Trends in Use of Pulmonary Rehabilitation Among Older Adults with Chronic Obstructive Pulmonary Disease Anita C. Mercado, Shawn P. Nishi, Wei Zhang, Yong-Fang Kuo, Gulshan Sharma Department Name Goes Here

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Pulmonary rehabilitation Evidence-based, multidisciplinary and comprehensive intervention for patients with chronic respiratory disease Symptomatic with decreased daily life activities Individualized treatment designed Reduce symptoms Optimize functional status Increased participation Possibly reduced healthcare costs By stabilizing or reversing systemic manifestations Evid … for pts with chronic resp dz Indiv tx designed to ATS/ERS statement on pulmonary rehabilitation. Am J of Respiratory Crit Care Med 2006: 173 (12): 1390 – 1413.

Pulmonary rehabilitation Standard of care for chronic lung disease ATS/ERS COPD- largest number of PR referrals Majority of the literature focuses on COPD (ATS/ERS 2006, Toosters 2005) Systemic effects of the illness well described Medicare approved pulmonary rehabilitation ***for ### sessions/yr over lifetime. Standard of care- based on a body of literature-PR

Background Medicare approved pulmonary rehabilitation ***for ### sessions/yr over lifetime. Standard of care- based on a body of literature-PR

Objective PR use in the general population remains low. We examined the rate of pulmonary rehabilitation and factors associated with receipt of pulmonary rehabilitation in patients with COPD using a 5% national sample of Medicare beneficiaries. Standard of care- based on a body of literature-PR

Methods: Design Retrospective study Pulmonary rehab use in COPD subjects Period: 2003-2009 Center for Medicare and Medicaid Services select a random sample 5% sample base on 8th and 9th digits Health insurance claim number (05, 20, 45, 70, 95) standard available for research purposes has been shown to be representative of the whole cohort [1]. Medicare data file descriptions. [cited January 24, 2013]; Available from: www.resdac.umb.edu/Medicare/file_descritions.asp.

Methods: Study Cohort 491.x [chronic bronchitis] 492.x [emphysema] or Diagnosis of COPD Two outpatient or consultation visits E &M codes: 99201-99205, 99211-99215 or 99241-99245 At least 30 days apart in one year One acute care hospitalization with 1° discharge diagnosis of COPD Based on the following ICD-9 codes 491.x [chronic bronchitis] 492.x [emphysema] or 496 [chronic airway obstruction] A patient met the diagnosis of COPD who had any of the following:; Evaluation and Management codes; International Classification of Diseases, 9th revision (ICD-9)

Methods: Study Cohort Separate denominator file of beneficiaries (2003, 2006, 2009): Diagnosis of COPD Age ≥66 years Complete enrollment (Part A and? B) ± in year Not enrolled in an HMO Not a resident of a nursing facility ± in year Each file was composed of participants in the year of interest who: 1) had a diagnosis of COPD; 2) was age ≥66 years; 3) had complete enrollment (Part A, Part B) in the year prior to and the year of interest; 4) were not enrolled in a health maintenance organization [HMO]); and 5) were not a resident of a nursing facility in the year of interest or one year prior.

Variables Age (66–74, 75–84, ≥85 years) Gender: M/F Race/ethnicity -White, Black and Others Medicaid eligibility (state buy-in) proxy for low socioeconomic status comorbidity score (0, 1, 2, ≥3) 27 Elixhauser comorbidity score (excluding COPD) from inpatient and outpatient billing data [2, 3]. Geographic regions- 9 CMS regions Elixhauser, A., et al., Comorbidity measures for use with administrative data. Med Care, 1998. 36(1): p. 8-27. Comorbidity Software, Version 3.7. 2013 [cited Jan 2013]; Available from: http://www.hcup-us.ahrq.gov/toolssoftware/comorbidity/comorbidity.jsp.

Outcome Measures PR performed in each year of interest for subjects with COPD PR identified- healthcare common procedure coding system (HCPCS) Codes: G0237, G0238, G0239 E&M codes (97001, 97003, 97110, 97116, 97124, 97139, 97150, 97530, 97535, 97537) with Primary ICD-9 codes (491.x, 492.x, or 496.x). Our outcome of interest was pulmonary rehabilitation performed in each calendar year of interest for subjects with COPD. Pulmonary rehabilitation was identified through the healthcare common procedure coding system (HCPCS) codes (G0237, G0238, G0239) or the evaluation and management (E&M) codes (97001, 97003, 97110, 97116, 97124, 97139, 97150, 97530, 97535, 97537) with primary ICD-9 codes (491.x, 492.x, or 496.x).

Characteristics of PR utilization among COPD patients (2003-2009)   COPD patients of 2003 COPD patients of 2006 COPD patients of 2009 Total PR No-PR Overall 33526 869 (2.59) 32657 (97.4) 32337 1082 (3.35) 31255 (96.7) 30255 1100 (3.64) 29155 (96.4) Age 66-74 16134 503 (3.12) 15631 (96.9) 15185 597 (3.93) 14588 (96.1) 12825 521 (4.06) 12304 (95.9) 75-84 14464 336 (2.32) 14128 (97.7) 14040 421 (3.00) 13619 (97.0) 13313 493 (3.70) 12820 (96.3) >=85 2928 30 (1.02) 2898 (98.9) 3112 64 (2.06) 3048 (97.9) 4117 86 (2.09) 4031 Gender Male 16652 394 (2.37) 16258 (97.6) 16043 560 (3.49) 15483 (96.5) 14759 542 (3.67) 14217 Female 16874 475 (2.81) 16399 (97.2) 16294 522 (3.20) 15772 (96.8) 15496 558 (3.60) 14938 Race White 30490 831 (2.73) 29659 (97.3) 29465 1027 28438 27567 1045 (3.79) 26522 (96.2) Black 1842 26 (1.41) 1816 (98.6) 1660 32 (1.93) 1628 (98.1) 1618 35 (2.16) 1583 (97.8) Others 1194 12 (1.01) 1182 1212 23 (1.90) 1189 (98.1) 1070 20 (1.87) 1050 Low socioeconomic No 27916 778 (2.79) 27138 26955 977 (3.62) 25978 25224 998 (3.96) 24226 (96.0) Yes 5610 91 (1.62) 5519 (98.4) 5382 105 (1.95) 5277 5031 102 (2.03) 4929

Characteristics of PR utilization among COPD patients (2003-2009)   COPD patients of 2003 COPD patients of 2006 COPD patients of 2009 Total PR No-PR Provider PCP only 18600 321 (1.73) 18279 (98.3) 16695 389 (2.33) 16306 (97.7) 14529 384 (2.64) 14145 (97.4) PUL only 2989 94 (3.14) 2895 (96.9) 2647 (3.55) 2553 (96.5) 2516 78 (3.10) 2438 (96.9) PCP + PUL 9731 423 (4.35) 9308 (95.7) 10771 567 (5.26) 10204 (94.7) 11250 606 (5.39) 10644 (94.6) Others 2206 31 (1.41) 2175 (98.6) 2224 32 (1.44) 2192 (98.6) 1960 (1.63) 1928 (98.4) Elixhauser Comorbidity Score   8780 222 (2.53) 8558 (97.5) 6971 205 (2.94) 6766 (97.1) 5319 177 (3.33) 5142 (96.7) 1 9131 233 (2.55) 8898 8359 272 (3.25) 8087 (96.8) 7147 266 (3.72) 6881 (96.3) 2 6562 162 (2.47) 6400 6710 (3.47) 6477 (96.5) 6339 228 (3.60) 6111 (96.4) >=3 9053 252 (2.78) 8801 (97.2) 10297 372 (3.61) 9925 11450 429 (3.75) 11021

Patients level Pulmonary Rehabilitation sessions by year (%), 2003-2009   2003 2004 2005 2006 2007 2008 2009 sessions 1 – 4 57.7 54.6 55.7 57.0 52.8 56.5 5 – 8 26.7 28.4 26.9 25.9 24.9 25.6 24.6 >8 15.7 16.9 17.4 17.0 19.4 21.6 18.9 Among COPD patients who received pulmonary rehabilitation, there was a small increase in those participating in >8 sessions.

Multivariate Analysis Variable Model 1 Odds of PR (95% CI) Model 2 Diagnosed Year   2003 1.00 2004 1.20 (1.10 – 1.31) 1.18 (1.08 – 1.29) 2005 1.23 (1.12 – 1.34) 2006 1.30 (1.19 – 1.43) 1.26 (1.15 – 1.37) 2007 1.32 (1.20 – 1.44) 1.25 (1.15 – 1.37) 2008 1.35 (1.23 – 1.48) 1.28 (1.17 – 1.41) 2009 1.41 (1.29 – 1.55) Age Group 66 - 74 75 - 84 0.79 (0.75 – 0.84) >= 85 0.48 (0.43 – 0.53) Gender Male Female 0.97 (0.92 – 1.02) Race White Black 0.97 (0.76 – 1.25) Others 1.32 (1.14 – 1.53) Low socioeconomic No Yes 0.60 (0.55 – 0.66)

Multivariate Analysis Variable Model 1 Odds of PR (95% CI) Model 2 Comorbidity   1.00 1 1.01 (0.94 – 1.09) 2 1.10 (1.02 – 1.19) >=3 1.18 (1.10 – 1.26) Provider PCP only PUL only 1.44 (1.25 – 1.66) PCP + PUL 3.20 (2.78 – 3.69) Others 2.22 (1.89 – 2.60)

PR rate per 10,000 person-months among COPD patients (2003 – 2009) 22.2 26.5 27.1 28.7 29.0 29.7 31.0

Conclusions Factors associated with utilization of pulmonary rehabilitation: Age <75 yo Multiple comorbidities Higher socioeconomic status Involvement of a pulmonary physician in care PR utilization overall has increased from 2.59% to 3.64% (2003-2009) The number of sessions completed has also increased during that time period Overall, PR utilization remains low