Original Study| Volume 22, ISSUE 12, P2478-2485.e1, December 2021

Palliative Rehabilitation Improves Health Care Utilization and Function in Frail Older Adults with Chronic Lung Diseases



      The Integrated Care for Advanced REspiratory Disorders (ICARE) service is a stay-in, post-acute care program for hospitalized patients with chronic, nonmalignant lung diseases. It provides palliative rehabilitation—a novel model integrating functional rehabilitation with early palliative care. We compare reduction of health care utilization among ICARE participants vs matched controls receiving usual care.


      This is a prospective, propensity score–matched study. Primary outcomes were reduction in hospital readmissions and length of stay and emergency department (ED) visits, comparing the period 6 months before and after ICARE, or 6 months before and after hospital discharge (for controls). Secondary outcomes included 6-minute walking distance (6MWD) and Modified Barthel Index (MBI).


      Participants were matched 1:1 to controls by age, respiratory diagnosis, socioeconomic strata, index hospitalization length of stay, frailty, and recent admissions into intensive care unit or noninvasive ventilation units.


      Multidisciplinary interventions focused on symptom relief, functional rehabilitation, targeted comorbidity management, and postdischarge care coordination.


      One hundred pairs of patients were matched. Participants were older adults (mean age 73.9 ± 8.2 years) with prolonged index hospitalization (median 12.0 days; interquartile range 7-18). Overall, 57% had high Hospital Frailty Risk Scores and 71% had overlapping respiratory diagnoses, the most common commonest being COPD (89%), followed by interstitial lung disease (54%) and bronchiectasis (28%). Small reductions in health care utilization were observed among controls. ICARE was associated with a further 9.1 ± 19.9 days’ reduction in hospitalization length of stay (P < .001), 0.8 ± 1.9 lesser admission (P < .001), and 0.6 ± 2.2 fewer ED visits (P < .02). Participants with longest index hospitalization were observed to have greatest reduction in length of stay. 6MWD and MBI scores improved by 41.0 ± 60.2 m and 12.3 ± 11.6 points, respectively (both P < .001). Greater improvement was observed in patients with lower baseline 6MWD and MBI scores. Prescription of slow-release opioids rose from 9% to 49%. Treatment for anxiety and depression rose from 5% to 19%.

      Conclusions and Implications

      Integrating palliative care with postexacerbation functional rehabilitation was associated with short-term reduction in health care utilization, improved functional capacity, and increased treatment of dyspnea, anxiety, and depression.


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        • Soriano J.B.
        • Abajobir A.A.
        • Abate K.H.
        • et al.
        Global, regional, and national deaths, prevalence, disability-adjusted life years, and years lived with disability for chronic obstructive pulmonary disease and asthma, 1990–2015: A systematic analysis for the global burden of disease study 2015.
        Lancet Respir Med. 2017; 5: 691-706
        • Guan W.J.
        • Han X.R.
        • de la Rosa-Carrillo D.
        • Martinez-Garcia M.A.
        The significant global economic burden of bronchiectasis: A pending matter.
        Eur Respir J. 2019; 53: 1802392
        • Hutchinson J.
        • Fogarty A.
        • Hubbard R.
        • McKeever T.
        Global incidence and mortality of idiopathic pulmonary fibrosis: A systematic review.
        Eur Respir J. 2015; 46: 795-806
        • Bhatt S.P.
        It's time to rehabilitate pulmonary rehabilitation.
        Ann Am Thorac Soc. 2019; 16: 55-57
        • Williams V.
        • Bruton A.
        • Ellis-Hill C.
        • McPherson K.
        The importance of movement for people living with chronic obstructive pulmonary disease.
        Qual Health Res. 2011; 21: 1239-1248
        • Lanken P.N.
        • Terry P.B.
        • Delisser H.M.
        • et al.
        An official American Thoracic Society clinical policy statement: Palliative care for patients with respiratory diseases and critical illnesses.
        Am J Respir Crit Care Med. 2008; 177: 912-927
        • Higginson I.J.
        • Reilly C.C.
        • Bajwah S.
        • et al.
        Which patients with advanced respiratory disease die in hospital? A 14-year population-based study of trends and associated factors.
        BMC Med. 2017; 15: 19
        • Gysels M.
        • Higginson I.J.
        Access to services for patients with chronic obstructive pulmonary disease: The invisibility of breathlessness.
        J Pain Symptom Manage. 2008; 36: 451-460
        • Reilly C.C.
        • Bausewein C.
        • Pannell C.
        • et al.
        Patients’ experiences of a new integrated breathlessness support service for patients with refractory breathlessness: Results of a postal survey.
        Palliat Med. 2016; 30: 313-322
        • Brighton L.J.
        • Miller S.
        • Farquhar M.
        • et al.
        Holistic services for people with advanced disease and chronic breathlessness: A systematic review and meta-analysis.
        Thorax. 2018; 74: 270-281
        • Schroedl C.J.
        • Yount S.E.
        • Szmuilowicz E.
        • et al.
        A qualitative study of unmet healthcare needs in chronic obstructive pulmonary disease. A potential role for specialist palliative care?.
        Ann Am Thorac Soc. 2014; 11: 1433-1438
        • Punekar Y.S.
        • Mullerova H.
        • Small M.
        • et al.
        Prevalence and burden of dyspnoea among patients with chronic obstructive pulmonary disease in five European countries.
        Pulm Ther. 2016; 2: 59-72
        • Puhan M.A.
        • Gimeno-Santos E.
        • Scharplatz M.
        • et al.
        Pulmonary rehabilitation following exacerbations of chronic obstructive pulmonary disease.
        Cochrane Database Syst Rev. 2011; 10: CD005305
        • Puhan M.A.
        • Gimeno-Santos E.
        • Cates C.J.
        • Troosters T.
        Pulmonary rehabilitation following exacerbations of chronic obstructive pulmonary disease.
        Cochrane Database Syst Rev. 2016; 12: CD005305
        • Hayton C.
        • Clark A.
        • Olive S.
        • et al.
        Barriers to pulmonary rehabilitation: Characteristics that predict patient attendance and adherence.
        Respir Med. 2013; 107: 401-407
        • Mathar H.
        • Fastholm P.
        • Lange P.
        • et al.
        Why do patients decline participation in offered pulmonary rehabilitation? A qualitative study.
        Clin Rehabil. 2017; 1 (269215517708821)
        • Stone R.A.
        • Holzhauer-Barrie J.
        COPD: Who cares when it matters most? National Chronic Obstructive Pulmonary Disease (COPD) Audit Programme: Outcomes from the clinical audit of COPD exacerbations admitted to acute units in England 2014.
        in: National supplementary report. RCP, London2017
        • Abernethy A.P.
        • Wheeler J.L.
        Total dyspnoea.
        Curr Opin Support Palliat Care. 2008; 2: 110-113
        • Valentijn P.P.
        • Schepman S.M.
        • Opheij W.
        • Bruijnzeels M.A.
        Understanding integrated care: A comprehensive conceptual framework based on the integrative functions of primary care.
        Int J Integr Care. 2013; 13: e010
        • Spathis A.
        • Booth S.
        • Moffat C.
        • et al.
        The breathing, thinking, functioning clinical model: A proposal to facilitate evidence-based breathlessness management in chronic respiratory disease.
        NPJ Prim Care Respir Med. 2017; 27: 27
        • Lim K.E.
        • Kim S.R.
        • Kim H.K.
        • Kim S.R.
        Symptom clusters and quality of life in subjects with COPD.
        Respir Care. 2017; 62: 1203-1211
        • Charlson M.E.
        • Pompei P.
        • Ales K.L.
        • MacKenzie C.R.
        A new method of classifying prognostic comorbidity in longitudinal studies: Development and validation.
        J Chronic Dis. 1987; 40: 373-383
        • Gilbert T.
        • Neuburger J.
        • Kraindler J.
        • et al.
        Development and validation of a Hospital Frailty Risk Score focusing on older people in acute care settings using electronic hospital records: An observational study.
        Lancet. 2018; 391: 1775-1782
        • ATS Statement
        Guidelines for the six-minute walk test.
        Am J Respir Crit Care Med. 2002; 166: 111-117
        • Shah S.
        • Vanclay F.
        • Cooper B.
        Improving the sensitivity of the Barthel Index for stroke rehabilitation.
        J Clin Epidemiol. 1989; 42: 703-709
        • Leuven E.
        • Sianesi B.
        PSMATCH2: Stata module to perform full Mahalanobis and propensity score matching, common support graphing, and covariate imbalance testing.
        • Kwok B.C.
        • Pua Y.H.
        • Mamun K.
        • Wong W.P.
        The minimal clinically important difference of six-minute walk in Asian older adults.
        BMC Geriatr. 2013; 13: 23
        • Holland A.E.
        • Spruit M.A.
        • Troosters T.
        • et al.
        An official European Respiratory Society/American Thoracic Society technical standard: Field walking tests in chronic respiratory disease.
        Eur Respir J. 2014; 44: 1428-1446
        • Spitzer K.A.
        • Stefan M.S.
        • Priya A.
        • et al.
        Participation in pulmonary rehabilitation after hospitalization for chronic obstructive pulmonary disease among Medicare beneficiaries.
        Ann Am Thorac Soc. 2019; 16: 99-106
        • Katajisto M.
        • Laitinen T.
        Estimating the effectiveness of pulmonary rehabilitation for COPD exacerbations: Reduction of hospital inpatient days during the following year.
        Int J Chron Obstruct Pulmon Dis. 2017; 12: 2763-2769
        • Donaldson G.C.
        • Wilkinson T.M.
        • Hurst J.R.
        • et al.
        Exacerbations and time spent outdoors in chronic obstructive pulmonary disease.
        Am J Respir Crit Care Med. 2005; 171: 446-452
        • Maddocks M.
        • Kon S.S.
        • Canavan J.L.
        • et al.
        Physical frailty and pulmonary rehabilitation in COPD: A prospective cohort study.
        Thorax. 2016; 71: 988-995
        • Nici L.
        • Donner C.
        • Wouters E.
        • et al.
        American thoracic society/European respiratory society statement on pulmonary rehabilitation.
        Am J Respir Crit Care Med. 2006; 173: 1390-1413
        • Reticker A.L.
        • Nici L.
        • ZuWallack R.
        Pulmonary rehabilitation and palliative care in COPD: Two sides of the same coin?.
        Chron Respir Dis. 2012; 9: 107-116
        • Janssen D.J.A.
        • McCormick J.R.
        Palliative care and pulmonary rehabilitation.
        Clin Chest Med. 2014; 35: 411-421
        • Silver J.K.
        • Raj V.S.
        • Fu J.B.
        • et al.
        Cancer rehabilitation and palliative care: Critical components in the delivery of high-quality oncology services.
        Support Care Cancer. 2015; 23: 3633-3643
        • Luckett T.
        • San Martin A.
        • Currow D.C.
        • et al.
        A systematic review and meta-analysis of studies comparing burden from lung cancer and chronic obstructive pulmonary disease.
        Palliat Med. 2020; 34: 1291-1304
        • Halpin D.M.G.
        Palliative care for chronic obstructive pulmonary disease. Signs of progress, but still a long way to go.
        Am J Respir Crit Care Med. 2018; 198: 1356-1358
        • Meffert C.
        • Hatami I.
        • Xander C.
        • Becker G.
        Palliative care needs in COPD patients with or without cancer: An epidemiological study.
        Eur Respir J. 2015; 46: 663-670
        • Mahler D.A.
        • Selecky P.A.
        • Harrod C.G.
        • et al.
        American College of Chest Physicians consensus statement on the management of dyspnea in patients with advanced lung or heart disease.
        Chest. 2010; 137: 674-691
        • Marciniuk D.D.
        • Goodridge D.
        • Hernandez P.
        • et al.
        Managing dyspnea in patients with advanced chronic obstructive pulmonary disease: A Canadian thoracic society clinical practice guideline.
        Can Respir J. 2011; 18: 69-78
        • Ahmadi Z.
        • Bernelid E.
        • Currow D.C.
        • Ekström M.
        Prescription of opioids for breathlessness in end-stage COPD: A national population-based study.
        Int J Chron Obstruct Pulmon Dis. 2016; 11: 2651-2657
        • Yohannes A.M.
        • Junkes-Cunha M.
        • Smith J.
        • Vestbo J.
        Management of dyspnea and anxiety in chronic obstructive pulmonary disease: A critical review.
        J Am Med Dir Assoc. 2017; 18: 1096.e1-1096.e17
        • Yohannes A.M.
        • Mülerová H.
        • Lavoie K.
        • et al.
        The association of depressive symptoms with rates of acute exacerbations in patients with COPD: Results from a 3-year longitudinal follow-up of the ECLIPSE Cohort.
        J Am Med Dir Assoc. 2017; 18: 955-959.e6
        • GBD Chronic Respiratory Disease Collaborators
        Prevalence and attributable health burden of chronic respiratory diseases, 1990-2017: A systematic analysis for the global burden of disease study 2017.
        Lancet Respir Med. 2020; 8: 585-596
        • Vitacca M.
        • Comini L.
        • Tabaglio E.
        • et al.
        Tele-assisted palliative homecare for advanced chronic obstructive pulmonary disease: A feasibility study.
        J Palliat Med. 2019; 22: 173-178
        • Janssens J.P.
        • Weber C.
        • Herrmann F.R.
        • et al.
        Can early introduction of palliative care limit intensive care, emergency and hospital admissions in patients with severe chronic obstructive pulmonary disease? A pilot randomized study.
        Respiration. 2019; 97: 406-415
        • Scheerens C.
        • Pype P.
        • Van Cauwenberg J.
        • et al.
        Early integrated palliative home care and standard care for end-stage COPD (EPIC): A phase II pilot RCT testing feasibility, acceptability, and effectiveness.
        J Pain Symptom Manage. 2020; 59: 206-224
        • Vasilopoulou M.
        • Papaioannou A.I.
        • Kaltsakas G.
        • et al.
        Home-based maintenance tele-rehabilitation reduces the risk for acute exacerbations of COPD, hospitalisations and emergency department visits.
        Eur Respir J. 2017; 49: 1602129
        • Austin P.C.
        An introduction to propensity score methods for reducing the effects of confounding in observational studies.
        Multivariate Behav Res. 2011; 46: 399-424
        • Verma J.Y.
        • Amar C.
        • Sibbald S.
        • Rocker G.M.
        Improving care for advanced COPD through practice change: Experiences of participation in a Canadian spread collaborative.
        Chron Respir Dis. 2018; 15: 5-18
        • Smallwood N.
        • Thompson M.
        • Warrender-Sparkes M.
        • et al.
        Integrated respiratory and palliative care may improve outcomes in advanced lung disease.
        ERJ Open Res. 2018; 4: 00102-2017