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Clinical Investigations: COPD/ASTHMA |

Impact of a Hospital-Based Home-Care Program on the Management of COPD Patients Receiving Long-term Oxygen Therapy* FREE TO VIEW

Eva Farrero, MD; Joan Escarrabill, MD, FCCP; Enric Prats, MD; Marian Maderal, NU; Federic Manresa, MD
Author and Funding Information

*From the UFISS-Respiratòria, Servei de Pneumologia, Ciutat Sanitària i Universitària de Bellvitge, L’Hospitalet (Barcelona), Spain.

Correspondence to: Eva Farrero, MD, UFISS-Respiratòria, Servei de Pneumologia, Ciutat Sanitària i Universitària Bellvitge, C/Feixa Llarga s/n, 08907-L’Hospitalet, Barcelona, Spain; e-mail: ufissr@csub.scs.es



Chest. 2001;119(2):364-369. doi:10.1378/chest.119.2.364
Text Size: A A A
Published online

Study objectives: To analyze the influence of a hospital-based home-care program (HCP) on the management of patients with COPD receiving long-term oxygen therapy.

Design and setting: Randomized, controlled study in a 1,000-bed university hospital.

Intervention: The HCP applied to patients in the intervention group (HCP group) consisted of a monthly telephone call, home visits every 3 months, and home or hospital visits on a demand basis. Patients in the control group were given conventional medical care.

Measurements: Pulmonary function data, gas exchange, use of hospital resources (emergency department visits, admissions, and hospital stay) and the cost of medical assistance were investigated in both groups before and after 1 year of study. Quality of life was analyzed using the chronic respiratory questionnaire in the first 40 consecutive patients included in the study. Survival throughout the study was also assessed.

Results: One hundred twenty-two patients were enrolled in the study, and 94 patients (46 in the HCP group and 48 in the control group) completed the 1-year follow-up period: 83 patients (88%) were men, and mean (± SD) age was 68 ± 8 years. During the follow-up period, there was a highly significant decrease in the mean number of emergency department visits (0.45 ± 0.83 vs 1.58 ± 1.96; p = 0.0001) and also a significant decrease in hospital admissions (0.5 ± 0.86 vs 1.29 ± 1.7; p = 0.001) and days of hospital stay (7.43 ± 15.6 vs 18.2 ± 24.5; p = 0.01) in the HCP group. Patients in the intervention group required a total of 221 home visits (mean per patient, 4.8 ± 0.8) and 69 hospital visits (mean per patient, 1.5 ± 1.07). In spite of the cost of the program, cost analysis showed a total saving of 8.1 million pesetas ($46,823) in the HCP group, mainly due to a decrease in the use of hospital resources. There was no difference in pulmonary function, gas exchange, quality of life, and survival between the two groups.

Conclusions: Hospital-based home care is an effective alternative to hospital admission. It reduces the use of hospital resources and the cost of health care.

Figures in this Article

COPD is a progressive disease with frequent exacerbations.1At our institution (a university hospital inside the Spanish National Health System [NHS], with universal coverage), acute exacerbations of COPD are a major cause of hospital admissions and emergency department attendance, and represent a considerable burden on health resources. Recently, several studies25 have been designed to evaluate the impact of home services on the management of COPD patients. Their results vary: some23 show a fall in hospital admissions and an increase in savings, while others4find no differences in the number of hospitalizations, and some5even report an increase in the costs of health care. In addition, the characteristics of home care provided and the type of patients included in the studies are extremely heterogeneous, and this probably accounts for the differences observed in the result. In our country, previous reports67 have demonstrated that home care is feasible and useful in decreasing hospital admissions in COPD patients. However, these studies were only local, and included a relatively small number of patients. In order to improve medical care and rationalize the use of hospital resources in our setting, we decided to carry out a prospective, randomized study to evaluate the effects of a hospital-based home-care program (HCP) in a large number of severe COPD patients. We specifically selected COPD patients receiving long-term oxygen therapy (LTOT) as candidates for inclusion because they form a homogenous group of patients with severe disease and suffer frequent, severe acute exacerbations.

Subjects

In this population-based study, patients were selected from the register of the NHS oxygen suppliers from September 1994 to December 1996. Inclusion criteria were as follows: (1) primary diagnosis of COPD according to the generally accepted clinical and functional criteria8and requiring LTOT9; (2) a history of at least 6 months of LTOT before entering the study; (3) willingness to participate in an HCP; and (4) residence within easy reach of the hospital. We selected patients living in the two largest cities (L’Hospitalet and El Prat) in our hospital reference area.

The study was approved by the Ethical Committee at our hospital, and informed consent was obtained from all patients.

Methods

All patients were evaluated in the outpatient department of the hospital. The following data were obtained: arterial blood gas values while breathing room air; forced spirometry (FVC and FEV1); and number of hospital admissions, emergency department visits, and days of hospital stay for COPD exacerbation during the previous year. After this initial evaluation, informed consent was obtained and patients were allocated randomly to the HCP treatment group or to the control group, which continued to receive the same standard medical management as before. Codes of randomization were kept in sealed envelopes.

HCP

The HCP was designed to combine home-care management and easy access to hospital resources. The program included scheduled activities and others designed to meet the requirements of patients on demand. The team directly responsible for all the activities in the HCP comprised a skilled respiratory nurse and a chest physician who were members of the respiratory team in charge of patients with chronic respiratory insufficiency.10 Planned activities include a monthly telephone call and a home visit every 3 months performed by a nurse under supervision of the physician, using questionnaires designed to detect changes in underlying respiratory symptoms. Spirometry (Micro Spirometer; Micro Medical, Ltd.; Rochester, Kent, UK) and pulse oximetry (Pulsox 5; Minolta AVL Medical Instruments; Schuffausen, Switzerland) breathing room air and oxygen were also conducted during the home visit. The response to a patient’s request was usually immediate, and varied according to the symptoms: a home visit by a nurse or physician; a hospital visit; or telephone advice with a planned (home or hospital) control visit in the next few days. Hospital visits were performed at a day hospital area equipped to carry out clinical examinations (chest radiography, arterial blood gases, ECG), and to provide intensive medical treatment if necessary.

Control Group

Patients in the control group were evaluated by the HCP team at the outpatient department in the initial visit, and after 1 year. There was no other contact during the year. The patients were followed up as previously in outpatient visits by their chest physician together with a family physician. The frequency of the visits and changes in treatment were at the discretion of each attending physician. Neither the physicians nor the patients in this group received specific instructions about emergency visits or hospital admissions.

Follow-up

A minimum follow up of 12 months was required to evaluate the effects of the program, except for the survival analysis. After this 1-year period, the same variables were assessed as in the initial evaluation in all patients in both groups. Quality of life was investigated in the first 40 consecutive patients included in the study, and the questionnaire used was the Spanish version of the chronic respiratory questionnaire,11 applied before the study and after 3 months and 12 months. Because our resources were limited and the administration of the test is time consuming (between 30 min and 1 h), we decided to restrict quality of life study to the first 40 patients, even though we were aware of the loss of statistical power.

Cost Analysis

The cost analysis focused on the expense deriving from the use of hospital resources. Data regarding the use of other health services, such as primary care, were not available. The economic evaluation was performed by a cost minimization analysis using data from the Financial Department of our institution, based on the NHS fees. The cost of each day of hospitalization and the cost of an emergency department visit were calculated according to diagnosis-related group and included staffing costs, costs of routine examinations (laboratory, arterial blood gases, chest radiography, ECG) and cost of drugs prescribed. The cost of HCP included staffing costs, administrative costs (secretary and telephone), cost of home visits (travel expenses and drugs administered), and costs of extra hospital visits, including the routine examinations performed, drugs administered, and costs of office space used such as electricity and maintenance.

Statistical Analysis

Student’s t test and the χ2 test were used to compare quantitative and qualitative variables between the two groups before and after a 1-year follow-up, respectively. Nonparametric tests (Mann-Whitney U) were used when necessary. All patients, regardless of months of follow-up, were included in the survival analysis from September 1994 to January 1997. Life-tables devised with the Kaplan-Meier method were used for survival analysis, using the log-rank test to evaluate the differences in survival between the two groups.

The study comprised a total of 122 patients (60 in the intervention group and 62 in the control group). There were no significant differences in mean age, sex distribution, severity of airflow obstruction, or arterial blood gas anomalies between the two groups at the initial evaluation or at mean follow-up time (Table 1 ). The sources of oxygen supply and other pharmacologic treatments taken by patients in both groups at the initial evaluation were also similar (Table 2 ). Compliance with LTOT was not analyzed because objective data were only available in the 72 patients (59%) who used a concentrator as oxygen source.

Twenty-three patients died in the intervention group and 21 died in the control group. Median survival time was 20 months in both groups, with no significant differences between groups (log-rank, p = 0.79) regarding probability of survival. The cause of death was related to COPD exacerbation in the majority of cases (16 patients in the treatment group and 14 in the control group). The other causes were as follows: hemoptysis (n = 2), myocardial infarction (n = 1), malignant pleural effusion (n = 1), and pneumonia (n = 1) in the treatment group; and pulmonary embolism (n = 1), pneumothorax (n = 1), and stroke (n = 1) in the control group. Data were not available in two cases in the treatment group and in four cases in the control group.

Of the whole group, 94 patients (46 in the intervention group and 48 in the control group) completed the 1-year follow-up period. The groups were comparable in terms of demographic data, severity of airflow obstruction, and arterial blood gas exchange on entry in the study (Table 1), nor were there differences between the groups in use of hospital resources (mean number of admissions or emergency department visits per patient, hospital stay) during the year prior to the study (Table 1). After the 1-year follow-up period, in the HCP group there was a highly significant decrease in emergency department visits per patient (0.45 ± 0.83 for the intervention group, 1.58 ± 1.96 for the control group; Mann-Whitney U test, p = 0.0001); a significant decrease in the number of hospital admissions (0.5 ± 0.86 for the intervention group, 1.29 ± 1.7 for the control group; Mann-Whitney U test, p = 0.001); and also a decrease in days of hospitalization (7.43 ± 15.6 for the intervention group, 18.20 ± 24.55 for the control group; t test, p = 0.01; Fig 1 ). Analyzing separately the use of hospital resources during the previous year compared with the study year in both groups, we found a significant decrease in all the variables in the treatment group but no changes in the control group (Fig 2 ). During the year of study, the HCP group required a total of 221 home visits (mean visits per patient, 4.8 ± 0.8) and 69 hospital visits (mean per patient, 1.5 ± 1.07).

Thirty-three of the 40 patients included in the quality of life study completed the 1-year follow-up period (17 in the intervention group and 16 in control group). Neither group showed significant differences among baseline, 3-month, and 12-month follow-up in any of the four domains of the questionnaire.

There were no significant differences in the evolution of arterial blood gas exchange between the groups, but they presented similar and significant decreases in FVC and FEV1 after the study (Table 3 ).

In the cost analysis, the cost of the HCP was estimated at 6.7 million pesetas ($38,292), but there was a saving of 14.8 million pesetas ($85,118) in the treatment group compared with the control group, due to the decrease in the days of hospitalization and in emergency department visits. The total saving thus amounted to 8.1 million pesetas ($46,214; Table 4 ).

We found evidence that in our setting, hospital-based home care is feasible and is a cost-effective alternative to hospitalization. The hospital-based design combining home-care and hospital requirements managed by the same team allows optimal use of medical resources. Other respiratory programs with similar characteristics have proved to be effective, although due to the study designs they present a number of limitations. Haggerty et al3 found results similar to ours, with a reduction in the use of hospital resources and health-care costs. However, the sample was very small (17 subjects); given the absence of a control group, preprogram and on-program data of the same patient were compared. Clini et al12 also found a reduction in hospital admissions without cost analysis, but again the sample was small (34 patients) and the study was retrospective, using historical control subjects.

The significant reduction in the use of hospital resources in our treatment group is probably related to the special characteristics of the study, since the same team is responsible for both home and hospital health care, guaranteeing continuity of health care and optimal use of resources. Therefore, most of the acute exacerbations of these patients are treated at home, thanks to the availability of information on the patient’s condition in the stable situation; a skilled team can properly assess the severity of the exacerbation and supervise the evolution. For their part, control group patients were usually referred to the emergency department and admitted to hospital. Gravil et al13 also reported that most exacerbations of COPD patients could be treated at home and monitored by a trained respiratory service after initial assessment, although their study did not include a cost analysis.

The reduction in costs observed in our study is due to the decrease in the use of hospital services and is probably also related to the design of the study. The study of Cummings et al14 applied to a different kind of patient but with a similar design (ie, the same physician was responsible for the patient’s home and in-hospital care) also showed a significant reduction in costs. Studies of home care without a hospital-based design, such as the study by Bergner et al,,5 suggest that home care leads to additional use of health services, rather than the substitution of inpatient care by outpatient care.

A recent randomized, controlled trial15reported decreases in use of health services in COPD patients treated with a multidisciplinary, outpatient pulmonary rehabilitation program. However, patients included in that study were less severely impaired (average FEV1 % predicted of 39.7) than our patients (average FEV1 % predicted of 28). The severity of our patients’ conditions, with frequent intercurrent acute exacerbations and physical decondition, excludes them as candidates for any standard pulmonary rehabilitation program; and probably the best option for patients in their condition is home care.16

Quality of life did not improve in the HCP group, even though these patients remained at home longer than the control subjects. This result may be due in part to the small size of the sample. Another consideration is the suitability of the method used to identify any existing differences. We chose the chronic respiratory questionnaire since it is specific for COPD patients and specially designed to evaluate changes after treatment or interventions,17 and because the Spanish version has proved to be useful.11 However, it may not be a valid instrument for measuring changes in this type of patient with severe COPD and chronic respiratory failure. In fact, the program does not involve any changes in the treatment or the introduction of new measures such as pulmonary rehabilitation; it is simply a different health-care system, and, as expected, there were no differences in functional or gasometric parameters between the groups. Similar results have been reported in other studies45,18 that used the Sickness Impact Profile as a measure of quality of life, finding minimal or no changes in the group of patients receiving home care. However, when a satisfaction questionnaire is used, as in the study by Gravil et al,13 80% of the patients reported that they would be happy to be treated at home again and only 13.5% expressed a preference for hospitalization. In the study by Cockcroft et al,4 most patients visited by a respiratory health worker considered that they had received a better quality of care than before.

Finally, we did not find significant differences in the probability of survival between the two groups. The majority of COPD patients receiving LTOT die from chronic respiratory failure,19as was the case in our study, and so early detection of exacerbation in a group of patients with home care is likely to reduce mortality. Two points should be considered in this connection. First, all the patients included had severe COPD and were receiving LTOT, so the prognostic factors are more closely related to the severity of the underlying disease, such as FEV1, and Pao2, 20 than to the pattern of health care provided; second, the follow-up time may not have been long enough to detect any changes in survival.

In conclusion, we demonstrate that home care for patients with severe COPD reduces both the use of hospital resources and costs. In our opinion, the positive results of our HCP are due to the hospital-based design, which allows for the combination of home and hospital resources, and to the simplicity of the intervention applied. Although an intervention as simple as this could in theory be successfully developed on a primary-care schedule, as Gravil et al13 reported for patients with severe COPD, a skilled hospital-based team is probably needed to properly evaluate the severity of exacerbations. We conclude that for a selected group of patients with severe COPD such as those receiving LTOT, a hospital-based HCP carried out by a skilled team is a cost-effective and safe alternative that reduces the number of hospitalizations and emergency department visits.

Abbreviations: HCP = home-care program; LTOT = long-term oxygen therapy; NHS = National Health System

Table Graphic Jump Location
Table 1. Patient Characteristics*
* 

All = the whole group included in the study. 12M = the group of patients who completed 1-yr follow-up. Data are shown as mean ± SD and comparisons between groups as mean difference and 95% confidence interval for that difference.

Table Graphic Jump Location
Table 2. Oxygen Supply Sources and Pharmacologic Treatment*
* 

Data shown as No. of patients (% of population).

Figure Jump LinkFigure 1. Use of hospital resources during the 1-year study. Emergency department visits and admissions are shown as mean ± SEM number per patient, and hospital stay as mean ± SEM days per patient during the 1-yr period. * = p = 0.01;** = p = 0.001; *** = p = 0.0001. Light-colored boxes indicate treatment group; dark-colored boxes indicate control groupGrahic Jump Location
Figure Jump LinkFigure 2. Use of hospital resources in the year previous to the study compared with the study year. Emergency department visits and admissions are shown as mean ± SEM number per patient and hospital stay as mean ± SEM days per patient during the year.* = p = 0.01; ** p = 0.0001. Light colored boxes indicate the year previous to the study; dark-colored boxes indicate the study year.Grahic Jump Location
Table Graphic Jump Location
Table 3. Evolution of Arterial Blood Gases and Functional Data
* 

Nonsignificant differences compared to the study values of intervention group.

Table Graphic Jump Location
Table 4. Cost Analysis*
* 

Values are given in pesetas (dollars).

Madison, JM, Irwin, RS (1998) Chronic obstructive pulmonary disease.Lancet352,467-473. [CrossRef] [PubMed]
 
Roselle, S, D’Amico, FJ The effect of home respiratory therapy on hospital readmission rates of patients with chronic obstructive pulmonary disease.Respir Care1982;27,1194-1199. [PubMed]
 
Haggerty, MC, Stockdale-Wooley, R, Nair, S Respi-Care: an innovative home care program for the patient with chronic obstructive pulmonary disease.Chest1991;100,607-612. [CrossRef] [PubMed]
 
Cockcroft, A, Bagnall, P, Heslop, A, et al Controlled trial of respiratory health worker visiting patients with chronic respiratory disability.BMJ1987;294,225-228. [CrossRef] [PubMed]
 
Bergner, M, Hudson, LD, Conrad, DA, et al The cost and efficacy of home care for patients with chronic lung disease.Med Care1988;26,566-579. [CrossRef] [PubMed]
 
Servera, E, Simó, L, Marín, J, et al Hospitalizaciones durante un año en un grupo de insuficientes respiratorios crónicos graves con cuidados a domicilio [letter]. Med Clin (Barc). 1989;;93 ,.:437
 
Zapater, J, Farré, MR, Escarrabill, J, et al Efectos de la asistencia domiciliaria (AD) en pacientes con oxigenoterapia domiciliaria (OD) [abstract]. Arch Bronconeumol. 1990;;26(suppl 1) ,.:15
 
American Thoracic Society.. Standards for the diagnosis and care of patients with chronic obstructive pulmonary disease.Am J Respir Crit Care Med1995;152(suppl),S77-S120
 
Walters, MI, Edwards, PR, Watherhouse, JC, et al Long-term domiciliary oxygen therapy in chronic obstructive pulmonary disease.Thorax1993;48,I170-I177
 
Escarrabill, J, Farrero, E, Prats, E Unidades funcionales interdisciplinarias respiratoriasMed Clin (Barc)1996;107,438-439. [PubMed]
 
Güell, R, Casan, P, Sangenís, M, et al Quality of life in patients with chronic respiratory disease: the Spanish version of the Chronic Respiratory Questionnaire (CRQ).Eur Respir J1998;11,55-60. [CrossRef] [PubMed]
 
Clini, E, Vittaca, M, Foglio, K, et al Long-term home care programs may reduce hospital admissions in COPD with chronic hypercapnia.Eur Respir J1996;9,1605-1610. [CrossRef] [PubMed]
 
Gravil, JH, Al-Rawas, OA, Cotton, MM, et al Home treatment of exacerbation of chronic obstructive pulmonary disease by an acute respiratory assessment service.Lancet1998;351,1853-1855. [CrossRef] [PubMed]
 
Cummings, JE, Hughes, SL, Weaver, FM, et al Cost-effectiveness of veterans administration hospital-based home care.Arch Intern Med1990;150,1274-1280. [CrossRef] [PubMed]
 
Griffiths, TL, Burr, ML, Campbell, IA, et al Results at 1 year of outpatient multidisciplinary pulmonary rehabilitation: a randomised controlled trial.Lancet2000;355,362-368. [CrossRef] [PubMed]
 
Donner, CF, Muir, JF Rehabilitation and chronic care scientific group of the European Respiratory Society: selection criteria and programmes for pulmonary rehabilitation in COPD patients.Eur Respir J1997;10,744-757. [PubMed]
 
Guyatt, GH, Towsend, M, Berman, LB, et al Quality of life in patients with chronic airflow limitation.Br J Dis Chest1987;81,45-54. [CrossRef] [PubMed]
 
Littlejohns, P, Baveystock, CM, Parnell, H, et al Randomised controlled trial of the effectiveness of a respiratory health worker in reducing impairment, disability, and handicap due to chronic airflow limitation.Thorax1991;46,559-564. [CrossRef] [PubMed]
 
Zielinski, J, MacNee, W, Wedzicha, J, et al Causes of death in patients with COPD and chronic respiratory failure.Monaldi Arch Chest Dis1997;52,43-47. [PubMed]
 
Piccioni, P, Caria, E, Bignamini, E, et al Predictors of survival in a group of patients with chronic airflow obstruction.J Clin Epidemiol1998;51,547-555. [CrossRef] [PubMed]
 

Figures

Figure Jump LinkFigure 1. Use of hospital resources during the 1-year study. Emergency department visits and admissions are shown as mean ± SEM number per patient, and hospital stay as mean ± SEM days per patient during the 1-yr period. * = p = 0.01;** = p = 0.001; *** = p = 0.0001. Light-colored boxes indicate treatment group; dark-colored boxes indicate control groupGrahic Jump Location
Figure Jump LinkFigure 2. Use of hospital resources in the year previous to the study compared with the study year. Emergency department visits and admissions are shown as mean ± SEM number per patient and hospital stay as mean ± SEM days per patient during the year.* = p = 0.01; ** p = 0.0001. Light colored boxes indicate the year previous to the study; dark-colored boxes indicate the study year.Grahic Jump Location

Tables

Table Graphic Jump Location
Table 1. Patient Characteristics*
* 

All = the whole group included in the study. 12M = the group of patients who completed 1-yr follow-up. Data are shown as mean ± SD and comparisons between groups as mean difference and 95% confidence interval for that difference.

Table Graphic Jump Location
Table 2. Oxygen Supply Sources and Pharmacologic Treatment*
* 

Data shown as No. of patients (% of population).

Table Graphic Jump Location
Table 3. Evolution of Arterial Blood Gases and Functional Data
* 

Nonsignificant differences compared to the study values of intervention group.

Table Graphic Jump Location
Table 4. Cost Analysis*
* 

Values are given in pesetas (dollars).

References

Madison, JM, Irwin, RS (1998) Chronic obstructive pulmonary disease.Lancet352,467-473. [CrossRef] [PubMed]
 
Roselle, S, D’Amico, FJ The effect of home respiratory therapy on hospital readmission rates of patients with chronic obstructive pulmonary disease.Respir Care1982;27,1194-1199. [PubMed]
 
Haggerty, MC, Stockdale-Wooley, R, Nair, S Respi-Care: an innovative home care program for the patient with chronic obstructive pulmonary disease.Chest1991;100,607-612. [CrossRef] [PubMed]
 
Cockcroft, A, Bagnall, P, Heslop, A, et al Controlled trial of respiratory health worker visiting patients with chronic respiratory disability.BMJ1987;294,225-228. [CrossRef] [PubMed]
 
Bergner, M, Hudson, LD, Conrad, DA, et al The cost and efficacy of home care for patients with chronic lung disease.Med Care1988;26,566-579. [CrossRef] [PubMed]
 
Servera, E, Simó, L, Marín, J, et al Hospitalizaciones durante un año en un grupo de insuficientes respiratorios crónicos graves con cuidados a domicilio [letter]. Med Clin (Barc). 1989;;93 ,.:437
 
Zapater, J, Farré, MR, Escarrabill, J, et al Efectos de la asistencia domiciliaria (AD) en pacientes con oxigenoterapia domiciliaria (OD) [abstract]. Arch Bronconeumol. 1990;;26(suppl 1) ,.:15
 
American Thoracic Society.. Standards for the diagnosis and care of patients with chronic obstructive pulmonary disease.Am J Respir Crit Care Med1995;152(suppl),S77-S120
 
Walters, MI, Edwards, PR, Watherhouse, JC, et al Long-term domiciliary oxygen therapy in chronic obstructive pulmonary disease.Thorax1993;48,I170-I177
 
Escarrabill, J, Farrero, E, Prats, E Unidades funcionales interdisciplinarias respiratoriasMed Clin (Barc)1996;107,438-439. [PubMed]
 
Güell, R, Casan, P, Sangenís, M, et al Quality of life in patients with chronic respiratory disease: the Spanish version of the Chronic Respiratory Questionnaire (CRQ).Eur Respir J1998;11,55-60. [CrossRef] [PubMed]
 
Clini, E, Vittaca, M, Foglio, K, et al Long-term home care programs may reduce hospital admissions in COPD with chronic hypercapnia.Eur Respir J1996;9,1605-1610. [CrossRef] [PubMed]
 
Gravil, JH, Al-Rawas, OA, Cotton, MM, et al Home treatment of exacerbation of chronic obstructive pulmonary disease by an acute respiratory assessment service.Lancet1998;351,1853-1855. [CrossRef] [PubMed]
 
Cummings, JE, Hughes, SL, Weaver, FM, et al Cost-effectiveness of veterans administration hospital-based home care.Arch Intern Med1990;150,1274-1280. [CrossRef] [PubMed]
 
Griffiths, TL, Burr, ML, Campbell, IA, et al Results at 1 year of outpatient multidisciplinary pulmonary rehabilitation: a randomised controlled trial.Lancet2000;355,362-368. [CrossRef] [PubMed]
 
Donner, CF, Muir, JF Rehabilitation and chronic care scientific group of the European Respiratory Society: selection criteria and programmes for pulmonary rehabilitation in COPD patients.Eur Respir J1997;10,744-757. [PubMed]
 
Guyatt, GH, Towsend, M, Berman, LB, et al Quality of life in patients with chronic airflow limitation.Br J Dis Chest1987;81,45-54. [CrossRef] [PubMed]
 
Littlejohns, P, Baveystock, CM, Parnell, H, et al Randomised controlled trial of the effectiveness of a respiratory health worker in reducing impairment, disability, and handicap due to chronic airflow limitation.Thorax1991;46,559-564. [CrossRef] [PubMed]
 
Zielinski, J, MacNee, W, Wedzicha, J, et al Causes of death in patients with COPD and chronic respiratory failure.Monaldi Arch Chest Dis1997;52,43-47. [PubMed]
 
Piccioni, P, Caria, E, Bignamini, E, et al Predictors of survival in a group of patients with chronic airflow obstruction.J Clin Epidemiol1998;51,547-555. [CrossRef] [PubMed]
 
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