• chronic obstructive pulmonary disease
• inpatient management
• mortality
• decision making

I read with great interest the paper by Roberts et al¹ and the accompanying editorial by Rudolf². The study highlights important variations in the outcomes of patients with a common chronic disease, and once more illustrates that doctor:patient ratios may be an important contributor to this. It is also likely that some of the observed variation may arise as a result of variations in decision making by individual clinicians.

A recent study carried out in the eight hospitals in the Heart of England Critical Care network interviewed 98 clinicians who made end of life decisions for patients with chronic obstructive pulmonary disease (COPD).³ Each had made a median of 10 end of life decisions for COPD patients in the previous 12 months. There was considerable variability in the decision whether or not to admit identical patients to the critical care unit, with those choosing not to admit patients forming very pessimistic predictions of outcome compared with clinicians who would admit. It seems possible that poor outcomes for patients with COPD may not simply reflect a …