations: CI, confidence interval; IV, inverse variance.

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