Lower mortality after early supervised pulmonary rehabilitation following COPD-exacerbations: a systematic review and meta-analysis

Ryrsø, Camilla Koch; Godtfredsen, Nina Skavlan; Kofod, Linette Marie; Lavesen, Marie; Mogensen, Line; Tobberup, Randi; Farver-Vestergaard, Ingeborg; Callesen, Henriette Edemann; Tendal, Britta; Lange, Peter; Iepsen, Ulrik Winning

doi:10.1186/s12890-018-0718-1

Table 2 GRADE Evidence Profile

From: Lower mortality after early supervised pulmonary rehabilitation following COPD-exacerbations: a systematic review and meta-analysis

Supervised early PR versus usual care for patients with acute exacerbation of COPD
Outcome Timeframe	Study results and measurements	Absolute effect estimates		Certainty in the effects estimates (Quality of evidence)	Plain text summary
Outcome Timeframe	Study results and measurements	Usual care	Early PR	Certainty in the effects estimates (Quality of evidence)	Plain text summary
Mortality End of treatment Critical	Relative risk 0.58 (CI 95% 0.35–0.98) Based on data from 319 patients (4 studies)	173 per 1.000	100 per 1.000	Moderate Due to serious risk of bias^a	Early pulmonary rehabilitation probably decreases mortality at the end of treatment
Mortality End of treatment Critical		Difference: 73 fewer per 1.000 (CI 95% 112 fewer - 3 fewer)		Moderate Due to serious risk of bias^a
Mortality Longest follow-up Critical	Relative risk 0.55 (CI 95% 0.12–2.57) Based on data from 127 patients (3 studies)	63 per 1.000	35 per 1.000	Low Due to serious risk of biasand serious risk of imprecision^a,b	Early pulmonary rehabilitation may decrease mortality slightly at the longest follow-up
Mortality Longest follow-up Critical		Difference: 28 fewer per 1.000 (CI 95% 55 fewer - 99 more)
Days in hospital End of treatment Important	Measured by: Days Lower is better Based on data from 180 patients (1 study)	0.86 (mean)	4.59 (mean)	Moderate Due to serious imprecision^c	Early pulmonary rehabilitation probably decreases days in hospital at the end of treatment
Days in hospital End of treatment Important		Difference: MD 4.27 lower (CI 95% 6.85 lower - 1.69 lower)		Moderate Due to serious imprecision^c
Days in hospital Longest follow-up Important					No studies were found that looked at number of days in hospital at the longest follow-up
Readmission due to exacerbation End of treatment Important					No studies were found that looked at readmission to hospital due to exacerbation at the end of treatment
Readmission due to exacerbation Longest follow-up Important	Rate ratio 0.47 (CI 95% 0.29–0.75) Based on data from 365 patients (6 studies)			Moderate Due to serious risk of bias^a,d	Early pulmonary rehabilitation probably decreases readmission to hospital due to exacerbation at the longest follow-up
Health-related quality of life End of treatment Important	Measured by: SGRQ Lower is better Based on data from 86 patients (2 studies)	Difference: MD 19.43 lower (CI 95% 29.09 lower - 9.77 lower)		Low Due to serious risk of bias and serious risk of imprecision^a,c	Early pulmonary rehabilitation may improve health-related quality of life at the end of treatment
Health-related quality of life Longest follow-up Important	Measured by: SGRQ Lower is better Based on data from 323 patients (4 studies)	Difference: MD 8.74 lower (CI 95% 12.02 lower - 5.45 lower)		Moderate Due to serious risk of bias^a,d	Early pulmonary rehabilitation probably improves health-related quality of life at the longest follow-up
Exercise capacity End of treatment Important	Measured by: SWT (meters) Higher is better Based on data from 95 patients (3 studies)	Difference: MD 54.7 more (CI 95% 30.83 more - 78.57 more)		Moderate Due to serious risk of bias^a,d	Early pulmonary rehabilitation probably increases exercise capacity at the end of treatment
Exercise capacity End of treatment Important	Measured by: 6MWT (meters) Higher is better Based on data from 274 patients (5 studies	Difference: MD 76.89 more (CI 95% 21.34 more - 132.45 more)		Low Due to serious risk of bias and serious inconsistency^a,d,e	Early pulmonary rehabilitation probably increases exercise capacity at the end of treatment
Exercise capacity Longest follow-up Important	Measured by: SWT (meters) Higher is better Based on data from 2017 patients (3 studies)	Difference: MD 90.27 higher (CI 95% 69.53 lower - 250.08 higher)		Low Due to serious risk of bias and serious inconsistency leading to serious imprecision^a,b,d,e	Early pulmonary rehabilitation may increase exercise capacity at the longest follow-up
Dropout rate End of treatment Important	Relative risk 0.99 (CI 95% 0.71–1.39) Based on data from 440 patients (8 studies)	217 per 1.000	215 per 1.000	Moderate Due to serious risk of bias^a,d	Early pulmonary rehabilitation probably has little impact on the dropout rate at the end of treatment
Dropout rate End of treatment Important		Difference: 2 fewer per 1.000 (CI 95% 63 fewer - 85 more)		Moderate Due to serious risk of bias^a,d
Dropout rate Longest follow-up Important	Relative risk 1.05 (CI 95% 0.6–1.85) Based on data from 181 patients (3 studies)	202 per 1.000	212 per 1.000	Moderate Due to serious risk of bias^a,d	Early pulmonary rehabilitation probably has little impact on dropout at the longest follow-up
Dropout rate Longest follow-up Important		Difference: 10 more per 1.000 (CI 95% 81 fewer - 172 more)		Moderate Due to serious risk of bias^a,d
Falls Longest follow-up Important					No studies were found that looked at falls at the longest follow-up
Activities of daily living End of treatment Important					No studies were found that looked at activities of daily living at the end of treatment
Activities of daily living Longest-follow-up Important					No studies were found that looked at activities of daily living at the longest follow-up

CI confidence interval, COPD chronic obstructive pulmonary disease, MD middle difference, PR pulmonary rehabilitation, SGRQ St. George’s Respiratory Questionnaire, SWT Shuttle Walking Test, 6MWT 6 min walking test
Quality of evidence. High quality: We are very confident that the true effect lies close to that of the estimate of the effect; Moderate quality: We are moderately confident in the effect estimate, the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different; Low quality: Our confidence in the effect estimate is limited, the true effect may be substantially different from the estimate of the effect
^aRisk of bias: Serious. Unclear/inadequate sequence generation and unclear/inadequate concealment of allocation during randomization process resulting in potential for selection bias
^bRisk of imprecision: Serious. Wide confidence intervals
^cRisk of imprecision: Serious. Low number of patients
^dRisk of bias: Serious. Inadequate/unclear or lack of blinding of outcome assessors resulting in potential for detection bias
^eRisk of inconsistency: Serious. The magnitude of statistical heterogeneity was high

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ISSN: 1471-2466

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