Home-based pulmonary rehabilitation, hospital-based pulmonary rehabilitation, and standard care in chronic obstructive pulmonary disease patients—a systematic review and network meta-analysis

Introduction

The common chronic lung condition known as chronic obstructive pulmonary disease (COPD) is typified by ongoing airway blockage, often linked to emphysema, chronic obstructive bronchitis, or a combination of both conditions (1,2). COPD is primarily defined by enduring respiratory symptoms and airflow limitations, with common manifestations including dyspnea, chronic cough (occasionally with sputum), and fatigue (3). It is a significant contributor to global morbidity and mortality, with projections indicating that the number of individuals affected by COPD may approach 600 million by 2050 (4). Effective management strategies are imperative to mitigate the future burden of COPD. Moreover, it is estimated that up to 70% of patients with COPD or asthma remain undiagnosed, suggesting that the global health impact of these conditions may be underestimated (5). COPD is closely associated with high healthcare utilization, diminished quality of life, and substantial economic burdens on both individuals and healthcare systems (6).

Pulmonary rehabilitation (PR), often referred to as respiratory rehabilitation, is designed to enhance exercise capacity, alleviate symptoms, and improve quality of life, serving as a fundamental component of COPD management (7). Studies have indicated that PR significantly improves exercise capacity and health-related quality of life for individuals with moderate to severe COPD when compared to standard therapy (8). Traditionally, PR programs are implemented in hospital settings under the supervision of healthcare professionals. However, there is a growing interest in the feasibility and effectiveness of home-based PR interventions, given their potential to enhance accessibility and convenience for COPD patients and to reduce some aspects of healthcare resource use (9). A meta-analysis has shown that home-based PR is comparably effective to hospital-based programs in improving exercise capacity and reducing dyspnea among COPD patients (10). Nonetheless, comparative research on the effectiveness of home-based PR versus hospital-based PR with specialized rehabilitation teams and standard care remains limited. This study investigates the effectiveness of hospital-based lung rehabilitation (including inpatient and outpatient programs), home-based and telerehabilitation programs, and standard care in individuals with moderate to severe stable COPD, and compares supervised (guided) versus unsupervised (unguided) delivery modes, thereby providing evidence-based insights to inform the selection of PR strategies across different clinical settings. We present this article in accordance with the PRISMA-NMA reporting checklist (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1-2650/rc).

Methods

Literature search

Two researchers independently conducted searches across several databases, including the Cochrane Library, ClinicalTrials.gov, EBSCOhost (Dental and Oral Sciences Sources), PubMed, Scopus, and Web of Science. The retrieved literature was imported into EndNote to eliminate duplicates. Search keywords included “pulmonary rehabilitation” and “COPD”, with language restrictions set to English and the search period extending from database inception to September 30, 2024. A manual secondary search was performed on the references cited in the retrieved articles and those recommended by the databases to prevent any potential errors or omissions, ensuring that the included studies were accurate, reliable, and comprehensive.

Literature screening

The inclusion of studies was determined based on the PICOS criteria (P, patient; I, intervention; C, control; O, outcome; S, study design). Two researchers independently screened the literature and cross-verified their selections. Any discrepancies were resolved by the third researcher.

• Patients (P): individuals with moderate to severe COPD classified according to the predicted value of forced expiratory volume in 1 second (FEV₁) based on the Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2022 staging, with moderate COPD defined as 50%≤ FEV₁ <80% and severe COPD as 30%≤ FEV₁ <50%, who were in a clinically stable phase (typically without an acute exacerbation or change in maintenance therapy within the previous 4–6 weeks). Trials focusing exclusively on post-exacerbation PR were not included in this network meta-analysis. In addition to spirometric indices, baseline clinical information such as comorbidities, functional status, symptom burden, and health-related quality of life was extracted when reported; however, these data were not consistently available across all trials and therefore could not be used as formal inclusion criteria or for predefined stratified analyses.
• Intervention (I) and control (C): comparisons between standard care and unguided PR (home-based PR), as well as between guided PR (hospital-based PR) and home-based PR. Due to significant variations in PR methods across studies, we categorized PR as guided PR under the following conditions: (I) supervised by specialized healthcare teams in inpatient or outpatient hospital settings; (II) provided with home visits by rehabilitation professionals in community settings; or (III) delivered as real-time, professionally supervised telerehabilitation (e.g., videoconference-based supervised sessions), including hybrid hospital-community-home models. Any intervention not requiring synchronous, on-site, or real-time professional guidance from rehabilitation teams was classified as unguided PR, which could include individualized training plans, web- or app-based programs, asynchronous telerehabilitation, video consultations, or telephone follow-ups in which patients performed exercises independently, but should not involve in-person or real-time supervision.
• Outcome (O): the primary outcome was the 6-minute walk distance (6MWD), which was selected because it was the most consistently reported indicator of exercise tolerance across the included trials and therefore allowed quantitative synthesis. Other clinically relevant outcomes (e.g., health-related quality of life, dyspnea scores, and exacerbation rates) were extracted when available, but were too heterogeneously reported to be combined in a network meta-analysis.
• Study design (S): prospective randomized controlled trials (RCTs).

Data extraction

Using a pre-made data extraction form, two researchers separately extracted data, including the first author, publication date, sample size, age, gender, severity of COPD, type of intervention, duration of intervention and follow-up, and outcome measures. For each trial, we also recorded, where reported, the main components of the rehabilitation programme (e.g., aerobic and/or resistance exercise training, breathing exercises, education, and psychosocial support) in order to qualitatively describe whether patients actually performed structured exercise training and how intensive the programmes were. Where available, additional baseline characteristics—such as comorbidities, baseline exercise capacity, functional disability, symptom scores, and health-related quality of life—were also collected to qualitatively describe the study populations and to aid interpretation of potential differences in rehabilitation response. Information on programme costs and detailed healthcare resource use was rarely reported and could not be extracted in a standardized manner, so formal cost or cost-effectiveness comparisons between rehabilitation modalities were not possible in this review. The corresponding authors were contacted to obtain any missing data or information. Studies from which data could not be extracted were recorded, along with reasons for exclusion. Any disagreements were resolved through discussion.

Quality assessment

Two researchers independently assessed the risk of bias (ROB) for each included study using the Cochrane risk-of-bias assessment tool for RCTs. Discrepancies were resolved through discussion, and a third review author was consulted when necessary. Blinding of participants and staff, blinding of outcome assessment, random sequence generation, allocation concealment, insufficient outcome data, selective reporting, and other biases are among the primary areas of bias risk that the Cochrane tool assesses. A funnel plot for publication bias was generated using the R package robvis.

Statistical analysis

This study utilized the R meta package to perform direct meta-analyses and create forest plots and funnel plots; the Stata software network package was employed for network meta-analysis and to generate surface under the cumulative ranking curve (SUCRA). To ensure that comparisons were made under equivalent methodological standards, we pre-specified a single primary outcome (6MWD), defined uniform follow-up time windows (<3, 6, and 12 months), and applied the same random-effects network meta-analytic framework and statistical assumptions across all treatment contrasts. Statistical heterogeneity was assessed using Cochran’s Q test and the I² statistic. In the Q test, a P value <0.10 was considered indicative of significant heterogeneity. In direct meta-analyses, continuous variables were represented using standardized mean differences (SMDs) along with their 95% confidence intervals (CIs). A 95% CI that does not include zero indicates statistical significance. A network plot was generated to illustrate the number of participants for each treatment and the volume of literature comparing different treatment modalities, with point sizes representing participant counts and line thicknesses indicating the number of studies. SUCRA values were computed to determine the relative efficacy of the three intervention types, with SUCRA values ranging from 0 to 100%. Higher SUCRA values indicate a greater likelihood of achieving optimal effectiveness and safety.

Results

Literature screening process

A total of 7,585 articles were retrieved from six databases, with 41 articles identified through manual searches. After excluding duplicates and screening titles and abstracts, 93 articles underwent full-text review. According to the predefined inclusion and exclusion criteria, 77 studies were excluded, resulting in 16 articles included for analysis (Figure 1).

Figure 1 Literature screening flowchart. 6MWD, 6-minute walk distance.

Basic characteristics of included studies

Sixteen studies were included, comprising a total of 1,235 participants, with an average age of 66 years and a male proportion of 61.5% (760/1,235). Although spirometric severity was relatively homogeneous within the eligibility criteria, the included populations likely differed in terms of comorbidities, baseline disability, and health-related quality of life, reflecting the well-recognized clinical heterogeneity of patients with similar levels of lung function in COPD. Among the interventions, 15 studies were parallel-group designs, with 11 comparing guided PR with standard care, 2 comparing unguided PR with standard care, and 2 comparing guided PR with unguided PR. One three-arm study compared guided PR, unguided PR, and standard care (Table 1). guided PR programs were mainly delivered in outpatient or community settings, with some studies incorporating inpatient or hybrid hospital-community-home components and real-time supervised telerehabilitation, whereas unguided PR programs were predominantly home-based and included unsupervised home exercise and asynchronous telerehabilitation; no study of early post-exacerbation PR met the inclusion criteria. The quality of the included studies was assessed using a ROB plot, which indicated unknown risks concerning participant blinding, while risks in other domains were relatively low. The ROB plot is shown in Figure 2.

Figure 2 ROB assessment chart. ROB, risk of bias.

Results of direct meta-analysis

Fourteen studies compared the outcomes of 6MWD following PR versus standard treatment. These studies were categorized based on follow-up duration: <3, 6, and 12 months, and subgroup analyses were conducted. Analyses were conducted using a random effects model, and each study differed considerably from the others. The overall pooled mean difference (MD) was −33.35 (95% CI: −65.21, −1.49). For the 12-month follow-up subgroup, the pooled MD was −110.24 (95% CI: −180.02, −40.45); for the 6-month follow-up subgroup, the pooled MD was −33.53 (95% CI: −101.53, 34.47); and for the <3-month follow-up subgroup, the pooled MD was −7.02 (95% CI: −41.09, 27.06). Across all follow-up durations, PR consistently improved 6MWD outcomes, with statistical significance observed only at the 12-month follow-up. The direct comparison forest plot for 6MWD is presented in Figure 3. Publication bias in the direct meta-analysis of 6MWD was assessed visually using a funnel plot (Figure 4).

Figure 3 Direct meta-analysis forest plot. CI, confidence interval; IV, inverse variance; PR, pulmonary rehabilitation; SD, standard deviation.

Figure 4 Funnel plot assessing publication bias in the direct meta-analysis of 6MWD. Each circle represents an individual trial, the vertical line indicates the pooled MD, and the dashed lines represent the 95% confidence limits. 6MWD, 6-minute walk distance; MD, mean difference.

Network meta-analysis

Subsequently, we performed a network meta-analysis to compare the benefits of different PR methods on 6MWD. For each follow-up duration, the network plot (Figures 5-7, panel A) displays the geometry of the treatment comparisons; the forest plot (panel B) presents the MDs and 95% CIs for each pairwise comparison; the cumulative ranking curves (panel C) show the ranking probabilities for each intervention; and the SUCRA table (panel D) summarizes the ranking statistics (SUCRA, probability of being best, and mean rank) for guided PR, unguided PR, and standard care. In the studies with <3 months of follow-up, the most common comparison was between guided PR and standard care, while studies comparing unguided PR with guided PR and standard care were less frequent. The network diagram is depicted in Figure 5A. Pairwise comparisons revealed that the 6MWD benefit of guided PR was significantly greater than that of standard care, while no significant difference was observed between unguided PR and either guided PR or standard care. The pairwise comparison forest plot is shown in Figure 5B. SUCRA values calculated for each intervention indicated that guided PR had the highest efficacy (78.1%), followed by unguided PR (68.1%), and standard care (3.8%). The SUCRA values are illustrated in Figure 5C,5D.

Figure 5 Network meta-analysis results for follow-up ≤3 months. (A) Network plot of treatment comparisons; circle size is proportional to the number of participants and line thickness reflects the number of studies for each comparison. (B) Forest plot of MDs in 6MWD with 95% CIs for each pairwise comparison and for the pooled estimates within design. (C) Cumulative ranking curves for guided PR, unguided PR, and standard care. (D) Summary table showing the SUCRA, PrBest, and mean rank for each intervention. 6MWD, 6-minute walk distance; CI, confidence interval; MD, mean difference; PR, pulmonary rehabilitation; PrBest, probability of being the best treatment; SUCRA, surface under the cumulative ranking curve.

Figure 6 Network meta-analysis results for follow-up of 6 months. (A) Network plot of treatment comparisons; circle size is proportional to the number of participants and line thickness reflects the number of studies for each comparison. (B) Forest plot of MDs in 6MWD with 95% CIs for each pairwise comparison and for the pooled estimates within design. (C) Cumulative ranking curves for guided PR, unguided PR, and standard care. (D) Summary table showing the SUCRA, PrBest, and mean rank for each intervention. 6MWD, 6-minute walk distance; CI, confidence interval; MD, mean difference; PR, pulmonary rehabilitation; PrBest, probability of being the best treatment; SUCRA, surface under the cumulative ranking curve.

Figure 7 Network meta-analysis results for follow-up of 12 months. (A) Network plot of treatment comparisons; circle size is proportional to the number of participants and line thickness reflects the number of studies for each comparison. (B) Forest plot of MDs in 6MWD with 95% CIs for each pairwise comparison and for the pooled estimates within design. (C) Cumulative ranking curves for guided PR, unguided PR, and standard care. (D) Summary table showing the SUCRA, PrBest, and mean rank for each intervention. 6MWD, 6-minute walk distance; CI, confidence interval; MD, mean difference; PR, pulmonary rehabilitation; PrBest, probability of being the best treatment; SUCRA, surface under the cumulative ranking curve.

For studies with a 6-month follow-up, the predominant comparison was between guided PR and standard care, followed by comparisons between unguided PR and standard care, with fewer studies comparing unguided PR and guided PR. The network diagram for this follow-up duration is shown in Figure 6A. Pairwise comparisons indicated no significant differences in 6MWD benefits among the three interventions. The pairwise comparison forest plot is shown in Figure 6B. SUCRA values for this follow-up duration were as follows: guided PR (75.7%), unguided PR (59.6%), and standard care (15.7%). The SUCRA values are presented in Figure 6C,6D.

In the studies with a 12-month follow-up, the most frequent comparison was again between guided PR and standard care, followed by unguided PR and standard care, with limited studies comparing unguided PR and guided PR. The network diagram for this follow-up duration is presented in Figure 7A. Pairwise comparisons revealed no significant differences in 6MWD benefits among the three interventions. The pairwise comparison forest plot is depicted in Figure 7B. SUCRA values for this follow-up duration indicated unguided PR (78.0%) had the highest efficacy, followed by guided PR (62.3%) and standard care (9.7%). The SUCRA values are shown in Figure 7C,7D.

Discussion

The findings of this meta-analysis indicated that PR, whether guided by healthcare professionals or delivered independently, could significantly enhance the 6MWD outcomes in patients with stable COPD. Nevertheless, it is important to recognize that patients with comparable levels of airflow limitation may exhibit substantial variability in comorbidity burden, functional capacity, and health-related quality of life, which can in turn influence their individual response to PR. Notably, the most substantial benefits were observed at the 12-month follow-up. The network meta-analysis revealed no statistically significant differences in 6MWD outcomes between guided PR and unguided PR. Nevertheless, SUCRA-based rankings suggested that guided PR had the highest probability of being the most effective option at the <3- and 6-month follow-ups, whereas at the 12-month follow-up, unguided PR had the highest probability of yielding the best 6MWD results; these probabilistic rankings should be interpreted with caution and do not imply definitive superiority in the absence of statistically significant pairwise differences.

PR is a vital component of COPD management, providing considerable benefits for patients (27). It has been shown to improve dyspnea, exercise tolerance, and health-related quality of life while simultaneously reducing healthcare utilization. Typically incorporating exercise training, education, and psychosocial support, PR addresses both the physiological and psychological aspects of COPD (28). The benefits of PR were well-supported by extensive research and meta-analyses (8,29-31), and this study corroborated these findings. Based on the presence of professional rehabilitation therapists or healthcare teams, PR can be classified as either guided or unguided. Traditionally, PR has involved structured, supervised programs rather than unguided interventions (32). However, supervised programs based in hospitals and led by professional teams can be resource-intensive and costly, and facilities providing high-quality care may become overwhelmed by increasing patient loads. Given the need for accessible and affordable healthcare resources, innovative PR approaches are urgently required. This need is underscored by the rehabilitation experiences of coronavirus disease 2019 (COVID-19) patients (33). Home-based PR emerges as a promising solution that could be sustainable in the long term and has garnered increasing attention (34). Evidence suggests that home-based PR yields improvements in exercise capacity, quality of life, and dyspnea comparable to those achieved through hospital-based programs (35). Furthermore, previous work has indicated that structured PR programs can be delivered with favorable cost-benefit profiles in COPD (16), and reduced travel and facility requirements may make home-based models economically attractive; however, formal comparative cost-effectiveness analyses of home-based versus hospital-based PR remain limited. The integration of telehealth with healthcare delivery has ushered in a new era of remote rehabilitation. Home-based, non-professional team-supervised PR offers enhanced flexibility and accessibility, while hospital-based approaches provide more structured supervision and social support, necessitating a tailored approach based on individual patient needs (36). Rather than placing different rehabilitation settings in competition, these findings support the principle of matching “the right patient to the right setting at the right time”, taking into account disease severity, comorbidity burden, functional disability, and whether the patient is in a stable versus post-acute phase. These interventions appear to be effective and practical and are broadly comparable to inpatient or outpatient treatment modalities; although they may reduce some direct and indirect costs (such as travel and facility use), our review did not include a formal cost-effectiveness evaluation, and any potential economic advantages should therefore be regarded as hypotheses rather than definitive conclusions.

In this analysis, SUCRA scores indicated that guided PR had higher ranking probabilities than unguided PR in the <3- and 6-month follow-ups, whereas unguided PR had the highest ranking probability at the 12-month follow-up. This pattern should be interpreted with caution, because the comparative trials differed in inclusion criteria, timing of rehabilitation, number of sessions, and total rehabilitation volume, and adherence was not reported in a consistent and comparable manner across studies, so these rankings do not establish the definitive superiority of any specific rehabilitation modality. The better maintenance of effects observed with unguided or home-based programs at 12 months may therefore be related, at least in part, to longer duration or continuation of some home-based interventions rather than intrinsically higher adherence to this delivery mode. Unguided PR may also help reduce certain direct and indirect costs and face fewer logistical barriers to widespread implementation, thereby representing a promising avenue in COPD management; however, programme-level cost and resource-use data were not available in a consistent form in the included trials, and we did not perform a formal cost-effectiveness analysis, so any potential economic advantages remain speculative and should be confirmed in future studies explicitly designed to evaluate costs and cost-effectiveness. Nonetheless, it is crucial to note that hospital-based PR may be more appropriate for patients with advanced disease, substantial functional impairment, or complex comorbidities (37), and for those in the early post-exacerbation phase who require closer monitoring; in such cases, home-based or unguided programmes should be viewed as complementary options rather than direct competitors.

There are several limitations in this study. First, although we only included patients in a stable phase of COPD and excluded trials that focused exclusively on early post-exacerbation PR, considerable heterogeneity remained in the content and organization of PR programs. The included interventions differed in setting (inpatient versus outpatient versus home-based), pathway (single-site versus hybrid hospital-community-home programs), and mode of delivery (face-to-face versus telerehabilitation, supervised versus unsupervised), which poses challenges for direct comparison and may limit the precision of the network estimates. Although we attempted to impose equivalent methodological standards at the review level—by restricting the design to RCTs, harmonizing eligibility criteria, using a single primary outcome, and analyzing all treatment contrasts within a unified network meta-analytic framework—the underlying trials were not fully standardized in terms of patient selection, timing of rehabilitation, programme content, and intensity, and therefore our indirect comparisons should be interpreted with appropriate caution. Currently, there are no standardized guidelines for PR, and outcomes are heavily influenced by patient adherence; however, adherence, attendance, and completion rates were either not reported or reported heterogeneously in most of the included trials, which prevented us from performing a meaningful comparison of adherence between home-based and hospital-based programmes or from formally exploring adherence as an explanation for differences in long-term outcomes. Second, 6MWD was the only outcome that could be used for quantitative synthesis, and our findings therefore reflect differences in exercise tolerance rather than the full spectrum of potential benefits of PR. Some programmes may have been more effective in improving symptoms, health-related quality of life, or exacerbation risk than in increasing walking distance, and these effects could not be captured in the present network meta-analysis. Moreover, the specific content, intensity, and volume of the interventions—including the extent to which structured exercise training was delivered—were often incompletely reported, which limited our ability to classify programmes beyond the guided versus unguided framework and to relate programme components to different clinical outcomes. Third, although FEV1 was used as the primary inclusion criterion to ensure a comparable level of spirometric impairment across studies, this single physiological measure does not fully reflect the multidimensional baseline condition of patients with COPD. Individuals with similar lung function may differ markedly in comorbidities, disability, symptom burden, and health-related quality of life, which are likely to modify their response to rehabilitation. Because these baseline domains were incompletely and inconsistently reported in the original trials, we were unable to adjust for them or to perform robust subgroup analyses, and thus some of the observed differences between interventions may still partly reflect underlying between-study heterogeneity in patient profiles. Thirdly, there might be a publication bias associated with the types of patients and interventions included. Future research should aim to compare various PR modalities in both stable and post-exacerbation phases, and to disentangle the effects of inpatient versus outpatient, home-based versus telerehabilitation, and supervised versus unsupervised models, while also considering cost-effectiveness to optimize patient outcomes. In particular, robust economic evaluations that prospectively collect programme costs and healthcare resource use are needed, because the present review did not include a formal cost-effectiveness analysis and the included trials did not provide sufficient cost data to support definitive conclusions about the economic value of home-based versus hospital-based rehabilitation.

Conclusions

PR is an essential intervention in the management of COPD. In this network meta-analysis, both guided and unguided home-based PR achieved improvements in 6MWD that were broadly comparable to each other and tended to be more favorable than standard care, although most between-intervention differences were not statistically significant. Home-based PR, therefore, represents a feasible and accessible alternative to professionally guided programmes, and our findings do not support the definitive superiority of one rehabilitation modality over another; SUCRA-based rankings across different follow-up periods should be regarded as exploratory signals to be confirmed in future, adequately powered comparative studies.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the PRISMA-NMA reporting checklist. Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1-2650/rc

Peer Review File: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1-2650/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1-2650/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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