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We read with interest the recent papers1 ,2 which report the findings of randomised controlled trials of early supported discharge for patients with exacerbations of chronic obstructive pulmonary disease (COPD). Both found that a proportion of such patients presenting to hospital could be safely cared for at home with respiratory nurse support, without adversely affecting mortality or readmission rates.
A similar service to those described operated for the first time in Sheffield over the winter of 1997/8, supported by government money to ease the demand for beds during the winter. Although this did not involve randomisation, our findings were essentially similar. Unselected patients with exacerbations referred by general practitioners for admission to hospital were reviewed and those fulfilling the British Thoracic Society guidelines3 were offered home treatment. Over a 4 month period 29 of 118 patients (25%) referred were found to be suitable for supported discharge, and we successfully treated the 22 patients who consented to participate in the scheme. Although this was only a small number of patients, there were no readmissions and no home deaths. The remaining 89 patients required admission because of respiratory complications (21 acidotic, 16 pneumonia, seven both) or coexisting medical conditions (17 cardiovascular, 28 other).
We also found that a proportion of suitable patients (seven of 29) did not want to participate in our home treatment scheme. Some of these simply wanted the reassurance of being in hospital, but two patients declined as they would have lost insurance scheme benefits paid for inpatient treatment.
In summary, our experience supports the findings of Skwarskaet al 2 that plans for future assisted discharge schemes should be based on an estimated discharge rate of 20–25% of the unselected COPD hospital referrals. We too have found that such patients can be safely treated at home, and that this is acceptable to most patients. We would welcome correspondence from the authors as to whether they encountered problems with non-participation due to insurance schemes and, if so, how they addressed them.
authors' reply We note that Dr Barber and colleagues have used an Acute Respiratory Assessment Service (ARAS) with winter bed money and have had similar results to ours and those of Skwarska et al in Edinburgh. We would like to comment on the proportion of patients referred for admission who are likely to be eligible for this model of care. Dr Barber's group found that 25% were suitable for supported discharge. In the Edinburgh study 29% were initially considered suitable for home care and in the study recently published from Liverpool 33% were eligible.1-1However, in our study in Glasgow 42% were considered eligible for early supported discharge and this difference may reflect the time when the patients are assessed. In Edinburgh and Liverpool assessment was done on the same day as the patients were referred, whereas in our study the patients were assessed on the day after admission. Clinical improvement and increase in forced expiratory volume in one second (FEV1) are maximal in the first 24 hours after admission1-2 and this may account for the higher FEV1 values and also for the greater eligibility for home care in the Glasgow patients. We now believe that the ARAS model is best employed by assessing patients after 24 hours in hospital. This uses nurses' time more effectively and increases the number of patients suitable for home care.
We were interested that two patients in Sheffield did not want to participate in the home treatment scheme because they would have lost insurance scheme benefits. This is not one of the many problems with which we have to cope in the East End of Glasgow.
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author's reply I am glad to see that the experience from Sheffield on supported discharge is similar to that from other parts of the country, with the exception that the high readmission rate was not apparent in this small number of patients. In our study 2% of patients did not wish to take part in the study for various reasons—often, as with the patients in Sheffield, because they wished the reassurance of being in hospital. However, we had no patient who did not participate because of problems with insurance schemes. This perhaps reflects a difference in health care funding between Scotland and England.