The data envelopment analysis as a model to evaluate the cost- utility study of a pulmonary rehabilitation programme for COPD patients in a university hospital in an European region

The data envelopment analysis as a model to evaluate the cost- utility study of a pulmonary rehabilitation programme for COPD patients in a university hospital in an European region | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The data envelopment analysis as a model to evaluate the cost- utility study of a pulmonary rehabilitation programme for COPD patients in a university hospital in an European region Francisco Reyes-Santias, María Elena Toubes, Francisco Gude, Óscar Lado-Baleato, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6604849/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 12 You are reading this latest preprint version Abstract Background. The efficiency of pulmonary rehabilitation (PR) programs in patients with COPD, as evaluated through cost-effectiveness analysis (CEA), yields mixed results. The aim of this study is to determine whether the efficiency demonstrated by a PR program using CEA is maintained when applying Data Envelopment Analysis (DEA), a tool used to develop an efficiency frontier for a given intervention. Methods . The profitability of this program was assessed based on its impact on the number of exacerbations and quality of life. The DEA model evaluates a given performance by taking into account all inputs and outputs simultaneously. The inputs were healthcare costs, and the outputs included the number of hospital admissions, hospital stays, ICU stays, emergency department visits, and quality of life (EuroQol-5D). Results . The DEA considers that implementing the PR program is efficient compared to not implementing it, which is deemed inefficient. Furthermore, it estimates the extent to which the inefficient option would need to improve its outcomes (outputs) in order to become efficient: QALYs, 114%; emergency department visits, 252%; ICU, 902%; hospitalizations, 289%; pharmacy, 260%; outpatient visits, 97%. Conclusions . DEA shows that implementing a PR program in patients with COPD is more efficient than not doing so. Moreover, it estimates to what extent the inefficient option would need to improve its outcomes in order to become efficient. However, CEA allows the financial investment to be related to health outcomes, usually measured in QALYs. Healthcare managers should use both methods in a complementary way when assessing the efficiency of a specific intervention before implementing it in clinical practice. Data Envelopment Analysis cost-effectiveness analysis pulmonary rehabilitation chronic obstructive pulmonary disease Figures Figure 1 Introduction Chronic obstructive pulmonary disease (COPD) is one of the three leading causes of death worldwide 1 . In 2017, more than 3 million people died from this disease, accounting for 6% of all deaths worldwide. COPD is a major public health challenge as it is a preventable and treatable disease. Nevertheless, many people suffer from COPD for years and die prematurely, either from COPD or from its complications. There is now ample evidence of the benefits of pulmonary rehabilitation (PR) for patients with COPD in terms of exercise capacity, peripheral muscle function, breathlessness, quality of life, physical activity, healthcare utilization 2,3 and possibly survival 4 . In Spain, however, these programmes are poorly implemented: Only 35% of hospitals have a specific PR unit, of which 53% are dependent on rehabilitation services and not on pulmonology services 5 . Patients with COPD utilise many healthcare resources. Both outpatient and inpatient exacerbations have a significant impact on disease progression and are associated with reduced lung function 6 and increased mortality 7 . However, there is very limited evidence on the impact of on exacerbations, and few studies have investigated the role of PR in reducing exacerbations. Although little is known about whether PR is a cost-effective test, some studies suggest that it may bring benefits to the healthcare system 8 . Recently, our group has confirmed that PR contributes to reducing the number of exacerbations in patients with COPD, thereby slowing clinical deterioration and it is cost‑effective in terms of quality adjusted life years (QALYs) 9 . Unlike cost-effectiveness analysis (CEA), which only allows for the consideration of a single outcome while ignoring other potential clinical benefits, Data Envelopment Analysis (DEA) enables the simultaneous evaluation of multiple inputs and outputs. This provides a more comprehensive and flexible framework for assessing the efficiency of different healthcare technologies implemented within an organizational unit 10 . The aim of this study is to assess the efficiency of a PR program in patients with COPD by applying the DEA approach. Materials and Methods Material The information on the variables used has been compiled from the Admission Service of the Santiago University Hospital Complex. The costs of the program have been used as inputs to the model. We used as input the health care costs for COPD patients with the rehabilitation program included and the health care costs for COPD patients without the rehabilitation program (NPR) and as outputs the number of emergencies attended; the number of hospital stays; the number of ICU stays; the number of outpatient consultations and QALYs. The costs of PR as well as exacerbations in the years before and after the start of the PR programme were determined. The cost of the PR programme was calculated on the basis of: purchase of equipment (2,002.85€) with a linear amortisation over 5 years; full-time salary of a physiotherapist as labour costs of the programme (33,693.3€/year); general maintenance, cleaning, supplies, security and communication overheads (PR room space of 37.5m 2 : 389.26€) 11 ; costs of patient travel from home to hospital at 0.19 €/km 12 ; cost of time spent travelling to the hospital (weighted average times for travel, parking, travel to the consultation area and the consultation itself, 79 minutes) depending on whether the population was active [based on patient average gross income (20,288.1€) and unemployment rate (7.9%)] 13 or retired (average pension 11,097.6€; 2.3% of subjects >65 are engaged in volunteer work 14 and 22.6% perform activities that contribute to the gross domestic product) 15 ; and costs related to leisure time (47% of labour cost) 16 ; and CO 2 emissions per private car travel (volume of CO 2 emitted per kilometre and cost of each CO 2 gram) 17,18 . The average number of PR sessions per patient was 25.5 9 . The cost of exacerbations was estimated based on the tariffs of the Galician Health Service ( Servizo Galego de Saúde ) ¹⁹ (emergency care, complementary tests, pharmacy costs, length of hospital stay, length of stay in the intensive care unit (ICU), when applicable, and follow-up visits) ( Table 1 ) ⁹ , in addition to travel costs and productivity loss during exacerbations. Table 1 . Servizo Galego de Saúde fees in relation to emergency care and hospital admissions due to exacerbation of chronic obstructive pulmonary disease 18 . Test Cost (€) Emergency care 361.59 Emergency care (with admission) 528.95 Blood test, arterial blood gas test included 180 Chest X-ray 40.35 Sputum culture 181 Pharmacy cost of moderate exacerbation 161.84 Pharmacy cost of moderate exacerbation before PR (mean stay, 7.2 days) 58.87 Pharmacy cost of moderate exacerbation after PR (mean stay, 7.4 days) 96.07 Follow-up consultations 58.37 Daily cost of hospital stay 528.95 Daily cost of ICU stay 1,142.47 ICU, intensive care unit; PR, pulmonary rehabilitation. Quality of life, used as output in the DEA analysis, was measured by the EuroQol-5D (EQ-5D) 20 , immediately before starting RP and one year after starting RP. An improvement in quality of life was assumed if the EQ-5D increased by at least 0.051. Patients with COPD with dyspnoea on the modified Medical Research Council (mMRC) scale ≥2 21 who agreed to participate in the study were included and those who were in the end-of-life phase (life expectancy <3 months), had an impediment to physical exercise, psychiatric problems, cardiovascular pathology in the acute phase, or did not agree to participate in the study were excluded. The PR programme applied was the one used in our usual clinical practice, consisting of 24-28 sessions (3/week) over a period of 8-9 weeks, of 75-90 minutes each 2 . Data Envelopment Analysis (DEA) DEA is a non-parametric frontier method used to measure the efficiency of each organisation or organisational unit (DMU, Decision Making Units), by solving a linear programming problem 22 for each unit under the assumption, in this study, of Constant Returns to Scale: Formula1. DMU: decision-making unit or programme; Yrj: i-th output of the j-th DMU; Xij: i-th input of the j-th DMU; Vi, Ur: weights of inputs and outputs, respectively. DMUs that are considered technically efficient lie on the efficiency frontier and have a score of 1. Data management units with scores below 1 are considered inefficient 23 . DMU measures productive efficiency and indicates how much productivity can be increased without using additional resources, thus providing a starting point for efficiency measures derived from a frontier-based methodology 24,25 . In short, DEA is a method that compares homogeneous decision-making units (DMUs) in terms of resources and production outcomes, providing a measure of relative efficiency. The relative technical efficiency of each DMU is calculated by computing the ratio obtained from dividing the weighted sum of outputs by the weighted sum of inputs, based on Paretian criteria (utility criteria that follow a natural optimization process aimed at reaching a point at which no further improvement in outcome is possible without using more resources). In this way, a theoretical efficiency frontier is established, which cannot exceed a value of one, and the distance of each DMU from this frontier is calculated 26-28 . This technique, widely used in the health sector 29 allows measuring several different types of efficiency: technical, allocative congestion and dynamic. In addition, it also allows for the observation of possible economies of scale. To carry out the corresponding analysis of technical efficiency in the public, private, and joint sector, a series of inputs and an output have been chosen, which has already been discussed in more detail in the Materials and Methods subsection. The program used to apply this analysis technique was DEA Frontier Software for Excel. Results Of the 645 patients who were proposed to participate in the RR program, only 219 (34%) started and 200 (31%) completed the program 9 . Of the 19 patients who did not complete the RR programme, 5 (26.3%) died. Table 2 shows the baseline characteristics of the 200 patients who completed PR, number of hospital admissions, days of stay in a general ward and in the ICU, emergency department visits during the previous year, and the baseline median EQ-5D scores 9 . Table 2 . Baseline characteristics of patients included in the study. CHARACTERISTICS Overall Patients (n) 200 Gender (n; men (%) / women (%)) 159 (79.5) / 41 (20.5) Age (years) 65 (59-70) Number of hospital admissions in the previous year 0 (%) 1 (%) 2 (%) 3 (%) 4 (%) 5 (%) 6 (%) 7 (%) Median (25th-75th percentile) 222 87 (43.5) 54 (27) 31 (15.5) 16 (8) 7 (3.5) 1 (0.5) 3 (1.5) 1 (0.5) 1 (0-2) Days hospitalized in the previous year 1597 ICU days in the previous year 20 Emergency department visitis in the previous year 365 EuroQol-5D score 0.617 (0.493-0.739) ICU, intensive care unit Data are expressed as absolute frequencies (percentages) and medians (25th–75th percentile). Outcomes after Pulmonary Rehabilitation (12 months) After completion of PR sessions, outcomes were assessed at 12 months (±1 week) by grouping the studied parameters into 2 domains [exacerbations and quality of life]. The number of hospital admissions decreased from 222 to 115; the admission rate per patient per year dropped from 1.1 to 0.6; days of stay in a general ward declined from 1,597 to 852; ICU days decreased from 20 to 2; and emergency department visits were reduced from 365 to 210 9 . Table 3 . Mean cost/patient of a pulmonary rehabilitation program (left side) and mean cost of exacerbation/patient before and after the pulmonary rehabilitation program (right side) (con permiso) 9 . Cost of the rehabilitation program (€) Costs (€) Prerehabilitation (€) Postrehabilitation (€) PR cost: 1,414.9 Mean hospital travel cost 30.3 24.6 Travel costs related to PR: 267.4 Mean cost of loss of productivity 391.3 195.3 Costs related to loss of productivity associated with PR: 161.2 Mean cost of pollution 5.5 4.4 Cost of pollution: 24.2 Mean cost of moderate exacerbation Mean cost of severe exacerbation Cost of ICU admission 1,804.3 5,549.6 114.2 1,038.1 2,937.1 11.4 Total cost/patient: 1,867.7 Total cost/patient 7,895.2 4,201.9 ICU = intensive care unit; PR , pulmonary rehabilitation. Table 3 shows the average cost per patient of the PR program (left side) and the average cost of exacerbations per patient before and after the PR program (right side). The total savings amounted to €365,200, which represents €1,826 per patient per year. The cost of exacerbations before and after PR differed due to variations in pharmacy costs and the average cost of hospital and intensive care unit (ICU) stays between the two periods 9 . The median EQ-5D was determined in 128 patients. Before the start of the PR program, it was 0.617 (0.4930–0.7601), and one year after starting the program, it was 0.724 (0.645–0.794). Table 4 Table 4 presents the DEA model results for evaluating the efficiency of implementing a PR program versus not doing so in patients with COPD. The DEA considers the PR program efficient because it optimizes its outcomes by achieving the best output values from its inputs, compared to not implementing the PR program, which is considered inefficient. The column 'Improved efficiency PR vs NPR' shows the values that indicate the 'distance' between the inefficient option (not implementing PR) and the efficiency frontier—that is, the difference between the two. DEA allows estimation of the degree to which the inefficient option would need to improve its outcomes (outputs) to become efficient. In our case, this would be 114% for QALYs, 252% for emergency visits, 902% for ICU use, 235% for chest X-rays, 289% for hospitalizations, 260% for pharmacy, and 97% for emergency department visits. Figure 1 graphically represents the results shown in Table 4 . Table 4 . Results DEA compared rehabilitation program with no rehabilitation for EPOC patients. Results DEA Rehabilitation program NO Rehabilitation program Improved efficiency PR vs NPR QALYs 1 0,46712 114% Returns of scale Constant Decreasing Emergencies 1 0,28443 252% Returns of scale Constant Decreasing ICU 1 0,09985 902% Returns of scale Constant Decreasing Tests 1 0,29841 235% Returns of scale Constant Decreasing Hospitalisation 1 0,25735 289% Returns of scale Constant Decreasing Pharmacy 1 0,27759 260% Returns of scale Constant Decreasing Emergency Department visits 1 0,50676 97% Returns of scale Constant Decreasing ICU , intensive care unit; QALYs , años de vida ajustados por calidad. Source: Own elaboration Discussion Our results show that DEA, through a more comprehensive analysis than the usual cost-effectiveness ratios, is a useful tool for evaluating the efficiency of PR programs in patients with COPD, as it confirms the efficiency of implementing PR compared to not doing so. The efficiency of PR programs in patients with COPD has been widely debated. First, because outcomes can be evaluated from very different perspectives (improvement in quality of life, exercise capacity, lung function, reduction in disease severity, and decrease in the number of exacerbations), and it is possible that a PR program improves certain parameters within these domains but not all of them. Second, because the methodology used to measure and compare different studies can vary. A clear example is the systematic review conducted by Leemans et al. across 11 studies (3,261 participants). In 4 of these, the results were interpreted as cost-effective; in two they were not, and in the remaining five, cost-effectiveness was uncertain 30 . Evidently, the intensity of the PR interventions, exacerbation rates, project design, and outcome measures used differed among the studies. Finally, the analytical method used to assess the efficiency of the PR program (cost-effectiveness ratios or DEA) can influence the results obtained. DEA is a dominant non-parametric quantitative method that evaluates healthcare efficiency through DMUs by creating a production frontier based on best practices observed in the data 31 . It can also be used to rank and compare the efficiency of different entities 32 . The difference between DEA and CEA is that DEA considers all inputs and outputs simultaneously when evaluating performance, whereas CEA combines only one input with one output at a time and is therefore not suitable for setting performance improvement targets for units. However, in some cases, the two methods can complement each other when used together 33 . The DEA model is relatively complex and can yield a substantial number of results. The full description and interpretation of these go beyond the scope of this article. Therefore, we present only the most relevant findings in a simplified form. The DEA model provides a ranking of the efficiency values of the PR program ( Table 4 ) and demonstrates that this program, compared to not implementing PR, is efficient as it achieves better output values from its inputs (i.e., better output/input ratios), while the non-PR option is inefficient. The most practically relevant contribution of the DEA model is that it identifies the reasons why certain programs are inefficient. For instance, in the 'Improved efficiency PR vs NPR' column of Table 4 , the required output percentage increases are shown for the inefficient program to become efficient. That is, the DEA model estimates to what extent the inefficient option would need to improve its outcomes (outputs) to reach the efficiency frontier. The DEA model provides each program with an efficiency score ranging from 0 to 1 and also allows estimation of the contribution of each input and output variable in determining that efficiency score (see Formula 1 ). The DEA results demonstrate a clear advantage of implementing PR programs for patients with COPD compared to providing NPR. Across all evaluated outputs, PR shows significantly higher efficiency scores, with each indicator normalized to a value of 1 for the PR group and considerably lower values for the NPR group. This implies that PR consistently operates on the efficiency frontier, whereas NPR does not. In terms of health outcomes, QALYs are more than doubled in the PR group (1 vs. 0.46712), reflecting a 114% improvement in efficiency. This indicates that patients in the PR program not only live longer but also enjoy a better quality of life. From a healthcare utilization perspective, PR dramatically reduces the need for intensive and costly services. The most striking difference is seen in ICU usage, where PR is over 900% more efficient than NPR (1 vs. 0.09985). Similar trends are observed in hospitalizations (289%), emergency visits (252%), and pharmaceutical use (260%), highlighting the potential for substantial cost savings and resource optimization. Notably, the returns to scale differ between the two strategies. PR consistently operates under constant returns to scale, suggesting that scaling up the program would maintain efficiency. In contrast, the NPR group shows decreasing returns to scale, implying that increased resource input leads to proportionally smaller improvements, further emphasizing the inefficiency of no rehabilitation. Overall, the DEA analysis strongly supports the implementation and expansion of PR programs for COPD patients, both from an outcomes and resource-utilization standpoint. It reveals that PR is not only more effective but also more efficient, making it a superior strategy for healthcare systems seeking to optimize both patient well-being and operational sustainability. Although DEA is more useful than CEA for demonstrating the greater efficiency of PR over NPR, the latter offers some advantages, as it incorporates cost data and is able to relate financial investment to health outcomes, typically measured in QALYs. In other words, while DEA shows that PR generates more than twice the QALYs compared to NPR, CEA can determine the cost per QALY gained and, therefore, assess whether it falls within the established willingness-to-pay threshold [the British National Health System established a cutoff value of £20,000/QALY to determine whether a drug is cost-effective (NICE)] 34 . This can help public decision-makers determine whether a program is worth funding. The study has some limitations. Beyond the limitations of DEA 35 , some issues are specific to this study. The number of quality measures analyzed was limited (only the domains of exacerbations and quality of life). Retrospective data collection on exacerbations prior the PR programe may cause a selection bias. As it is a single-center study, the generalizability of our results to other populations, geographic regions or health systems may be limited. The study cohort consisted of a limited number of patients. Although all patients were diagnosed with COPD, the group was heterogeneous, as the only selection criterion was severity of dyspnoea. These results have not been confirmed in a validation cohort. Lastly, a high percentage of patients declined to participate, likely due to living far from the hospital, needing assistance to travel, or fear of the COVID-19 pandemic, which may have influenced the results. This study shows that DEA—a methodology that offers great flexibility in the use of information and adapts to a wide variety of inputs and outputs—can help identify the factors affecting the efficiency of a technique, and that efficiency does not necessarily have to come at the expense of quality. In this case, DEA demonstrates that implementing a PR program in COPD patients is more efficient than not doing so. Therefore, including it in a hospital’s service portfolio for treating these patients would be particularly valuable for increasing efficiency levels while maintaining a high and consistent quality of care. Furthermore, this model allows for estimating the extent to which the inefficient option (not performing PR) must improve its outcomes to become efficient. Nevertheless, a CEA could help quantify its cost and profitability. Both methods should be used in a complementary manner: DEA to identify efficient practices, and CEA to validate their economic viability. Healthcare managers should routinely use both tools when evaluating the efficiency of a specific intervention before deciding to introduce it into clinical practice. Abbreviations CEA , cost-effectiveness analysis COPD , Chronic obstructive pulmonary disease DEA , Data Envelopment Analysis DMU , Decision Making Units ICU , intensive care unit mMRC , modified Medical Research Council NPR , no pulmonary rehabilitation PR , pulmonary rehabilitation QALYs , quality adjusted life years Declarations Conflict of interest Authors declare no conflict of interest. We wish to confirm that there are no known conflicts of interest associated with this publication and there has been no significant financial support for this work that could have influenced its outcome. We confirm that the manuscript has been read and approved by all named authors. We further confirm that the order of authors listed in the manuscript has been approved by all of us. We confirm that we have given due consideration to the protection of intellectual property associated with this work and that there are no impediments to publication. We understand that the Corresponding Author is the sole contact for the Editorial process (including Editorial Manager and direct communications with the office). She is responsible for communicating with the other authors about progress, submissions of revisions and final approval of proofs. We confirm that we have provided a current, correct email address which is accessible by the Corresponding Author ( [email protected] ). We confirm that the manuscript has not been published elsewhere in any other language and is not currently being considered for publication in another journal. Ethics approval and consent to participate: Not applicable. Consent for publication: Done Availability of data and materials: On request Competing interests: Not applicable. Funding: Not applicable. Authors' contributions: Francisco Reyes Santias , Author and drafting. Conception and design. Reviewed intellectual content. Approval of the final manuscript. María Elena Toubes , Author and drafting. Conception and design. Data acquisition. Reviewed intellectual content. Approval of the final manuscript. Francisco Gude , Co-author. Statistical study. Reviewed intellectual content. Approval of the final manuscript. Óscar Lado-Baleato , Co-author. Statistical study. Reviewed intellectual content. Approval of the final manuscript. Luis Valdés , Author and drafting. Reviewed intellectual content. Approval of the final manuscript. Acknowledgement: Not applicable. References GBD 2017 Causes of Death Collaborators. Global, regional, and national age‑sex‑specific mortality for 282 causes of death in 195 countries and territories, 1980‑2017: A systematic analysis for the Global Burden of Disease Study 2017. Lancet 2018;392:1736‑88. Güell-Rous MR, Díaz-Lobato S, Rodríguez-Trillo G, et al. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6604849","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":473165086,"identity":"f9765047-737a-4130-b0c8-5f8a91da997b","order_by":0,"name":"Francisco Reyes-Santias","email":"data:image/png;base64,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","orcid":"","institution":"Universidade de Vigo","correspondingAuthor":true,"prefix":"","firstName":"Francisco","middleName":"","lastName":"Reyes-Santias","suffix":""},{"id":473165089,"identity":"52ece800-081e-43a8-8b4f-cd9f06993c10","order_by":1,"name":"María Elena Toubes","email":"","orcid":"","institution":"Hospital Clinico Santiago","correspondingAuthor":false,"prefix":"","firstName":"María","middleName":"Elena","lastName":"Toubes","suffix":""},{"id":473165091,"identity":"6a6bae3e-fefe-43f1-acfc-64fbea4e8a60","order_by":2,"name":"Francisco Gude","email":"","orcid":"","institution":"Concepcion Arenal, Primary Care Center","correspondingAuthor":false,"prefix":"","firstName":"Francisco","middleName":"","lastName":"Gude","suffix":""},{"id":473165094,"identity":"dc91c126-b797-4dc9-a0e1-5776361a9cf2","order_by":3,"name":"Óscar Lado-Baleato","email":"","orcid":"","institution":"Instituto de Investigación Sanitaria de Santiago","correspondingAuthor":false,"prefix":"","firstName":"Óscar","middleName":"","lastName":"Lado-Baleato","suffix":""},{"id":473165095,"identity":"0b2433f7-079f-46b3-8a94-dea8b38854cf","order_by":4,"name":"Luis Valdés","email":"","orcid":"","institution":"University of Santiago de Compostela","correspondingAuthor":false,"prefix":"","firstName":"Luis","middleName":"","lastName":"Valdés","suffix":""}],"badges":[],"createdAt":"2025-05-06 15:53:20","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6604849/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6604849/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":85173103,"identity":"b126e6a7-90df-42ef-851f-e31dfd6d18b5","added_by":"auto","created_at":"2025-06-23 05:55:15","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":107367,"visible":true,"origin":"","legend":"\u003cp\u003eComparative results between the Rehabilitation program and the No Rehabilitation program.\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-6604849/v1/cbef18ab6bffd7b4e5cc5ca7.jpeg"},{"id":85174151,"identity":"b298bedc-5cbb-4c6f-9479-576b335db9d3","added_by":"auto","created_at":"2025-06-23 06:11:15","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":891446,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6604849/v1/8f761807-a862-4ac3-a7b7-f76b88212e1c.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The data envelopment analysis as a model to evaluate the cost- utility study of a pulmonary rehabilitation programme for COPD patients in a university hospital in an European region","fulltext":[{"header":"Introduction","content":"\u003cp\u003eChronic obstructive pulmonary disease (COPD) is one of the three leading causes of death worldwide\u003cstrong\u003e\u003csup\u003e1\u003c/sup\u003e\u003c/strong\u003e. In 2017, more than 3 million people died from this disease, accounting for 6% of all deaths worldwide. COPD is a major public health challenge as it is a preventable and treatable disease. Nevertheless, many people suffer from COPD for years and die prematurely, either from COPD or from its complications.\u003c/p\u003e\n\u003cp\u003eThere is now ample evidence of the benefits of pulmonary rehabilitation (PR) for patients with COPD in terms of exercise capacity, peripheral muscle function, breathlessness, quality of life, physical activity, healthcare utilization\u003cstrong\u003e\u003csup\u003e2,3\u003c/sup\u003e\u003c/strong\u003e and possibly survival\u003cstrong\u003e\u003csup\u003e4\u003c/sup\u003e\u003c/strong\u003e. In Spain, however, these programmes are poorly implemented: Only 35% of hospitals have a specific PR unit, of which 53% are dependent on rehabilitation services and not on pulmonology services\u003cstrong\u003e\u003csup\u003e5\u003c/sup\u003e\u003c/strong\u003e.\u003c/p\u003e\n\u003cp\u003ePatients with COPD utilise many healthcare resources. Both outpatient and inpatient exacerbations have a significant impact on disease progression and are associated with reduced lung function\u003cstrong\u003e\u003csup\u003e6\u003c/sup\u003e\u003c/strong\u003e and increased mortality\u003cstrong\u003e\u003csup\u003e7\u003c/sup\u003e\u003c/strong\u003e. However, there is very limited evidence on the impact of on exacerbations, and few studies have investigated the role of PR in reducing exacerbations. Although little is known about whether PR is a cost-effective test, some studies suggest that it may bring benefits to the healthcare system\u003cstrong\u003e\u003csup\u003e8\u003c/sup\u003e\u003c/strong\u003e. Recently, our group has confirmed that PR contributes to reducing the number of exacerbations in patients with COPD, thereby slowing clinical deterioration and it is cost‑effective in terms of quality adjusted life years (QALYs)\u003cstrong\u003e\u003csup\u003e9\u003c/sup\u003e\u003c/strong\u003e. Unlike cost-effectiveness analysis (CEA), which only allows for the consideration of a single outcome while ignoring other potential clinical benefits, Data Envelopment Analysis (DEA) enables the simultaneous evaluation of multiple inputs and outputs. This provides a more comprehensive and flexible framework for assessing the efficiency of different healthcare technologies implemented within an organizational unit\u003cstrong\u003e\u003csup\u003e10\u003c/sup\u003e\u003c/strong\u003e. The aim of this study is to assess the efficiency of a PR program in patients with COPD by applying the DEA approach.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cbr\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eMaterial\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe information on the variables used has been compiled from the Admission Service of the Santiago University Hospital Complex. The costs of the program have been used as inputs to the model.\u003c/p\u003e\n\u003cp\u003eWe used as input the health care costs for COPD patients with the rehabilitation program included and the health care costs for COPD patients without the rehabilitation program (NPR) and as outputs the number of emergencies attended; the number of hospital stays; the number of ICU stays; the number of outpatient consultations and QALYs.\u003c/p\u003e\n\u003cp\u003eThe costs of PR as well as exacerbations in the years before and after the start of the PR programme were determined. The cost of the PR programme was calculated on the basis of: purchase of equipment (2,002.85\u0026euro;) with a linear amortisation over 5 years; full-time salary of a physiotherapist as labour costs of the programme (33,693.3\u0026euro;/year); general maintenance, cleaning, supplies, security and communication overheads (PR room space of 37.5m\u003csup\u003e2\u003c/sup\u003e: 389.26\u0026euro;)\u003cstrong\u003e\u003csup\u003e11\u003c/sup\u003e\u003c/strong\u003e; costs of patient travel from home to hospital at 0.19 \u0026euro;/km\u003cstrong\u003e\u003csup\u003e12\u003c/sup\u003e\u003c/strong\u003e; cost of time spent travelling to the hospital (weighted average times for travel, parking, travel to the consultation area and the consultation itself, 79 minutes) depending on whether the population was active [based on patient average gross income (20,288.1\u0026euro;) and unemployment rate (7.9%)]\u003cstrong\u003e\u003csup\u003e13\u003c/sup\u003e\u003c/strong\u003e or retired (average pension 11,097.6\u0026euro;; 2.3% of subjects \u0026gt;65 are engaged in volunteer work\u003cstrong\u003e\u003csup\u003e14\u003c/sup\u003e\u003c/strong\u003e and 22.6% perform activities that contribute to the gross domestic product)\u003cstrong\u003e\u003csup\u003e15\u003c/sup\u003e\u003c/strong\u003e; and costs related to leisure time (47% of labour cost)\u003cstrong\u003e\u003csup\u003e16\u003c/sup\u003e\u003c/strong\u003e; and CO\u003csub\u003e2\u003c/sub\u003e emissions per private car travel (volume of CO\u003csub\u003e2\u003c/sub\u003e emitted per kilometre and cost of each CO\u003csub\u003e2\u003c/sub\u003e gram)\u003cstrong\u003e\u003csup\u003e17,18\u003c/sup\u003e\u003c/strong\u003e. The average number of PR sessions per patient was 25.5\u003cstrong\u003e\u003csup\u003e9\u003c/sup\u003e\u003c/strong\u003e. The cost of exacerbations was estimated based on the tariffs of the Galician Health Service (\u003cem\u003eServizo Galego de Sa\u0026uacute;de\u003c/em\u003e)\u003cstrong\u003e\u0026sup1;⁹\u003c/strong\u003e (emergency care, complementary tests, pharmacy costs, length of hospital stay, length of stay in the intensive care unit (ICU), when applicable, and follow-up visits) (\u003cstrong\u003eTable 1\u003c/strong\u003e)\u003cstrong\u003e\u003csup\u003e⁹\u003c/sup\u003e\u003c/strong\u003e, in addition to travel costs and productivity loss during exacerbations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1\u003c/strong\u003e. \u003cem\u003eServizo Galego de Sa\u0026uacute;de\u003c/em\u003e fees in relation to emergency care and hospital admissions due to exacerbation of chronic obstructive pulmonary disease\u003cstrong\u003e\u003csup\u003e18\u003c/sup\u003e\u003c/strong\u003e.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 80.0347%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTest\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.9653%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCost (\u0026euro;)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 80.0347%;\"\u003e\n \u003cp\u003eEmergency care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.9653%;\"\u003e\n \u003cp\u003e361.59\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 80.0347%;\"\u003e\n \u003cp\u003eEmergency care (with admission)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.9653%;\"\u003e\n \u003cp\u003e528.95\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 80.0347%;\"\u003e\n \u003cp\u003eBlood test, arterial blood gas test included\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.9653%;\"\u003e\n \u003cp\u003e180\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 80.0347%;\"\u003e\n \u003cp\u003eChest X-ray\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.9653%;\"\u003e\n \u003cp\u003e40.35\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 80.0347%;\"\u003e\n \u003cp\u003eSputum culture\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.9653%;\"\u003e\n \u003cp\u003e181\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 80.0347%;\"\u003e\n \u003cp\u003ePharmacy cost of moderate exacerbation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.9653%;\"\u003e\n \u003cp\u003e161.84\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 80.0347%;\"\u003e\n \u003cp\u003ePharmacy cost of moderate exacerbation before PR (mean stay, 7.2 days)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.9653%;\"\u003e\n \u003cp\u003e58.87\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 80.0347%;\"\u003e\n \u003cp\u003ePharmacy cost of moderate exacerbation after PR (mean stay, 7.4 days)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.9653%;\"\u003e\n \u003cp\u003e96.07\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 80.0347%;\"\u003e\n \u003cp\u003eFollow-up consultations\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.9653%;\"\u003e\n \u003cp\u003e58.37\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 80.0347%;\"\u003e\n \u003cp\u003eDaily cost of hospital stay\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.9653%;\"\u003e\n \u003cp\u003e528.95\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 80.0347%;\"\u003e\n \u003cp\u003eDaily cost of ICU stay\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.9653%;\"\u003e\n \u003cp\u003e1,142.47\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eICU, intensive care unit; PR, pulmonary rehabilitation.\u003c/p\u003e\n\u003cp\u003eQuality of life, used as output in the DEA analysis, was measured by the EuroQol-5D (EQ-5D)\u003cstrong\u003e\u003csup\u003e20\u003c/sup\u003e\u003c/strong\u003e, immediately before starting RP and one year after starting RP. An improvement in quality of life was assumed if the EQ-5D increased by at least 0.051.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePatients with COPD with dyspnoea on the modified Medical Research Council (mMRC) scale \u0026ge;2\u003cstrong\u003e\u003csup\u003e21\u003c/sup\u003e\u003c/strong\u003e who agreed to participate in the study were included and those who were in the end-of-life phase (life expectancy \u0026lt;3 months), had an impediment to physical exercise, psychiatric problems, cardiovascular pathology in the acute phase, or did not agree to participate in the study were excluded. The PR programme applied was the one used in our usual clinical practice, consisting of 24-28 sessions (3/week) over a period of 8-9 weeks, of 75-90 minutes each\u003cstrong\u003e\u003csup\u003e2\u003c/sup\u003e\u003c/strong\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eData Envelopment Analysis (DEA)\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eDEA is a non-parametric frontier method used to measure the efficiency of each organisation or organisational unit (DMU, Decision Making Units), by solving a linear programming problem\u003cstrong\u003e\u003csup\u003e22\u003c/sup\u003e\u003c/strong\u003e for each unit under the assumption, in this study, of Constant Returns to Scale:\u003c/p\u003e\n\u003cp\u003e\u003cimg 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\" width=\"715\" height=\"266\"\u003e\u003c/p\u003e\n\u003cp\u003eFormula1. DMU: decision-making unit or programme; Yrj: i-th output of the j-th DMU; Xij: i-th input of the j-th DMU; Vi, Ur: weights of inputs and outputs, respectively.\u003c/p\u003e\n\u003cp\u003eDMUs that are considered technically efficient lie on the efficiency frontier and have a score of 1. Data management units with scores below 1 are considered inefficient\u003cstrong\u003e\u003csup\u003e23\u003c/sup\u003e\u003c/strong\u003e.\u003c/p\u003e\n\u003cp\u003eDMU measures productive efficiency and indicates how much productivity can be increased without using additional resources, thus providing a starting point for efficiency measures derived from a frontier-based methodology\u003cstrong\u003e\u003csup\u003e24,25\u003c/sup\u003e\u003c/strong\u003e. In short, DEA is a method that compares homogeneous decision-making units (DMUs) in terms of resources and production outcomes, providing a measure of relative efficiency. The relative technical efficiency of each DMU is calculated by computing the ratio obtained from dividing the weighted sum of outputs by the weighted sum of inputs, based on Paretian criteria (utility criteria that follow a natural optimization process aimed at reaching a point at which no further improvement in outcome is possible without using more resources). In this way, a theoretical efficiency frontier is established, which cannot exceed a value of one, and the distance of each DMU from this frontier is calculated\u003cstrong\u003e\u003csup\u003e26-28\u003c/sup\u003e\u003c/strong\u003e.\u003c/p\u003e\n\u003cp\u003eThis technique, widely used in the health sector\u003cstrong\u003e\u003csup\u003e29\u003c/sup\u003e\u003c/strong\u003e allows measuring several different types of efficiency: technical, allocative congestion and dynamic. In addition, it also allows for the observation of possible economies of scale. To carry out the corresponding analysis of technical efficiency in the public, private, and joint sector, a series of inputs and an output have been chosen, which has already been discussed in more detail in the Materials and Methods subsection. The program used to apply this analysis technique was DEA Frontier Software for Excel.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eOf the 645 patients who were proposed to participate in the RR program, only 219 (34%) started and 200 (31%) completed the program\u003cstrong\u003e\u003csup\u003e9\u003c/sup\u003e\u003c/strong\u003e. Of the 19 patients who did not complete the RR programme, 5 (26.3%) died. \u003cstrong\u003eTable 2\u003c/strong\u003e shows the baseline characteristics of the 200 patients who completed PR, number of hospital admissions, days of stay in a general ward and in the ICU, emergency department visits during the previous year, and the baseline median EQ-5D scores\u003cstrong\u003e\u003csup\u003e9\u003c/sup\u003e\u003c/strong\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2\u003c/strong\u003e. Baseline characteristics of patients included in the study.\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 73.7374%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCHARACTERISTICS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.2626%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eOverall\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 73.7374%;\"\u003e\n \u003cp\u003ePatients (n) \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.2626%;\"\u003e\n \u003cp\u003e200\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 73.7374%;\"\u003e\n \u003cp\u003eGender (n; men (%) / women (%))\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.2626%;\"\u003e\n \u003cp\u003e159 (79.5) / 41 (20.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 73.7374%;\"\u003e\n \u003cp\u003eAge (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.2626%;\"\u003e\n \u003cp\u003e65 (59-70)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 73.7374%;\"\u003e\n \u003cp\u003eNumber of hospital admissions in the previous year\u003c/p\u003e\n \u003cp\u003e0 (%)\u003c/p\u003e\n \u003cp\u003e1 (%)\u003c/p\u003e\n \u003cp\u003e2 (%)\u003c/p\u003e\n \u003cp\u003e3 (%)\u003c/p\u003e\n \u003cp\u003e4 (%)\u003c/p\u003e\n \u003cp\u003e5 (%)\u003c/p\u003e\n \u003cp\u003e6 (%)\u003c/p\u003e\n \u003cp\u003e7 (%)\u003c/p\u003e\n \u003cp\u003eMedian (25th-75th percentile)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.2626%;\"\u003e\n \u003cp\u003e222\u003c/p\u003e\n \u003cp\u003e87 (43.5)\u003c/p\u003e\n \u003cp\u003e54 (27)\u003c/p\u003e\n \u003cp\u003e31 (15.5)\u003c/p\u003e\n \u003cp\u003e16 (8)\u003c/p\u003e\n \u003cp\u003e7 (3.5)\u003c/p\u003e\n \u003cp\u003e1 (0.5)\u003c/p\u003e\n \u003cp\u003e3 (1.5)\u003c/p\u003e\n \u003cp\u003e1 (0.5)\u003c/p\u003e\n \u003cp\u003e1 (0-2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 73.7374%;\"\u003e\n \u003cp\u003eDays hospitalized in the previous year\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.2626%;\"\u003e\n \u003cp\u003e1597\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 73.7374%;\"\u003e\n \u003cp\u003eICU days in the previous year\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.2626%;\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 73.7374%;\"\u003e\n \u003cp\u003eEmergency department visitis in the previous year\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.2626%;\"\u003e\n \u003cp\u003e365\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 73.7374%;\"\u003e\n \u003cp\u003eEuroQol-5D score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.2626%;\"\u003e\n \u003cp\u003e0.617 (0.493-0.739)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eICU, intensive care unit\u003c/p\u003e\n\u003cp\u003eData are expressed as absolute frequencies (percentages) and medians (25th\u0026ndash;75th percentile).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eOutcomes after Pulmonary Rehabilitation (12 months)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAfter completion of PR sessions, outcomes were assessed at 12 months (\u0026plusmn;1 week) by grouping the studied parameters into 2 domains [exacerbations and quality of life].\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eThe number of hospital admissions decreased from 222 to 115; the admission rate per patient per year dropped from 1.1 to 0.6; days of stay in a general ward declined from 1,597 to 852; ICU days decreased from 20 to 2; and emergency department visits were reduced from 365 to 210\u003cstrong\u003e\u003csup\u003e9\u003c/sup\u003e\u003c/strong\u003e.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3\u003c/strong\u003e. Mean cost/patient of a pulmonary rehabilitation program (left side) and mean cost of exacerbation/patient before and after the pulmonary rehabilitation program (right side) (con permiso)\u003cstrong\u003e\u003csup\u003e9\u003c/sup\u003e\u003c/strong\u003e.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCost of the rehabilitation program (\u0026euro;)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCosts (\u0026euro;)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePrerehabilitation (\u0026euro;)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePostrehabilitation (\u0026euro;)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePR cost: 1,414.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMean hospital travel cost\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e30.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e24.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTravel costs related to PR: 267.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMean cost of loss of productivity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e391.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e195.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCosts related to loss of productivity associated with PR: 161.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMean cost of pollution\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCost of pollution: 24.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMean cost of moderate exacerbation\u003c/p\u003e\n \u003cp\u003eMean cost of severe exacerbation\u003c/p\u003e\n \u003cp\u003eCost of ICU admission\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1,804.3\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e5,549.6\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e114.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1,038.1\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e2,937.1\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e11.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTotal cost/patient: 1,867.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTotal cost/patient\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e7,895.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4,201.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eICU\u003c/strong\u003e = intensive care unit; \u003cstrong\u003ePR\u003c/strong\u003e, pulmonary rehabilitation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3\u003c/strong\u003e shows the average cost per patient of the PR program (left side) and the average cost of exacerbations per patient before and after the PR program (right side). The total savings amounted to \u0026euro;365,200, which represents \u0026euro;1,826 per patient per year. The cost of exacerbations before and after PR differed due to variations in pharmacy costs and the average cost of hospital and intensive care unit (ICU) stays between the two periods\u003cstrong\u003e\u003csup\u003e9\u003c/sup\u003e\u003c/strong\u003e.\u003c/p\u003e\n\u003cp\u003eThe median EQ-5D was determined in 128 patients. Before the start of the PR program, it was 0.617 (0.4930\u0026ndash;0.7601), and one year after starting the program, it was 0.724 (0.645\u0026ndash;0.794).\u003c/p\u003e\n\u003cp\u003eTable 4\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4\u003c/strong\u003e presents the DEA model results for evaluating the efficiency of implementing a PR program versus not doing so in patients with COPD. The DEA considers the PR program efficient because it optimizes its outcomes by achieving the best output values from its inputs, compared to not implementing the PR program, which is considered inefficient.\u003cbr\u003eThe column \u0026apos;Improved efficiency PR vs NPR\u0026apos; shows the values that indicate the \u0026apos;distance\u0026apos; between the inefficient option (not implementing PR) and the efficiency frontier\u0026mdash;that is, the difference between the two. DEA allows estimation of the degree to which the inefficient option would need to improve its outcomes (outputs) to become efficient. In our case, this would be 114% for QALYs, 252% for emergency visits, 902% for ICU use, 235% for chest X-rays, 289% for hospitalizations, 260% for pharmacy, and 97% for emergency department visits. \u003cstrong\u003eFigure 1\u003c/strong\u003e graphically represents the results shown in \u003cstrong\u003eTable 4\u003c/strong\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4\u003c/strong\u003e. Results DEA compared rehabilitation program with no rehabilitation for EPOC patients.\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 20px;\"\u003e\n \u003cp\u003eResults DEA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 28px;\"\u003e\n \u003cp\u003eRehabilitation program\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 32px;\"\u003e\n \u003cp\u003eNO Rehabilitation program\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 19px;\"\u003e\n \u003cp\u003eImproved efficiency PR vs NPR\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 20px;\"\u003e\n \u003cp\u003eQALYs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 28px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 32px;\"\u003e\n \u003cp\u003e0,46712\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 19px;\"\u003e\n \u003cp\u003e114%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 20px;\"\u003e\n \u003cp\u003eReturns of scale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 28px;\"\u003e\n \u003cp\u003eConstant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 32px;\"\u003e\n \u003cp\u003eDecreasing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 19px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 20px;\"\u003e\n \u003cp\u003eEmergencies\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 28px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 32px;\"\u003e\n \u003cp\u003e0,28443\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 19px;\"\u003e\n \u003cp\u003e252%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 20px;\"\u003e\n \u003cp\u003eReturns of scale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 28px;\"\u003e\n \u003cp\u003eConstant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 32px;\"\u003e\n \u003cp\u003eDecreasing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 19px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 20px;\"\u003e\n \u003cp\u003eICU\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 28px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 32px;\"\u003e\n \u003cp\u003e0,09985\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 19px;\"\u003e\n \u003cp\u003e902%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 20px;\"\u003e\n \u003cp\u003eReturns of scale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 28px;\"\u003e\n \u003cp\u003eConstant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 32px;\"\u003e\n \u003cp\u003eDecreasing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 19px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 20px;\"\u003e\n \u003cp\u003eTests\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 28px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 32px;\"\u003e\n \u003cp\u003e0,29841\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 19px;\"\u003e\n \u003cp\u003e235%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 20px;\"\u003e\n \u003cp\u003eReturns of scale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 28px;\"\u003e\n \u003cp\u003eConstant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 32px;\"\u003e\n \u003cp\u003eDecreasing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 19px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 20px;\"\u003e\n \u003cp\u003eHospitalisation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 28px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 32px;\"\u003e\n \u003cp\u003e0,25735\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 19px;\"\u003e\n \u003cp\u003e289%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 20px;\"\u003e\n \u003cp\u003eReturns of scale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 28px;\"\u003e\n \u003cp\u003eConstant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 32px;\"\u003e\n \u003cp\u003eDecreasing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 19px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 20px;\"\u003e\n \u003cp\u003ePharmacy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 28px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 32px;\"\u003e\n \u003cp\u003e0,27759\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 19px;\"\u003e\n \u003cp\u003e260%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 20px;\"\u003e\n \u003cp\u003eReturns of scale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 28px;\"\u003e\n \u003cp\u003eConstant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 32px;\"\u003e\n \u003cp\u003eDecreasing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 19px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 20px;\"\u003e\n \u003cp\u003eEmergency Department visits\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 28px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 32px;\"\u003e\n \u003cp\u003e0,50676\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 19px;\"\u003e\n \u003cp\u003e97%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 20px;\"\u003e\n \u003cp\u003eReturns of scale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 28px;\"\u003e\n \u003cp\u003eConstant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 32px;\"\u003e\n \u003cp\u003eDecreasing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 19px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eICU\u003c/strong\u003e, intensive care unit; \u003cstrong\u003eQALYs\u003c/strong\u003e, a\u0026ntilde;os de vida ajustados por calidad.\u003c/p\u003e\n\u003cp\u003eSource: Own elaboration\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eOur results show that DEA, through a more comprehensive analysis than the usual cost-effectiveness ratios, is a useful tool for evaluating the efficiency of PR programs in patients with COPD, as it confirms the efficiency of implementing PR compared to not doing so.\u003c/p\u003e \u003cp\u003eThe efficiency of PR programs in patients with COPD has been widely debated. First, because outcomes can be evaluated from very different perspectives (improvement in quality of life, exercise capacity, lung function, reduction in disease severity, and decrease in the number of exacerbations), and it is possible that a PR program improves certain parameters within these domains but not all of them. Second, because the methodology used to measure and compare different studies can vary. A clear example is the systematic review conducted by Leemans et al. across 11 studies (3,261 participants). In 4 of these, the results were interpreted as cost-effective; in two they were not, and in the remaining five, cost-effectiveness was uncertain\u003csup\u003e\u003cb\u003e30\u003c/b\u003e\u003c/sup\u003e. Evidently, the intensity of the PR interventions, exacerbation rates, project design, and outcome measures used differed among the studies. Finally, the analytical method used to assess the efficiency of the PR program (cost-effectiveness ratios or DEA) can influence the results obtained.\u003c/p\u003e \u003cp\u003eDEA is a dominant non-parametric quantitative method that evaluates healthcare efficiency through DMUs by creating a production frontier based on best practices observed in the data\u003csup\u003e\u003cb\u003e31\u003c/b\u003e\u003c/sup\u003e. It can also be used to rank and compare the efficiency of different entities\u003csup\u003e\u003cb\u003e32\u003c/b\u003e\u003c/sup\u003e. The difference between DEA and CEA is that DEA considers all inputs and outputs simultaneously when evaluating performance, whereas CEA combines only one input with one output at a time and is therefore not suitable for setting performance improvement targets for units. However, in some cases, the two methods can complement each other when used together\u003csup\u003e\u003cb\u003e33\u003c/b\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe DEA model is relatively complex and can yield a substantial number of results. The full description and interpretation of these go beyond the scope of this article. Therefore, we present only the most relevant findings in a simplified form. The DEA model provides a ranking of the efficiency values of the PR program (\u003cb\u003eTable\u0026nbsp;4\u003c/b\u003e) and demonstrates that this program, compared to not implementing PR, is efficient as it achieves better output values from its inputs (i.e., better output/input ratios), while the non-PR option is inefficient. The most practically relevant contribution of the DEA model is that it identifies the reasons why certain programs are inefficient. For instance, in the 'Improved efficiency PR vs NPR' column of \u003cb\u003eTable\u0026nbsp;4\u003c/b\u003e, the required output percentage increases are shown for the inefficient program to become efficient. That is, the DEA model estimates to what extent the inefficient option would need to improve its outcomes (outputs) to reach the efficiency frontier.\u003c/p\u003e \u003cp\u003eThe DEA model provides each program with an efficiency score ranging from 0 to 1 and also allows estimation of the contribution of each input and output variable in determining that efficiency score (see \u003cb\u003eFormula 1\u003c/b\u003e). The DEA results demonstrate a clear advantage of implementing PR programs for patients with COPD compared to providing NPR. Across all evaluated outputs, PR shows significantly higher efficiency scores, with each indicator normalized to a value of 1 for the PR group and considerably lower values for the NPR group. This implies that PR consistently operates on the efficiency frontier, whereas NPR does not. In terms of health outcomes, QALYs are more than doubled in the PR group (1 vs. 0.46712), reflecting a 114% improvement in efficiency. This indicates that patients in the PR program not only live longer but also enjoy a better quality of life. From a healthcare utilization perspective, PR dramatically reduces the need for intensive and costly services. The most striking difference is seen in ICU usage, where PR is over 900% more efficient than NPR (1 vs. 0.09985). Similar trends are observed in hospitalizations (289%), emergency visits (252%), and pharmaceutical use (260%), highlighting the potential for substantial cost savings and resource optimization. Notably, the returns to scale differ between the two strategies. PR consistently operates under constant returns to scale, suggesting that scaling up the program would maintain efficiency. In contrast, the NPR group shows decreasing returns to scale, implying that increased resource input leads to proportionally smaller improvements, further emphasizing the inefficiency of no rehabilitation. Overall, the DEA analysis strongly supports the implementation and expansion of PR programs for COPD patients, both from an outcomes and resource-utilization standpoint. It reveals that PR is not only more effective but also more efficient, making it a superior strategy for healthcare systems seeking to optimize both patient well-being and operational sustainability.\u003c/p\u003e \u003cp\u003eAlthough DEA is more useful than CEA for demonstrating the greater efficiency of PR over NPR, the latter offers some advantages, as it incorporates cost data and is able to relate financial investment to health outcomes, typically measured in QALYs. In other words, while DEA shows that PR generates more than twice the QALYs compared to NPR, CEA can determine the cost per QALY gained and, therefore, assess whether it falls within the established willingness-to-pay threshold [the British National Health System established a cutoff value of \u0026pound;20,000/QALY to determine whether a drug is cost-effective (NICE)]\u003csup\u003e\u003cb\u003e34\u003c/b\u003e\u003c/sup\u003e. This can help public decision-makers determine whether a program is worth funding.\u003c/p\u003e \u003cp\u003eThe study has some limitations. Beyond the limitations of DEA\u003csup\u003e\u003cb\u003e35\u003c/b\u003e\u003c/sup\u003e, some issues are specific to this study. The number of quality measures analyzed was limited (only the domains of exacerbations and quality of life). Retrospective data collection on exacerbations prior the PR programe may cause a selection bias. As it is a single-center study, the generalizability of our results to other populations, geographic regions or health systems may be limited.\u003c/p\u003e \u003cp\u003eThe study cohort consisted of a limited number of patients. Although all patients were diagnosed with COPD, the group was heterogeneous, as the only selection criterion was severity of dyspnoea. These results have not been confirmed in a validation cohort. Lastly, a high percentage of patients declined to participate, likely due to living far from the hospital, needing assistance to travel, or fear of the COVID-19 pandemic, which may have influenced the results.\u003c/p\u003e \u003cp\u003eThis study shows that DEA\u0026mdash;a methodology that offers great flexibility in the use of information and adapts to a wide variety of inputs and outputs\u0026mdash;can help identify the factors affecting the efficiency of a technique, and that efficiency does not necessarily have to come at the expense of quality. In this case, DEA demonstrates that implementing a PR program in COPD patients is more efficient than not doing so. Therefore, including it in a hospital\u0026rsquo;s service portfolio for treating these patients would be particularly valuable for increasing efficiency levels while maintaining a high and consistent quality of care. Furthermore, this model allows for estimating the extent to which the inefficient option (not performing PR) must improve its outcomes to become efficient. Nevertheless, a CEA could help quantify its cost and profitability. Both methods should be used in a complementary manner: DEA to identify efficient practices, and CEA to validate their economic viability. Healthcare managers should routinely use both tools when evaluating the efficiency of a specific intervention before deciding to introduce it into clinical practice.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003e\u003cstrong\u003eCEA\u003c/strong\u003e, cost-effectiveness analysis\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCOPD\u003c/strong\u003e, Chronic obstructive pulmonary disease\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDEA\u003c/strong\u003e, Data Envelopment Analysis\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDMU\u003c/strong\u003e, Decision Making Units\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eICU\u003c/strong\u003e, intensive care unit\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003emMRC\u003c/strong\u003e, modified Medical Research Council\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNPR\u003c/strong\u003e, no pulmonary rehabilitation\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePR\u003c/strong\u003e, pulmonary rehabilitation\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eQALYs\u003c/strong\u003e, quality adjusted life years\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eConflict of interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAuthors declare no conflict of interest.\u003c/p\u003e\n\u003cp\u003eWe wish to confirm that there are no known conflicts of interest associated with this publication and there has been no significant financial support for this work that could have influenced its outcome. We confirm that the manuscript has been read and approved by all named authors. We further confirm that the order of authors listed in the manuscript has been approved by all of us. We confirm that we have given due consideration to the protection of intellectual property associated with this work and that there are no impediments to publication.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;We understand that the Corresponding Author is the sole contact for the Editorial process (including Editorial Manager and direct communications with the office). She is responsible for communicating with the other authors about progress, submissions of revisions and final approval of proofs. We confirm that we have provided a current, correct email address which is accessible by the Corresponding Author ([email protected]).\u003c/p\u003e\n\u003cp\u003eWe confirm that the manuscript has not been published elsewhere in any other language and is not currently being considered for publication in another journal.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003e Not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e Done\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u003c/strong\u003e On request\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u003c/strong\u003e Not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e Not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFrancisco Reyes Santias\u003c/strong\u003e,\u0026nbsp;Author and drafting. Conception and design.\u0026nbsp;Reviewed intellectual content.\u0026nbsp;Approval of the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMar\u0026iacute;a Elena Toubes\u003c/strong\u003e,\u0026nbsp;Author and drafting.\u0026nbsp;Conception and design.\u0026nbsp;Data acquisition. Reviewed intellectual content.\u0026nbsp;Approval of the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFrancisco Gude\u003c/strong\u003e,\u0026nbsp;Co-author. Statistical study. Reviewed intellectual content.\u0026nbsp;Approval of the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026Oacute;scar Lado-Baleato\u003c/strong\u003e, Co-author. Statistical study. Reviewed intellectual content.\u0026nbsp;Approval of the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLuis Vald\u0026eacute;s\u003c/strong\u003e,\u0026nbsp;Author and drafting.\u0026nbsp;Reviewed intellectual content.\u0026nbsp;Approval of the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgement:\u003c/strong\u003e Not applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eGBD 2017 Causes of Death Collaborators. Global, regional, and national age‑sex‑specific mortality for 282 causes of death in 195 countries and territories, 1980‑2017: A systematic analysis for the Global Burden of Disease Study 2017. Lancet 2018;392:1736‑88.\u003c/li\u003e\n\u003cli\u003eG\u0026uuml;ell-Rous MR, D\u0026iacute;az-Lobato S, Rodr\u0026iacute;guez-Trillo G, et al. Pulmonary rehabilitation. Normativa SEPAR. Arch Bronconeumol 2014;50:332-44. \u003c/li\u003e\n\u003cli\u003eHolland AE, Cox NS, Houchen-Wolloff L, et al. 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Data Envelopment Analysis: Theory, Methodology and Applications, New York, Kluwer Academic Publisher, Second edition.\u003c/li\u003e\n\u003cli\u003eSengupta JK. Efficiency measurement in non market systems through DEA. International Journal of Systems Science. 1987;18:2279-2304. Doi: https://doi.org/10.1080/00207728708967187.\u003c/li\u003e\n\u003cli\u003eMart\u0026iacute;n-Mart\u0026iacute;n JJ, L\u0026oacute;pez del Amo-Gonz\u0026aacute;lez MP. La medida de la eficiencia en las organizaciones sanitarias. Presupuesto y gasto p\u0026uacute;blico 2007;49:139-161. ISSN 0210-5977, N\u0026ordm; 49, pp. 139-161.\u003c/li\u003e\n\u003cli\u003eLeemans G, Taeymans J, Van Royen P, Vissers D. Respiratory physiotherapy interventions focused on exercise training and enhancing physical activity levels in people with chronic obstructive pulmonary disease are likely to be cost‐effective: A systematic review. J Physiother 2021;67:271‐83.\u003c/li\u003e\n\u003cli\u003ePiubello Orsini L, Leardin, C, Vernizzi S, Campedelli B. Inefficiency of public hospitals: A multistage data envelopment analysis in an Italian region. BMC Health Serv Res. 2021;21:1281.\u003c/li\u003e\n\u003cli\u003eCharnes A, Cooper W, Rhodes E. Measuring the efficiency of decision-making units. Eur J Oper Res. 1979;3:339.\u003c/li\u003e\n\u003cli\u003eThanassoulis E, A. Boussofiane A, Dyson RG. A comparison of data envelopment analysis and ratio analysis as tools for performance assessment, Omega, Int J Mgmt Sci 1996;24:229-244. (https://doi.org/10.1016/0305-0483(95)00060-7).\u003c/li\u003e\n\u003cli\u003eClaxton K, Briggs A, Buxton MJ, et al. Value based pricing for NHS drugs: An opportunity not to be missed? BMJ 2008;336:251‐4. \u003c/li\u003e\n\u003cli\u003eKohl S, Schoenfelder J, Fügener A, Brunner JO. The use of data envelopment analysis (DEA) in healthcare with a focus on hospitals. Health Care Manag Sci. 2019;22:245\u0026ndash;86.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Data Envelopment Analysis, cost-effectiveness analysis, pulmonary rehabilitation, chronic obstructive pulmonary disease","lastPublishedDoi":"10.21203/rs.3.rs-6604849/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6604849/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground. \u003c/strong\u003eThe efficiency of pulmonary rehabilitation (PR) programs in patients with COPD, as evaluated through cost-effectiveness analysis (CEA), yields mixed results. The aim of this study is to determine whether the efficiency demonstrated by a PR program using CEA is maintained when applying Data Envelopment Analysis (DEA), a tool used to develop an efficiency frontier for a given intervention.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e. The profitability of this program was assessed based on its impact on the number of exacerbations and quality of life. The DEA model evaluates a given performance by taking into account all inputs and outputs simultaneously. The inputs were healthcare costs, and the outputs included the number of hospital admissions, hospital stays, ICU stays, emergency department visits, and quality of life (EuroQol-5D).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e. The DEA considers that implementing the PR program is efficient compared to not implementing it, which is deemed inefficient. Furthermore, it estimates the extent to which the inefficient option would need to improve its outcomes (outputs) in order to become efficient: QALYs, 114%; emergency department visits, 252%; ICU, 902%; hospitalizations, 289%; pharmacy, 260%; outpatient visits, 97%.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e. DEA shows that implementing a PR program in patients with COPD is more efficient than not doing so. Moreover, it estimates to what extent the inefficient option would need to improve its outcomes in order to become efficient. However, CEA allows the financial investment to be related to health outcomes, usually measured in QALYs. Healthcare managers should use both methods in a complementary way when assessing the efficiency of a specific intervention before implementing it in clinical practice.\u003c/p\u003e","manuscriptTitle":"The data envelopment analysis as a model to evaluate the cost- utility study of a pulmonary rehabilitation programme for COPD patients in a university hospital in an European region","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-23 05:55:10","doi":"10.21203/rs.3.rs-6604849/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-07-21T08:41:23+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"24134909632818075685530002385710829926","date":"2025-07-07T15:59:00+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-07T12:04:52+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-27T10:37:48+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"252074570244567291159515240105976967203","date":"2025-06-26T07:17:42+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"80269847081686267604137044077833093495","date":"2025-06-23T10:16:18+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"227518466536319857473603131650831775808","date":"2025-06-20T10:14:41+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-06-18T09:47:06+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-05-20T09:28:28+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-05-19T11:27:25+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-05-19T11:25:02+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2025-05-06T15:43:40+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"8228b547-fee6-4805-a6e7-c3f7cc2ab786","owner":[],"postedDate":"June 23rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-08-24T18:08:10+00:00","versionOfRecord":[],"versionCreatedAt":"2025-06-23 05:55:10","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6604849","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6604849","identity":"rs-6604849","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}