Economic Analysis of

Rehabilitation*

Respiratory

Roger S. Goldstein, MBChB, FCCP; Elaine H. Gort, MSc;

Gordon H. Guyatt, MD, MSc; and David Feeny, PhD
Study objective: We report on the incremental costs associated with improvements in healthrelated quality of life (HRQL) following 6 months of respiratory rehabilitation compared with
conventional community care.
Design: Prospective randomized controlled trial of rehabilitation.
Setting: A respiratory rehabilitation unit.
Participants: Eighty-four subjects who completed the rehabilitation trial.
Intervention: Two months of inpatient rehabilitation followed by 4 months of outpatient
supervision.

Measurements and results: All costs (hospitalization, medical care, medications, home care,
assistive devices, transportation) were included. Simultaneous allocation was used to determine

indirect hospitalization costs. The incremental cost of achieving improve

capital and direct and
minimal
the
clinically important difference in dyspnea, emotionalto function, and
beyond
More than 90% of this cost was attributable the inpatient
was
(Canadian).
$11,597
mastery
the nonphysician health-care professionals, nursing was identified as
phase of the program. Offollowed
the largest cost center,
therapy. The number of
by physical therapy and occupational
4.1
was
for
one
to
treated
to
be
needed
(NNT) improve
dyspnea, 4.4 for fatigue,
subject
subjects
3.3 for emotion, and 2.5 for mastery.
Conclusion: Cost estimates of various approaches to rehabilitation should be combined with valid,
reliable, and responsive measures of outcome to enable cost-effectiveness measures to be
reported. Comparison studies with the same method are necessary to determine whether the
improvements in HRQL that follow inpatient rehabilitation are cheap or expensive. Such
information will be important in identifying the extent to which alternative approaches to
rehabilitation can influence resource allocation. A consideration of cost-effectiveness from the
perspective of NNT may be useful in the evaluation of health-care programs.
ments

(CHEST 1997; 112:370-79)

Abbreviations: CRQ=chronic respirator)' questionnaire; HRQL=health-related quality of life; NNT=number needed
to treat; WMS=W7orkload Measurement System

/^ OPD remains a major public health problem. Its

^^ natural history is one of progression to disability
and death from respiratory failure at a relatively early
age. The need for repeated admissions to hospital
and ongoing outpatient medical supervision has re*From the Department of Medicine (Dr. Goldstein) and Institute
of Clinical Evaluative Studies (Ms. Gort), University of Toronto,
Toronto, Ontario, and the Department of Clinical Epidemiology
and Biostatistics (Dr. Guyatt), and the Centre for Health
Economics and Policy Analysis (Dr. Feeny), McMaster Univer
Ontario, Canada.
sity, Hamilton,
in part by the West Park Hospital Foundation and
Supported
the Ontario Ministry of Health grant 02196, and by the Respi
rator)/ Health Network of Centres of Excellence.
Manuscript received November 22, 1996; revision accepted

February 25, 1997.

Reprint requests: Roger S. Goldstein, MBChB, do West Park

Hospital, 82 Buttomvood Ave, Toronto, ON, Canada M6M 2J5;

email:

roger.goldstein@utoronto.ca

suited in this condition having an important impact

the utilization of health-care resources.
Respiratory rehabilitation programs are becoming
accepted as important in the treatment of patients
with COPD.1 Such programs aim to alleviate and
control symptoms as well as to address the secondary
deconditioning and emotional sequelae that fre
quently accompany any chronic respiratory condi
on

tion.2
In view of the commitment asked of the

patients,

their families, and the health-care professionals,

those who recommend respiratory rehabilitation
should be able to justify it by demonstrating im
provements in health-related quality of life (HRQL)
and functional exercise tolerance attributable to the
rehabilitation program. Since pressure to rationalize
health-care services both in Europe and in North
America continues to grow, it is also important for

370
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Clinical

Investigations

those who advise or allocate health-care resources to

be aware of the additional costs involved in providing
respiratory rehabilitation as compared with conven
tional community care.
In a recent study, we compared 6 months of
supervised rehabilitation (2 months inpatient and 4

outpatient) with conventional community

care in which patients received their usual care from
their primary care physician with no emphasis on
rehabilitation. We found clinically important and
months

statistically
significant improvements in our primary
outcome measures of exercise tolerance and

HRQL.3 We also included an economic evaluation in

which all costs associated with the inpatient and the
outpatient phases of our program were calculated
and compared with costs associated with the pa
tients' usual care. This economic analysis forms the
subject of this report.
Materials

and

Methods

The economic analysis was included as part of a prospective

randomized controlled trial of respiratory rehabilitation that has
been described in detail elsewhere.3 We randomized 89 patients
to either a treatment (n=45) or a control (n=44) group. At the
time of randomization, we recorded the use of community
services, coverage by government programs, and particulars of
the patient's insurance coverage. We showed all patients how to
use customized "diaries" to record medical appointments and

tests,

community services accessed, prescriptions filled, assistive

devices purchased, and any expenses associated with transporta

tion. Patients mailed their completed diaries to the study coor
dinator at the end of each month. Patients assigned to the control
group completed their diaries throughout the study, and those
assigned to the treatment group did so for the 4-month outpatient
phase of the rehabilitation program.

Program Description
During the 2-month inpatient phase, the patients were based
at the facility from Monday to Friday. The inpatient activities
included supervised exercise training, patient education, and
psychosocial support. The exercise component included breath
ing classes, treadmill walking, leisure walking, upper extremity
exercises, and interval training. Therapists modified the training
regimen and increased the work levels according to the patient's

symptom limitation. Patient education included group lectures,

information, and individual teaching from a member of

written

the team. Recreational activities and relaxation classes were the

principal psychosocial supports. During the 4-month outpatient

phase, the patients were based at home. They continued with a
daily home exercise program while being enrolled in a graduated
discharge program structured to allow lengthening periods be
tween each encounter. The graduated discharge schedule in
cluded three to four home-care visits by the physical therapist as
well as four to five outpatient appointments for supervised
training.

Patients allocated to conventional community care received

their usual clinical care from their family practitioners and/or
respiratory specialist with no special attention to rehabilitation.
The frequency of office or home visits was determined entirely by
the physician's and patient's judgment. The use of community

support services such as home care (nursing, physical therapy,

home assistance) was noted by the patients in their diaries and
confirmed during follow-up interviews.

Viewpoint
cost analysis was designed to measure the incremental
associated with 6 months of respiratory rehabilitation
compared with conventional community care. The viewpoint of
the cost analysis was that of society. Thus, we included costs
regardless of whether they were borne by government, private
insurers, or the patients. In the current Canadian health-care
system, funding is predominantly by public funds administered
by the government. The provincial Drug Benefit Plan covers the
costs of medication and supplemental oxygen for residents aged
65 years and older and for those who receive social assistance.
Costs associated with upgrading ward accommodation were
considered to be optional and we therefore did not consider them
as "program or treatment." Out-of-pocket costs for television or
telephone were treated similarly. The mean SD age of 66
patients recently discharged from our program (prior to this
study) was 688 years. The vast majority were not actively
in the work force and therefore our economic analysis
engaged
did not include differences in indirect benefits (productivity
gains) between groups. Also, we did not include potential cost
savings associated with the hospitalization phase of the study
(utilities, food, etc) which were likely to have been very small,
especially in the context of a family setting.

The

costs

Costs

The incremental costs of respiratory rehabilitation vs commu

care were assessed. The following costs were identified:
hospitalization (by service); medical care; medications; homecare services; assistive devices; and transportation costs.

nity

Measurement of Costs

Hospitalization Costs: The fiscal year 1989 was chosen as the

determining hospital costs. Each hospital cost
center was assigned to one of three categories based on its
relationship to the respiratory rehabilitation program. The cate
gories were service, support, and miscellaneous.
Service departments were defined as those providing direct
care services to those in the
base year for

respiratory rehabilitation
the
service
program. Departments
category were as follows:
nursing, physical therapy, occupational therapy, respiratory ther
apy, social work, radiology, pharmacy, and laboratory. Support
departments were defined as those providing indirect services to
respiratory rehabilitation patients by supporting the designated
service departments. These were general administration, nursing
administration, financial services, human resources, community

patient

in

relations, quality assurance, occupational health, plant operation

and maintenance, transportation, housekeeping, food services,

materials management, communications, linen and laundry ser
vices, admitting, clinical records, central supply, and library.
The departments in the miscellaneous category provided ser
vices or support to patients in other programs. They were the
other 14 nursing units, the ambulatory clinic, the day hospital,

chiropody, communications disorders, recreation therapy, chap

laincy, volunteer services, prosthetics, neurologic rehabilitation,
transitional living, and community psychogeriatrics. Direct and
indirect services provided by chaplaincy, volunteer services, and
recreation therapy were rarely used by patients in any of the

rehabilitation programs. Staff associated with these services

verified that well over 90% of their activities were directed to
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371

received a small, moderate, or large improvement in each of the

four domains of the CRQ and then calculated the cost required
for a single patient to achieve a reduction in dyspnea or fatigue or
an improvement in mastery or emotional function.

Results

Table 2 summarizes the costs associated with the

and control groups during the 6-month
of
the
program. The
period are respiratoryforrehabilitation
all
results
(38/45 in the
subjects
presented
in
control
who
40/44
the
and
treatment group
group)

66
7
the study. Their ages were
years in
completed
the treatment group and 65 8 years in the control
group. Of the seven subjects who were withdrawn,
five were for medical reasons (including three with
respiratory exacerbations) and two for
prolonged
renewal of smoking. Of the four subjects who
was noncompliant with completing
dropped out, one
the outcome measures and in three others, there
were issues relating to travel or anxiety. For the
inpatient phase, fully complete cost information was
available for each subject who completed the study.
For the outpatient phase, fully completed diary cards
were available for 36 control and 24 treatment
subjects; remaining diaiy cards were judged to have
been only partially completed if any information was
missing from them. The costs have been grouped to
indicate those associated with the initial 2 months of
4 months of supervised
hospitalization, the following
and
outpatient management, the related costs over
the 6-month period. The costs are in Canadian
dollars (0.72 US dollars in 1989). The largest com
ponent, $10,228 (>70%) of the incremental costs
treatment

Table 2.Six-Month Cost Analysis

Initial 2 mo
Inclusive inpatient costs*
Medical feesf
Prescribed drugs *

Subsequent 4 mo
Physical therapy and occupational
therapy outpatient follow-up
Outpatient medical fees
Prescribed drugs
Related costs spread over 6 mo

associated with rehabilitation, was attributable to the

inpatient costs. All other costs were incremental only
to the rehabilitation group with the exception of
prescribed
drugs and community services such as
home-care nursing or home help. As per the model
used (Fig 1), all costs included an appropriate com
ponent of overhead (land, building, and equipment)
as well as support costs (housekeeping, administra
tion) in their unit calculations. Costs associated with
the inpatient program are summarized in Figure 2.
Of the allied health professionals, nursing was iden
tified as the largest cost center as inpatient units
were staffed day and night by nurses. The next most
important costs were related to physical therapy and
occupational therapy, since these were the two dis
in the rehabilitation program.
ciplines most involved
services
medical
were similar between
Outpatient
the two groups during the 4-month follow-up phase.
For the study group, medication costs during the
first 2 months were included in the costs of hospi
talization. For the 4-month outpatient phase, how
ever, the medication costs were slightly less than the
control group, likely reflecting the optimization of
treatment that occurred as part of the
pharmacologic
rehabilitation program. Of note, the study group had
a higher cost attributable to assistive devices. As part
of their rehabilitation, patients were frequently in
troduced to devices, such as rollators, and encour
to use them to promote ambulation.
aged
Table 3 summarizes the results of the simulta
neous method used to calculate unit costs. Units of
measurement are indicated in the first column. For
the nursing unit, patient days were selected and for
the pharmacy, the number of prescriptions. The

($Canada) of Respiratory Rehabilitation Program for COPD Compared With

Conventional Community Care

Incremental Cost of Rehabilitation

Treatment

Control

Group

Group

Category

Cumulative

10,228

0
17
195

10,228

(168)

10,228
10,809
10,641

688

11,329

10

11,339
11,269

598
27

581

688

53
280

43
350

(70)

185
15
200
Assistive devices
11,454
160
11
171
Travel
11,614
23
6
Other community services^
11,597
(17)
^Includes all costs associated with inpatient rehabilitation program (1988 to 1989) except medical fees (see Fig 2).
^Includes billings for inpatient medical rehabilitation services and community medical services associated with respiratory disease.
'For treatment group, these are in addition to drugs provided through the hospital pharmacy that were incorporated in the cost of hospitalization.
Services obtained to offset deficits related to
respiratory condition, for example, home-care nurse or homemaker.

374
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Clinical Investigations

Table

1.Support and Service Centers and Allocation

Basis

Allocation Basis*

Centers

Support
General administration
Nursing administration
Rehabilitation
administration
Financial services
Human

FTE/nursing unit

FTE/rehabilitation unit

Budget dollars/hospital
department
FTE/hospital department
FTE/hospital department
FTE/hospital department
Average FTE/hospital department
and No. of attendees
Square footage

resources

Community relations

Quality assurance
Occupational health
Plant

FTE/hospital department

operation and

Cost of Assistive Devices: The cost of assistive devices was

determined using invoices provided by the patients. For veterans,
the Federal Department of Veterans Affairs paid 100% of these
costs. For nonveterans, the provincial government-funded Assis
tive Devices Program paid 75% of the costs of devices such as
walkers, strollers, or scooters. The remaining 25% was an out-ofpocket expense for most patients, although some extended

health-care plans covered the remaining 25%. Smaller devices

such as bath stools, cold weather masks, long-handled cleaning
tools, etc, were identified as out-of-pocket expenses unless

covered by third-party insurance.

Cost of Transportation: The cost of supplying "Wheeltrans," a
subsidized transportation service for the disabled, was based on
data supplied by the Toronto Transit Commission. Out-of-pocket
transportation costs such as distance traveled by private vehicle,
parking fees, and taxi fares were recorded by the patients in their
diaries.

maintenance

Transportation

Evenly across centers

Food services
Materials management

Meal days
Supply dollars
No. of phones
Kilograms of laundry
No. of admissions
No. of discharges

Housekeeping

Communications

Linen/laundry
Admitting

Clinical records

Square footage

Evenly across centers

Library

days
Nursing care in respiratory Patient days
rehabilitation unit
WMS units
Pharmacy
WMS units
Physiotherapy
WMS units
Occupational therapy
WMS units
Respiratoiy therapy
WMS units
Laboratory
WMS units
Radiology
Social work
WMS units
WMS units
Pulmonary function

Central
Service

supply

Patient

laboratory

*FTE full-time
=

equivalent.

"partial assessment" fee for specialist visits. The same approach

used for in-hospital assessments during the 2-month inpa
tient phase.
Costs Associated With Medications: For patients covered by
the provincial Drug Benefit Plan, we used the standard formulary
schedule for any costs associated with prescribing or dispensing
medications. For patients not covered by the Drug Benefit Plan,
actual costs were recorded from bills submitted to us with the
monthly diaries. For patients assigned to the treatment group,
the costs of medication were included as part of the hospitaliza
tion costs for the first 2 months of the program.
Costs of Home Care Services: Home care is a provincially
funded, municipally administered service. During the graduated
discharge phase of the respiratoiy rehabilitation program, pa
tients were referred to home care for physical therapy supervi
sion. Control patients were referred to home care at the discre
tion of their primary care physician or local hospital for nursing or
homemaking services. Costs associated with services at home
were derived from information provided by municipalities imme
diately adjacent to Metropolitan Toronto. These municipalities
(Peel and Halton regions) provided information from a review of
home-care costs in
was

our

base year 1989.6

Measurement of Effectiveness

We selected the chronic

respiratory questionnaire (CRQ),

disease-specific, interviewer-administered, HRQL question

naire7 as our measure of effectiveness for the economic analysis.
This measure was also a primary outcome of our clinical study.3
This questionnaire has been widely used and is available in
several languages. The questionnaire has domains of dyspnea,
function, and mastery (the extent to which the
fatigue, emotional
in
Each domain includes
to seven
control).

four
scale of 1 to 7. The CRQ
domains of fatigue, emotional function, and mastery have a high
reliability (test stability over two test periods, reproducibility of
observations within or between raters), content (the adequacy
with which the specified content is sampled by the items), and
construct (the degree to which the measure correlates with other
measures of the concept) validity in differentiating between
patients with better or worse HRQL. The items within the
dyspnea domain are self-generated and therefore are less effec
tive in discriminating between patients with more or less dys
pnea. When used as an evaluative instrument, all four domains
have performed well in detecting small treatment effects.
The minimal clinically important difference (the smallest
difference that is considered important by the patients) has been
shown to be 0.5 per question.89 A moderate difference corre
sponds to 1 per question and a large difference to 1.5. The
conventional approach to cost-effectiveness entails a comparison
of incremental costs, with incremental effects expressed as group
mean differences. We have therefore presented the results in
terms of cost per unit change in selected domains of HRQL.

patient feels

items and each item is scored

on a

Number Needed to Treat

We

recently described a method that allows estimation of the

proportion of patients who achieve a small but important differ

ence as a result of an intervention in a randomized parallel design
controlled trial such as the trial of respiratory rehabilitation.10
This method also allows estimation of the proportion of patients
who achieve a moderate or large benefit as a result of the
intervention. The inverse of the proportion of patients who
benefit is the number of patients needed to treat (NNT) (in this
instance the number one would have to enter into a respiratory
rehabilitation program) for a single patient to achieve a small (but
clinically important), moderate, or large degree of benefit.811
Multiplying the incremental cost of treating a single patient in the
rehabilitation program, vs conventional care, by the NNT for a
single patient to benefit provides an alternative formulation of
cost-effectiveness. We estimated the proportion of patients who
CHEST/112/2/AUGUST, 1997

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373

after rehabilitation at home. Eur Respir J 1994; 7:269-73

Kaplan RM, Ries AL. Cost effectiveness of pulmonary reha
bilitation. In: Fishman AP, ed. Pulmonary rehabilitation. New
York: Marcel Dekker, 1996; 379-98
19 Dunham JL, Hodgkin JE, Nicol J, et al. Cost effectiveness of
pulmonary rehabilitation programs. In: Hodgkin JE, Zorn
EG, Connors GL, eds. Pulmonary rehabilitation: guidelines
to success. Boston: Butterworth, 1984; 389
20 Hudson LD, Tyler ML, Petty TL. Hospitalization needs
during an outpatient rehabilitation program for severe
chronic airway obstruction. Chest 1976; 70:606-10
21 Sneider R, O'Malley JA, Kahn M. Trends in pulmonary reha
bilitation at Eisenhower Medical Center: an 11 year experience
(1976-1987). J Cardiopulm Rehabil 1988; 11:453-61
18

Wong E, Guyatt GH, et al. Meta-analysis of

respiratory rehabilitation in chronic obstructive pulmonary

22 Lacasse Y,

disease. Lancet 1996; 348:1115-19

23 Toevs CD, Kaplan RM, Atkins CJA. The costs and effects of

behavioral programs in chronic obstructive pulmonary dis

Med Care 1984; 22:1088-1100
24 Kaplan RM, Bush JW, Berry CC. Health status index:
ease.

category rating

versus

magnitude

estimation for

measuring

levels of well being. Med Care 1979; 17:501-25

25 Kaplan RM, Bush JW. Health related quality of life measure
ment for evaluation of research and policy analysis. Health

Psychol 1982; 1:61-80

26 Ontario

Ministry

of Health.

Hospital

statistics, 1988/1989.

Ontario, Canada: Ontario Ministry of Health, 1989

CHEST / 112 / 2 / AUGUST, 1997

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379

COST OF 2 MONTH IN-PATIENT RESPIRATORY

REHABILITATION BY HOSPITAL SERVICE
5% 0%3%

X-ray
Pulmonary Function Laboratory
D Hospitalization
Physiotherapy
? Social Work
? Respiratory Therapy
Pharmacy
Laboratory
Occupational Therapy

13%

Figure 2. Cost of 2-month inpatient respiratory rehabilitation by hospital service. Legend begins with
X-ray at 0% and moves clockwise on the graph.

second column shows fully allocated costs, including

overhead, depreciation, and opportunity costs. The
total work output (from each department) was used
to calculate the unit costs shown in column 4. The
average cost per patient per service is shown in
column 6. The per diem cost (cost per stay divided
by the number of days [41.5]) was $246. When the
workload measurement for the nursing unit was
as nursing hours rather than patient days,
expressed
the per diem cost was almost identical ($227).
Table 4 summarizes the results of the effects of 6
months of respiratory rehabilitation on HRQL as
assessed by the CRQ. The first column summarizes
the mean difference (per item) between the treat
ment and control groups for each of the four do
mains. This score is derived from the results of each
domain (dyspnea, fatigue, emotional function, and
mastery) divided by the number of items in each
domain (5, 4, 7, and 4, respectively). The costs
resulted in changes in dyspnea and mastery that
exceeded the minimal clinically important differ

ence.

The incremental

cost

of rehabilitation for

$11,597. Using CRQ-mastery

singlemeasure
patient
of effects, the incremental effects ex
pressed as the mean difference between groups was
0.70 (Table 4). Expressed in these terms, the costeffectiveness ratio was $16,567 per unit difference in
mastery. For CRQ-dyspnea, the cost-effectiveness
ratio was $19,011 per unit difference. For emotional
function and fatigue, the cost-effectiveness ratios
were $26,357 and $35,142 per unit difference, re
spectively.
In Table
have also
was

as

the

we
shown an alternate
of
cost-effectiveness.
Columns 2 and 3
presentation
show the proportion of patients achieving at least a
small benefit or at least a moderate benefit from
rehabilitation. Columns 4 and 5 show the number (of
subjects) needed to treat to achieve at least a small or
at least a moderate benefit in one subject. A cost for
achieving small or moderate benefits can be calcu
lated as the product of the NNT and the average
incremental cost ($11,597) for rehabilitation. In

4,

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375

Table 3.Calculation of Unit Costs

Fully Allocated
Cost ($)f

Service-Work Measurement
Units

($Canada) for Inpatient Respiratory Rehabilitation Program

(WMS)

Total Work

Output1

Average
Cost
per Stay ($)f

Rounded-Out
Unit Costs

Nursing unit (patient days)*

Laboratory

1,165,597
6,714
852,409 580,094
292,39971,690
194,086
94,465
Respiratory therapy
418,054
61,539
Pharmacy (No. of prescriptions)
1,489,925
1,451,289
Physical therapy
993,235 1,085,201
Occupational therapy
work
Social
439,596 849,510
390,117
65,032
Pulmonary function laboratory
Hospitalization cost per stay 10,228

($)

Average Use"

173.61
1.47
4.08
2.05
6.79
1.03
0.92

Radiology'

0.52
6.00

1.0
168.00
6.02
26.00
42.00

7,204.69

1,257.38

1,290.85

527.58
668.00
49.00

482.87
345.67
293.94

246.86
24.55
53.42
285.32

Substituting patient days with nursing care hours has only a minimal influence on the per diem rate.
fDerived from the simultaneous allocation method (Fig 1).

*From each

department within the hospital.

Allocated cost divided by total work output.

"From direct therapist records or chart review.
^Unit cost multiplied by average use per patient.

these terms, the cost required for a single patient to

achieve at least a small benefit (greater than the
minimal clinically important difference) was (Cana
da) $28,993 for mastery, $38,270 for emotional
function, $47,548 for dyspnea, and $51,027 for fa

tigue.

Discussion

Respiratory rehabilitation is becoming increasingly

management of chronic
accepted as important inofthewhich
by far the mostin
respiratory conditions,
Professional
is
COPD.
organizations
prevalentand North America have drafted
guidelines
Europe

for pulmonary rehabilitation1213 and a number of

randomized controlled trials have reported the influ
ence of rehabilitation on HRQL and exercise toler
ance.314-17 Information regarding the costs associ
ated with rehabilitation has been confined to a
number of trials that have reported decreases in
days among patients following rehabilitation,
hospital
the inference being that the costs of rehabilitation
may be offset by reductions in the utilization of
Table 4.Results

CRQ Domain

Dyspnea
Fatigue

Emotional function
Masterv

health-care resources. In a review of these studies

Kaplan and Ries18 noted that most were uncon
trolled, nonrandomized,1920 or included self-se
lected patients,21 thus limiting their interpretability.
In one randomized controlled trial,16 the reduction
in hospital days did not reach statistical significance.
In a recent search of both MEDLINE and CINAHL for randomized controlled trials of rehabili
tation between 1966 and 1996,22 the authors identi
fied only one study23 in which actual costs associated
with the intervention were estimated. In this study,
Toevs et al23 randomized 76 (28 male and 48 female)
patients, all of whom were given a home exercise
prescription, to one of five groups. Three groups
received behavioral programs designed to enhance
compliance with the exercise program: cognitivebehavior modification, cognitive modification, and
behavior modification (experimental groups). For
each of the three groups, the patient and the exper
imenter met for some hours on seven occasions over
a 3-month period. An attention control group and a
no-treatment group received only their exercise pre
scription. At 3 months, the experimental groups

of Rehabilitation on HRQL

Mean Difference

Proportion With
Small (or Greater)
Benefit From
Rehabilitation

Proportion With
Moderate or Large
Benefit From
Rehabilitation

0.61
0.33
0.44
0.70

0.24
0.23
0.30
0.39

0.17
0.15
0.16
0.36

NNT to Have
One Patient
Receive at Least

NNT to Have One

Patient Receive a

Small Benefit

Moderate or Large
Benefit

4.1
4.4
3.3
2.5

5.8
6.9
6.3
2.8

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Clinical

Investigations

the treadmill, had a higher

and
tolerance, improved in their Quality of
Well Being and self-efficacy scores when compared
with the control groups. Using a General Health
Policy Model24 and utilizing a Quality of Well Being
Questionnaire,25 the authors calculated that over an
18-month period, the behavioral program (as an
to exercise) produced well years at a unit cost
adjunct
of just over $24,000 (US) (comparable to the costs of
hypertension
screening and less than the costs of
renal dialysis). Although the study by Toevs et al23
provided useful information on costs, a behavioral
adjunct to a home-based walking program is clearly
different from a comprehensive multidisciplinary
inpatient program. The outcome measures used to
assess the effect of the intervention were different as
was the duration of follow-up.
Programs in rehabilitation can be institutionally
based (inpatient or outpatient) or community based

spent

more

time

on

exercise

(store front, physician's office, or home). To our

knowledge, formal studies comparing the outcomes

of these approaches have not been reported. How

ever, it would appear from studies in which valid and
responsive measures of exercise tolerance and qual
ity of life were utilized to measure the influence of
supervised comprehensive rehabilitation (education,
psychosocial support, and exercise for at least 4
weeks) that for many patients, the effect sizes might
be similar irrespective of the approach used.1617 If
so, an understanding of costs could have an impor
tant role in planning wider accessibility of respiratory
rehabilitation for those with COPD. The largest
costs were associated with the "hotel" costs of insti
tutionalizing patients for rehabilitation. For those
who are in clinically stable condition and have access
to transportation, an outpatient approach would be
substantially less expensive. However, medical or
psychosocial circumstances may preclude regular
attendance at a community-based or outpatient fa
cility. For such individuals, the increased availability
of nursing and other members of the rehabilitation
team may be an important component of their
rehabilitation. Alternatively, given that nursing sala
ries account for the major part of the inpatient
rehabilitation costs, a staffing mix that was less
expensive (lower skilled nursing aids), especially
reduce the hotel com
overnight,of could substantially
rehabilitation.
ponent inpatient
There were a number of limitations in the method
of this study. The study group (inpatient rehabilita
tion) comprised patients with a meanSD age of
66 7 years with severe COPD (FEV1? 35 15%
predicted; diffusion of carbon monoxide, 39 14%
predicted; total lung capacity, 148 27% predicted;
baseline exercise tolerance, 36699 m). The results
are generalizable to this population. Less impaired

patients might have been treated less intensively

(and therefore less expensively) even had they been
hospitalized. Second, although our utilization infor

standardized by a work unit measure

system, many departments rely on a measure
system that is applicable to a particular
institution. The precision of such measures is not
alwaysbeknown and therefore interfacility comparisons
may imprecise.
Third, potential problems exist among the bases
used to allocate support to cost centers. The appli
cation of common means of allocation over several
cost centers may not be completely indicative of
their individual utilizations. For example, it is prob
able that individual departments may have differing
intensities of housekeeping services even though the
latter have been allocated on a square foot basis. We
were not aware of a standardized method that would
easily compensate for these differences. Finally the
estimates are in 1989 dollars. Although prices for
some resources may have changed since then, it is
unlikely that the incremental costs of rehabilitation
compared with standard community care have
mation

was

ment
ment

changed markedly.
Although the above
issues for economic

limitations raise

interesting

studies, they are unlikely to have

had a major impact on the validity or accuracy of our

results. The pulmonary mechanics, exercise toler
ance, and HRQL of our patients at baseline were
consistent with those reported in other trials and
suggest that the study group were likely to have been
representative of the population with severe COPD
who are referred for respiratory rehabilitation. Sec
ond, the simultaneous equation method used to
allocate support costs to the cost centers is consid
more accurate than a per diem estimate taken
erably
from the overall budget.5 The latter often excludes
capital, land, depreciation, and opportunity costs,
combining the costs of all types of patients to achieve
an "average" cost. Furthermore, the rates may be
arbitrary if atypical
patients, outpatients, or day
were
excluded. For example, the
hospital patients
diem
costs26 for 1988/1989
reported hospital per
were $224.29, which when multiplied by the average
length of stay (41 days) would yield a program cost of
$9,195.90, an underestimate of the "true" costs.
We have presented two of several possible ways of
measures of cost-effectiveness. We cou
formulating
this
pled approach to a comprehensive method of
costing the program. The standard practice in costeffectiveness analysis is to report incremental costs
relative to incremental effects as measured by group
mean differences. The incremental cost of rehabili
was $11,597 per patient. Using CRQ-mastery
and expressing the results in unit costs, the costeffectiveness ratio was $16,567 per unit difference in

tation

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377

mastery (Table 4). This was similar for the other

domains of the CRQ. We have also presented a new

alternative approach to the analysis of the costeffectiveness of respiratory rehabilitation in which

we calculated the proportion of patients who sus
tained a minimum clinically important improvement
in a particular domain and then derived the number
of patients one would need to treat for a single
patient to obtain a clinically important improvement.
The estimate would appear to be robust to the choice
of domain within the CRQ. The latter measure of
HRQL has become widely used with more than 90
articles and 20 abstracts citing the original 1987
the NNT approach to an
publication.7 In choosing
economic analysis of inpatient respiratory rehabilita
tion, we were aware of the difficulty in comparing
our report with those of other interventions in the
absence of a similar method being used. Out-ofcontext quotations of the cost of this intervention
might be misleading and should be avoided. Al
we recognize that it is unusual to identify the
though
cost per patient improved (relative to the control
the minimal or moderate clinically
group) beyond
difference
important
using the NNT (the inverse of
the risk difference), we believe that this method
be useful in future economic studies.
might
How to interpret these cost-effectiveness ratios
and whether to present the results as group mean
differences, cost per unit outcome of a domain
within a specific HRQL questionnaire, or as the
NNT remains to be explored. As more studies
include components of an economic evaluation and
disease-specific measures of HRQL, enough evi
dence will be accumulated to determine whether
respiratory rehabilitation is a relatively cheap or
expensive way to improve HRQL. Although during
the outpatient phase of the study a few individuals
(three treatment, three control) required brief (<7
days) hospitalization for respiratory exacerbations,
the study was not of sufficient length for us to
comment on the influence of rehabilitation on the
rate or duration of subsequent hospitalization.
The results from this report suggest that 2 months
of inpatient rehabilitation followed by 4 months of
outpatient supervision resulted in an incremental
cost of $11,597 (Canada). The bulk of the costs
(>90%) were associated with the initial phase of
more specifically, they were attribut
hospitalization;
able to nursing salaries. The rehabilitation program
resulted in statistically significant and clinically im
portant improvements in at least two domains of
HRQL as well as in functional exercise capacity.3
This pilot study should be used to encourage a
comparison of cost estimates of the various ap
proaches to rehabilitation, which when combined
with short-term and long-term measures of outcome

will enable cost-effectiveness, cost utility, and cost

benefit measures to be reported. Such information
will be invaluable in reducing the cost of health-care
resources while making rehabilitation more widely
available.

Acknowledgment for teaching the si

multaneous allocation method is due to Mr. Ron Goeree and to
Mr. William Furlong (both at McMaster University) and Mr. Ron
Wall (currently at the University of Western Ontario) for assisting
with the methods for costing hospital services.
ACKNOWLEDGMENT:

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