1. 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

2. Disclosures
No disclosures

3. 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.

4. 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

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

6. 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

7. Methods: Design Retrospective study
Pulmonary rehab use in COPD subjects
Period:
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:

8. Methods: Study Cohort 491.x [chronic bronchitis] 492.x [emphysema] or
Diagnosis of COPD
Two outpatient or consultation visits
E &M codes: , or
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)

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.

10. 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, (1): p
Comorbidity Software, Version [cited Jan 2013]; Available from:

11. 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, , 97116, 97124, 97139, 97150, , 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, , 97116, 97124, 97139, 97150, 97530, 97535, 97537) with primary ICD-9 codes (491.x, 492.x, or 496.x).

12. 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

13. 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

14. 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.

15. 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
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)

16. 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)

17. 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

18. 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% ( )
The number of sessions completed has also increased during that time period
Overall, PR utilization remains low