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Factors that predict failure in home management of an acute exacerbation of COPD
  1. Eleanor M Dunican,
  2. Brenda M Deering,
  3. Dorothy M Ryan,
  4. Niamh M McCormack,
  5. Richard W Costello
  1. Department of Respiratory Medicine, Beaumont Hospital, Dublin, Ireland
  1. Correspondence to Professor Richard Costello, Department of Respiratory Medicine, Beaumont Hospital, Dublin 9, Ireland; rcostello{at}rcsi.ie

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There is increasing interest in managing patients with non-severe acute exacerbation of chronic obstructive pulmonary disease (AECOPD) in the community. Hospital at Home and COPD Outreach programmes facilitate discharge of patients that would otherwise require hospital admission and have been shown to reduce hospital stay,1 readmission2 and healthcare costs without compromising patient care and satisfaction.3 Despite the human and health-related benefits associated with home services, ∼30% of patients relapse within 8 weeks, requiring hospital readmission.2

In an effort to better understand the factors that predict relapse in these patients, we prospectively studied consecutive admissions with AECOPD discharged to a COPD Outreach programme. Patients with an AECOPD who met specific criteria4 were enrolled within 24 h of presentation to hospital. At presentation demographics, number of hospitalisations in the previous year, oxygen use, vaccination status (pneumococcal and influenza) and smoking history were assessed. Breathlessness and quality of life scores were recorded and oxygen saturations and spirometry were measured. Rehospitalisation data were collected at day 14, 6 weeks and 3 months following discharge. Readmission for AECOPD was defined as hospitalisation for >24 h and was assessed using hospital records.

Patient variables were analysed for their association with readmission by day 14, 6 weeks and 3 months using χ2 or the Fischer exact test. Multivariate analyses to evaluate for independent risk factors were performed using logistic regression with readmission as the categorical dependent variable. Admissions for reasons other than COPD were not included in the analyses.

In total, 349 admissions with AECOPD were enrolled in the study. There were 46 readmissions (13%) for AECOPD to hospital by day 14, 81 (23%) by 6 weeks and 106 (30%) by 3 months. The study had approximately equal numbers of males (49%) and females (51%), with a mean age of 69.2 years. Median FEV1 (forced expiratory volume in 1 s) % predicted was 46.43%.

Univariate analysis is shown in table 1. We found no association between readmission and age, gender, spirometry, quality of life score or length of index admission.

Table 1

Univariate analyses of association between independent variables and readmission

Multivariate analysis identified that hospitalisation in the previous year (p=0.03, OR 2.26, CI 1.1 to 4.8) and a Borg score ≥3 (p=0.04, OR 2.15, CI 1.0 to 4.6) predicted readmission by day 14 in 75% of cases. Long-term oxygen therapy (p=0.001, OR 3.28, CI 1.6 to 6.5), pack-year history ≥50 (p=0.008, OR 3.13, CI 1.4 to 7.3) and Borg score ≥3 (p=0.001, OR 3.31, CI 1.6 to 6.8) predicted 6 week admission in 68.9%.

Our study identifies independent risk factors that are easy to assess, reproducible and can be carried out as early as arrival to hospital, allowing these patients to be identified early in their admission. A significant factor associated with early readmission was the level of dyspnoea reported by patients at the time of enrolment. This reflects the importance of the subjective symptom of breathlessness as a factor that drives patients to seek medical attention.

This is the first study to identify specifically the factors that are associated with rehospitalisation in exacerbations managed out of hospital. This management strategy will become increasingly important in reducing the costs associated with AECOPD but efforts need to be made to reduce readmission rates. Further investigation needs to be carried out to identify if interventions can reduce rehospitalisation in the high risk patients identified by this study and what these interventions may be.

References

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Footnotes

  • Competing interests None.

  • Ethics approval This study was conducted with the approval of the Beaumont Hospital ethics (medical research) Committee.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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