Clinical Effectiveness and Cost-Effectiveness of Pulmonary Rehabilitation for People in Uganda With Post-TB Lung Disease

BACKGROUND: Post-TB lung disease (PTLD) causes significant disability in survivors of TB. Pulmonary rehabilitation (PR) may offer effective disease management but lacks high-quality evidence in this underrepresented population. RESEARCH QUESTION: Compared with usual care, does a 6-week PR program improve exercise capacity and health-related quality of life (HRQoL) cost-effectively in adults living with post-TB lung disease? STUDY DESIGN AND METHODS: We conducted a single-center randomized controlled trial with blinded outcome assessments, comparing PR vs usual care (UC) for adults in Kampala, Uganda with PTLD. Participants were randomized (1: 1) to receive either PR or UC, with assessments at 6 weeks postintervention. The primary outcome was change in exercise capacity measured by the Incremental Shuttle Walk Test. Secondary outcomes included HRQoL, respiratory symptoms, psychological well-being, and cost-benefit analysis. A generalized linear mixed model was used for the primary efficacy analysis (intention-to-treat) and a difference-in-differences analysis for secondary outcomes (modified intention-to-treat). RESULTS: Between November 2020 and September 2022, 178 adults with PTLD were assessed for eligibility and 114 were randomized (mean age ± SD, 43. 3 ± 15. 2 years; 65 57% were male). The postintervention improvement in mean Incremental Shuttle Walk Test in the PR group was significantly greater than in the UC group, by 54. 36 m (95% CI, 17. 22-91. 51 m; P =. 004). We also observed significant improvements in HRQoL in PR compared with UC: COPD Assessment Test score, -3. 6 (95% CI, -6. 7 to -0. 39; P =. 015) ; and Clinical COPD Questionnaire total, -0. 37 (95% CI, -0. 68 to -0. 06; P =. 004). The EuroQol Visual Analog Scale and quality-adjusted life-years (QALYs) marginally improved in the PR group vs the UC group: 3. 98 (95% CI, -2. 05 to 10. 02; P =. 191) and 0. 02 (95% CI, -0. 02 to 0. 05; P =. 334), respectively. The average cost of PR was 6, 468/QALY gained, equating to 20, 000/QALY gained after adjusting for purchasing power (below the National Institute for Health and Care Excellence cost-effectiveness threshold). INTERPRETATION: In adults with PTLD, a 6-week PR program elicited clinically and statistically significant improvements in exercise capacity and HRQoL compared with UC, and was cost-effective. CLINICAL TRIAL REGISTRATION: ISRCTN Clinical Trial Registry; No.: ISRCTN18256843; URL: isrctn. com.