Comparative effectiveness of different home-based pulmonary rehabilitation models in patients with COPD: a systematic review and network meta-analysis

To compare the efficacy and safety of four home-based pulmonary rehabilitation models-traditional home-based pulmonary rehabilitation, telerehabilitation, hybrid pulmonary rehabilitation, and self-management pulmonary rehabilitation-in patients with COPD. We sought to generate comparative evidence against usual care and center-based pulmonary rehabilitation to guide model selection in clinical practice. We systematically searched PubMed, Embase, CINAHL, Scopus, and the Cochrane Library from inception to May 1, 2025 for randomized controlled trials involving adults with COPD. A frequentist random-effects network meta-analysis was conducted using Stata 15.0 to synthesize direct and indirect evidence across prespecified outcomes: the six-minute walk test (6MWT), St. George's Respiratory Questionnaire (SGRQ), COPD Assessment Test (CAT), modified Medical Research Council (mMRC) dyspnea scale, Chronic Respiratory Disease Questionnaire (CRQ) domains, Hospital Anxiety and Depression Scale (HADS), and adverse events (AEs). Global and local consistency were assessed and rankings were summarized using the surface under the cumulative ranking curve (SUCRA). The risk of bias was evaluated with RoB 2.0 tool, and the protocol was registered on PROSPERO (CRD420251038495). A total of 39 RCTs involving 3610 patients were included. For exercise capacity, telerehabilitation, traditional home-based pulmonary rehabilitation, and hybrid pulmonary rehabilitation significantly improved 6MWT compared with usual care, and no statistically significant differences were observed between any home-based model and center-based pulmonary rehabilitation for the 6MWT. For health-related quality of life, telerehabilitation, traditional home-based pulmonary rehabilitation, and hybrid pulmonary rehabilitation significantly reduced SGRQ total scores versus usual care. For health status, telerehabilitation significantly improved CAT scores compared with usual care [MD = -2.49, 95% CI (-4.76, -0.22)]. For dyspnea-related outcomes, self-management pulmonary rehabilitation, hybrid pulmonary rehabilitation and traditional home-based pulmonary rehabilitation improved the mMRC dyspnea scale versus usual care. Telerehabilitation also improved HADS-Anxiety scores versus usual care [MD = -1.40, 95% CI (-2.79, -0.01)] and depression scores versus both self-management pulmonary rehabilitation [MD = -1.31, 95% CI (-2.53, -0.09)] and usual care[MD = -1.34, 95% CI (-2.51, -0.18)]. Ranking probabilities suggested that traditional home-based pulmonary rehabilitation had the lowest likelihood of adverse events among home-based models. Home-based pulmonary rehabilitation models yield clinically meaningful improvements in COPD and may provide exercise-capacity benefits comparable to center-based pulmonary rehabilitation. As effects and rankings vary across outcomes, no single model is optimal for all patients. Model selection should consider patient needs, digital access, and available resources.