0
Original Research: COPD |

The Association Between Hospital Readmission and Pulmonologist Follow-up Visits in Patients With COPDCOPD Readmissions and Pulmonologist Follow-up FREE TO VIEW

Rachel Gavish, MD, MPH; Amalia Levy, PhD, MPH; Or Kalchiem Dekel, MD; Erez Karp, MD; Nimrod Maimon, MD
Author and Funding Information

From the Department of Public Health (Drs Gavish and Levy), the Department of Medicine (Drs Dekel and Karp), and the Department of Pulmonology (Dr Maimon), Faculty of Health Sciences, Ben-Gurion University of the Negev; and Soroka University Medical Center (Drs Dekel, Karp, and Maimon), Beer-Sheva, Israel.

CORRESPONDENCE TO: Nimrod Maimon, MD, Division of Pulmonology, Soroka University Medical Center, POB 151, Beer-Sheva 84111, Israel; e-mail: nimrod@bgu.ac.il


This article was presented orally at the Israeli National Pulmonology Meeting, May 2013, Tel Aviv, Israel.

FUNDING/SUPPORT: The authors have reported to CHEST that no funding was received for this study.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2015;148(2):375-381. doi:10.1378/chest.14-1453
Text Size: A A A
Published online

BACKGROUND:  The high frequency of readmissions in patients with COPD remains a significant problem. The impact of a pulmonologist follow-up visit during the month after discharge from hospital because of COPD exacerbation on reducing readmissions was examined. A profile of patients who did not attend the follow-up visits was built.

METHODS:  Our population-based retrospective cohort study analyzed the data of all patients with COPD who were treated at a lung institute in an Israeli hospital and were hospitalized between January 1, 2004, and December 31, 2010. Multivariate logistic regression was used to characterize the patient who did not attend the follow-up visit and to examine the effect of lack of visit on rehospitalization within 90 days of discharge. Cox proportional hazards analysis was used to model the effect of lacking visit on additional hospitalization or death during the study period.

RESULTS:  Of the 195 patients enrolled in the study, 44.1% had follow-up visits with pulmonologists within 30 days of discharge. Not attending the follow-up visit was associated with distant residence, a higher number of hospitalizations in the previous year, a lack of a recommendation in the discharge letter for a follow-up visit, and a lower frequency of follow-up visits with pulmonologists in the previous year. Moreover, not attending the follow-up visit was associated with a significant increased risk of rehospitalization within 90 days of discharge (OR, 2.91; 95% CI, 1.06-8.01).

CONCLUSIONS:  Early follow-up visits with pulmonologists seem to reduce the exacerbation-related rehospitalization rates of patients with COPD. We recommend that patients have early postdischarge follow-up visits with pulmonologists.

Figures in this Article

COPD is a significant burden on global health. The prevalence of COPD in adults is 4% to 10%,1 and it is considered to be the fourth leading cause of death in the United States; it is predicted to rise to the third place by 2020.2 Exacerbations of the disease have strong negative consequences on patient quality of life and lead to disease deterioration. COPD exacerbations often require hospitalizations, which are a major economic burden on public health. In the United States alone, COPD exacerbation accounts for 500,000 hospital admissions and $18 billion in direct health-care costs annually.3 These hospitalizations are not isolated events: More than one-half the patients will be readmitted at least once during the first year after discharge, and among them, 14% will be readmitted during the first month after discharge and another 7% will be readmitted within 3 months.4 Furthermore, hospitalization is associated with a significant mortality rate.5 Many studies have attempted to establish the profile of patients who tend to be readmitted and die a short time after hospitalization. However, to date, no such profile has been found.48 Both the need for and the cost effectiveness of an organized discharge plan in reducing readmission have been shown previously,911 but information is limited on the importance of doctors’ follow-up after discharge from the hospital and its impact on the course of the disease.5,1214 In particular, the effectiveness of a follow-up visit with a pulmonologist in decreasing the rehospitalization rate has, until now, not yet been examined to our knowledge. In this research, we examined the impact of a pulmonologist follow-up visit during the month after discharge from hospital because of COPD exacerbation on reducing readmissions, with the aim of compiling a profile of the patient who did not attend the follow-up.

Study Design

We conducted a population-based retrospective cohort study using the data of patients who were treated at the lung institute in Soroka University Medical Center (Beer-Sheva, Israel) and who were hospitalized for COPD exacerbations between January 1, 2004, and December 31, 2010. Soroka is the main hospital in the southern district of Israel and it serves the majority of the district’s population. Of note, the health system in Israel is publically funded, and it provides healthcare to all Israeli citizens, all of whom are insured by law. During the study period, 195 patients who were hospitalized met our criteria of being > 40 years of age with COPD diagnosed by a pulmonologist based on pulmonary function testing and smoking histories of > 10 pack-years. Excluded from our sample were patients with other lung diseases (including asthma); patients for whom lung function testing, FEV1, indicated mild severity (FEV1 ≥ 80); and patients with severe preexisting medical conditions caused by hepatic failure, renal failure with the need for hemodialysis, or immune deficiency. Also excluded were patients who were discharged to another institution rather than to their homes.

Hospitalizations were limited to those for a primary diagnosis of COPD exacerbation using the codes from the International Classification of Diseases, Ninth Revision, related to COPD (490.x, 491.x, 492.x, and 496.x). In the event that the same patient was admitted to hospital more than once, we randomly chose one of the occurrences to be the index hospitalization. The last index hospitalizations took place at the end of 2010, and 2011 was designated as the follow-up period. Subsequent admission to hospital with the same primary diagnosis of COPD exacerbation during the first 90 days after discharge was considered to be a rehospitalization. We collected data on follow-up visits that occurred during the first 30 days after discharge by a pulmonologist only. The demographic and clinical data of patients were obtained from electronic and hardcopy medical records. The Soroka University Medical Center institutional review board approved all study activities [approval number SOR-0713-2012].

Statistical Analysis

The two primary outcomes were (1) not attending the pulmonologist follow-up visit during 30 postdischarge days and (2) rehospitalization within 90 days of the discharge date. The secondary outcome was time until additional hospitalization or until death.

Potential risk factors included age, sex, ethnicity (Jewish or Bedouin), area of residence, smoking status, number of pulmonologist visits in the previous year, written recommendation in the discharge letter for a follow-up visit, length of hospitalization, and disease severity as reflected by the following factors: lung function test updated within a year of index hospitalization, disease duration, and number of hospitalizations during the previous year because of COPD exacerbations. In addition, for the second primary outcome, the main potential risk factor was not attending the follow-up visit.

Analytic Technique:

Quantitative variables with normal distributions were expressed as means ± SD, variables with nonnormal distributions were expressed as median ± range, and qualitative variables were expressed as numbers and percentages. Place of residence was categorized as distant residence (> 30 km from the city of Beer-Sheva) or as Beer-Sheva and surroundings. FEV1 results were categorized according to the accepted clinical classification issued by GOLD (Global Initiative for Chronic Obstructive Lung Disease): moderate (50 ≤ FEV1 < 80), severe (30 ≤ FEV1 < 50), and very severe (FEV1 < 30).15 A comparison was made between the two study groups, one who attended the follow-up visit and the other who did not attend it, using the Student t test for parametric variables, the Mann-Whitney U test for nonparametric variables, and the χ2 test for binary variables. A multivariate logistic regression model was built to characterize the patient who did not attend the follow-up visit. Another logistic regression modeled the effect of lack of visit on the primary outcome (ie, rehospitalization within 90 days of initial discharge).

In addition, using the Kaplan-Meier survival curve, we compared the time until additional hospitalization or death (whichever came first) between the two study groups. For cases in which neither of these two events occurred, the follow-up time was entered as until December 31, 2011. Using Cox proportional hazards analysis, we modeled the effect of lack of visit on additional hospitalization or death and identified other contributing factors. In each model, we adjusted for clinically important factors and for covariates that maintained their significance in the final model. In those last two models, four patients were excluded because they attended their follow-up visit after they had been rehospitalized. A two-tailed P value of < .05 was considered statistically significant. All analyses were conducted using SPSS software, version 17 (IBM Corporation).

A total of 195 patients who were treated at the lung institute were hospitalized because of COPD exacerbation during the study period. Of these patients, 86 (44.1%) had follow-up visits with pulmonologists within 30 days of discharge. Patients who were categorized as having a distant residence had lower frequencies of office visits in the previous year, and patients whose discharge letter did not include a recommendation for a follow-up visit with a pulmonologist were less likely to make that visit. There were no differences between the groups in their demographic characteristics, age, sex, or ethnicity. There were also no differences in their clinical characteristics, FEV1 results, disease duration, number of hospitalizations in the previous year, length of index hospitalization, or smoking status (Table 1).

Table Graphic Jump Location
TABLE 1 ]  Comparison of Demographic and Clinical Characteristics of Patients Who Did and Did Not Attend Follow-up Visits With Pulmonologists Within 30 d of Discharge From Hospital

Data are presented as No. (%) unless otherwise indicated.

a 

OR not shown for parametric and nonparametric variables that were analyzed by t test and Mann-Whitney U test.

b 

Lung function test updated within a year of index hospitalization, described as a continuous variable.

c 

Data missing (n = 170).

d 

Numbers of office visits and hospitalizations in the year before the index hospitalization.

Table 2 shows the multivariate analyses. Factors that were independently associated with not attending the follow-up visit were distant residence, higher number of hospitalizations in the previous year, lack of recommendation in the discharge letter to have a follow-up visit, and lower frequency of office visits in the previous year. This result was valid after adjusting for age and sex.

Table Graphic Jump Location
TABLE 2 ]  Risk Factors Independently Associated With Not Attending Pulmonologist Follow-up Visit

Out of 191 patients, 35 (18.3%) were readmitted within 90 days of discharge. An examination of the impact of the follow-up visit on hospital readmission during this period showed that of the 35 patients who were readmitted, 77.1% did not attend the follow-up visit with a pulmonologist within 30 days of discharge from their index hospitalization and 22.9% did attend such a follow-up visit (P = .008). After adjusting for age, sex, and disease severity, this finding remained unchanged. Patients who did not see a pulmonologist during the 30-day postdischarge period had an increased risk of hospital readmission (OR, 2.91; 95% CI, 1.06-8.01). In addition, we found a positive correlation between the number of hospitalizations in the previous year and the risk of hospital readmission (Table 3).

Table Graphic Jump Location
TABLE 3 ]  Risk Factors Independently Associated With Readmission Within 90 d of Discharge

The model includes 166 patients; four patients were excluded because they attended their follow-up visit after they had been rehospitalized, and FEV1 data were missing for 25 patients.

a 

Patients who did not attend the follow-up visits with pulmonologists within 30 d of discharge.

A similar tendency was observed in the survival analysis. There was a significant difference between the two groups in the time to additional hospitalization or death (P = .003) (Fig 1).

Figure Jump LinkFigure 1 –  Cumulative risk of additional hospitalization or death for patients who had or did not have follow-up visits with pulmonologist within 30 d after discharge.Grahic Jump Location

After adjusting for age, sex, and disease severity, we found that the patients who did not attend the pulmonologist follow-up visit were at an increased risk of additional hospitalization or death (hazard ratio, 1.83; 95% CI, 1.21-2.75). In addition, in this model, hospitalization in the previous year and poor lung function in lung function tests increased the risk of this event (Table 4).

Table Graphic Jump Location
TABLE 4 ]  Cox Proportional Hazard Model: Effect of Lack of Follow-up and Other Characteristics on Additional Hospitalization or Death

The model includes 166 patients; four patients were excluded because they attended their follow-up visit after they had been rehospitalized, and FEV1 data were missing for 25 patients. HR = hazard ratio.

a 

To prevent time interaction, the variables were modified as follows: previous hospitalizations, dichotomous division (none; ≥ 1); FEV1, dichotomous division (moderate-severe, 80 > FEV1 ≥ 30; very severe, FEV1 < 30); age, dichotomous division (≤ 70 y; > 70 y).

Our study demonstrates the importance of a follow-up visit with a pulmonologist within a month of hospital discharge in patients with COPD. We found that these follow-up visits are associated with fewer rehospitalizations and, thus, may reduce the harm to patient quality of life and lower the corresponding burden on the health-care system. In our sample, we found that 18.3% of all patients were readmitted within a 90-day period after discharge from hospital. Other studies found wide ranges, from 10% to 34%, of rehospitalization rates.4,6,13

We found a strong association between lack of follow-up and a higher risk of rehospitalization within 90 days of discharge (OR, 2.91; 95% CI, 1.06-8.01) and an increased risk of additional hospitalization or death (hazard ratio, 1.83; 95% CI, 1.21-2.75). A similar trend was found in two previous studies that examined the effects of follow-up visits. Sin et al14 reported that patients who had follow-up visits compared with those who did not were associated with 23% fewer emergency readmissions during the 90 days after hospital discharge. Likewise, Sharma et al13 found that they had 14% fewer ED visits and 9% fewer readmissions during the 30 days after hospital discharge. Other studies that examined the effect on mortality rate among patients with COPD and among the congestive heart failure population found supportive results.5,12 In addition, we found that the number of hospitalizations in the previous year also contributed to the risk of rehospitalization (OR, 2.24; 95% CI, 1.57-3.19), a connection that had already been identified in previous research.14 However, other studies revealed relations that were not significant in our model. In one study, older age and male sex were found to be risk factors for rehospitalization,14 whereas other research showed that younger age was a risk factor.4

In an effort to further characterize the patient who did not attend the follow-up visit, we found that place of residence was an important factor, in that patients who lived > 30 km from the clinic were associated with a higher risk of not attending the follow-up (OR, 3.0; 95% CI, 1.24-7.28). This surprising result teaches us that even in a small country like Israel, health services accessibility, in this case a relatively short distance such as 30 km, can constitute a significant obstacle for some patients. However, we could not compare this finding with those of other studies that focused on city size instead of on the accessibility of the clinics. We also found that patients with large numbers of hospitalizations during the previous year tended to not attend their follow-up visits, a finding in-line with the results of a previous study.13 The question raised by these findings is whether this connection between hospitalization rates and lack of visit can be explained by the assumption that patients with high numbers of hospitalizations are also those with poor compliance to treatment and a reluctance to visit their doctors. Alternatively, perhaps these patients had severe COPD (ie, reflected by their large numbers of hospitalizations) and, as such, their medical situations practically prevented them from seeing their doctors.

Two factors that were found to be associated with higher attendance for a follow-up visits offer some insight. One was the inclusion in the discharge letter of a written recommendation to visit a pulmonologist. Although we found no references in other studies to this relation, it is a significant finding of our study, indicating the importance both of appending written recommendations to discharge letters and of facilitating continuity of treatment. Furthermore, it also has implications for the quality of the communication between hospitals and community health systems. The second factor was prehospital-admission visits by patients to pulmonologists: those who saw pulmonologists in the year prior to their admission tended to have higher rates of attendance at postdischarge follow-up visit. This correlation is reasonable and not surprising. Other factors identified in previous studies13,14 as significant influences on attending the follow-up visit, such as patient age or sex, were not found to be significant in our study.

In contrast to previous work, our study examined the impact of a follow-up visit with a pulmonologist only and did not include general practitioners, whereas earlier research included primary care physicians. In our study, we found an impressive high overall attendance rate for follow-up visit of 44.1% for all patients compared with previous studies, where the majority of patients received medical care from their primary physicians with the remainder, about 15% of all patients, receiving that care from their pulmonologists.13,14 We suggest two explanations for the high rate of attendance observed in our study. First, the health system in Israel is public, and, therefore, pulmonologists (and all other medical specialists) are readily accessible to any patient, regardless of economic status. Second, it is a common practice among the internal wards of Soroka Medical Center to issue in the patient discharge letter a recommendation to visit a pulmonologist, although 31 patients in our study did not receive such a recommendation.

In part of the study design, the index hospitalization was chosen randomly. Because the patients in our study had different numbers of hospitalizations, which probably reflects the difference in disease severity, choosing index hospitalization other than randomly may have caused selection bias. Furthermore, selection of the first or last hospitalization may not have been representative of the whole study period and could have caused a selection bias for a certain time period during the 7 years of the study.

Our study has several limitations. First, by restricting our sample to a single hospital and specifically to patients who were treated in the lung institute of that hospital, we found only 195 patients who met the inclusion criteria. It is possible that the small number of patients prevented us from finding other significant correlations described in earlier studies. Second, no data were collected regarding the treatment or quality of care during hospitalization, which may have had an impact on the risk of rehospitalization, although we based our sampling decision on the assumption that the patient treatment guidelines across all the internal wards in the same hospital would be similar. A third and more important limitation of our study was the lack of data about the patients’ compliance with the long-term treatments that were recommended to them at discharge, treatment that could have had a significant impact on rehospitalization rates, although the recommended treatment by the pulmonologist in the follow-up visit may also have had a significant impact on readmission. Fourth, our study only examined how follow-up visits with pulmonologists affected rates of rehospitalization after discharge from hospital. As described previously, this intentional limitation, which we found distinguished our study from others on the same topic, did not prevent us from finding a difference between the two study groups or from answering our primary objectives. The impact of follow-up visits with one’s primary care physician on rehospitalization rates, therefore, could be the basis for important future research to investigate whether the rehospitalization rates of patients who saw their primary care physicians for follow-up visits differed from those who saw their pulmonologists.

In summary, our study showed a strong association between an early follow-up visit with a pulmonologist after discharge from hospital and reduced exacerbation-related rehospitalization rates of patients with COPD. Our recommendation is that recently discharged patients, especially those at high risk of not attending the follow-up visit, be invited for follow-up visits with pulmonologists. In addition, the inclusion of a written recommendation in the discharge letters of patients with COPD for follow-up visits with pulmonologists is important.

Author contributions: R. G. had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. R. G., A. L., O. K. D., E. K., and N. M. contributed to the conception and design of the study, critical revision of the article for important intellectual content, and final approval of the version to be published, and had full access to the primary study data; R. G. contributed to the acquisition of data; and R. G. and A. L. contributed to the data analysis.

Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Halbert RJ, Isonaka S, George D, Iqbal A. Interpreting COPD prevalence estimates: what is the true burden of disease? Chest. 2003;123(5):1684-1692. [CrossRef] [PubMed]
 
Fauchi AS, Braunwald E, Kasper D, et al. Harrison’s Principles of Internal Medicine.17th ed. New York, NY: McGraw-Hill Medical; 2008:1635.
 
American Thoracic Society/European Respiratory Society Task Force. Standards for the Diagnosis and Management of Patients With COPD, Version 1.2. New York, NY: American Thoracic Society; 2004:166, 170-171, 174.
 
Groenewegen KH, Schols AMWJ, Wouters EFM. Mortality and mortality-related factors after hospitalization for acute exacerbation of COPD. Chest. 2003;124(2):459-467. [CrossRef] [PubMed]
 
Nie JX, Wang L, Upshur RE. Mortality of elderly patients in Ontario after hospital admission for chronic obstructive pulmonary disease. Can Respir J. 2007;14(8):485-489. [PubMed]
 
Roberts CM, Lowe D, Bucknall CE, Ryland I, Kelly Y, Pearson MG. Clinical audit indicators of outcome following admission to hospital with acute exacerbation of chronic obstructive pulmonary disease. Thorax. 2002;57(2):137-141. [CrossRef] [PubMed]
 
McGhan R, Radcliff T, Fish R, Sutherland ER, Welsh C, Make B. Predictors of rehospitalization and death after a severe exacerbation of COPD. Chest. 2007;132(6):1748-1755. [CrossRef] [PubMed]
 
Chan FW, Wong FY, Yam CH, et al. Risk factors of hospitalization and readmission of patients with COPD in Hong Kong population: analysis of hospital admission records. BMC Health Serv Res. 2011;11:186. [CrossRef] [PubMed]
 
Naylor MD, Brooten D, Campbell R, et al. Comprehensive discharge planning and home follow-up of hospitalized elders: a randomized clinical trial. JAMA. 1999;281(7):613-620. [CrossRef] [PubMed]
 
Lawlor M, Kealy S, Agnew M, et al. Early discharge care with ongoing follow-up support may reduce hospital readmissions in COPD. Int J Chron Obstruct Pulmon Dis. 2009;4:55-60. [PubMed]
 
Jack BW, Chetty VK, Anthony D, et al. A reengineered hospital discharge program to decrease rehospitalization: a randomized trial. Ann Intern Med. 2009;150(3):178-187. [CrossRef] [PubMed]
 
Ezekowitz JA, van Walraven C, McAlister FA, Armstrong PW, Kaul P. Impact of specialist follow-up in outpatients with congestive heart failure. CMAJ. 2005;172(2):189-194. [CrossRef] [PubMed]
 
Sharma G, Kuo YF, Freeman JL, Zhang DD, Goodwin JS. Outpatient follow-up visit and 30-day emergency department visit and readmission in patients hospitalized for chronic obstructive pulmonary disease. Arch Intern Med. 2010;170(18):1664-1670. [CrossRef] [PubMed]
 
Sin DD, Bell NR, Svenson LW, Man SF. The impact of follow-up physician visits on emergency readmissions for patients with asthma and chronic obstructive pulmonary disease: a population-based study. Am J Med. 2002;112(2):120-125. [CrossRef] [PubMed]
 
Global strategy for the diagnosis, management and prevention of COPD. Global Initiative for Chronic Obstructive Lung Disease (GOLD) website. http://www.goldcopd.org/. Published 2013. Accessed July 15, 2013.
 

Figures

Figure Jump LinkFigure 1 –  Cumulative risk of additional hospitalization or death for patients who had or did not have follow-up visits with pulmonologist within 30 d after discharge.Grahic Jump Location

Tables

Table Graphic Jump Location
TABLE 1 ]  Comparison of Demographic and Clinical Characteristics of Patients Who Did and Did Not Attend Follow-up Visits With Pulmonologists Within 30 d of Discharge From Hospital

Data are presented as No. (%) unless otherwise indicated.

a 

OR not shown for parametric and nonparametric variables that were analyzed by t test and Mann-Whitney U test.

b 

Lung function test updated within a year of index hospitalization, described as a continuous variable.

c 

Data missing (n = 170).

d 

Numbers of office visits and hospitalizations in the year before the index hospitalization.

Table Graphic Jump Location
TABLE 2 ]  Risk Factors Independently Associated With Not Attending Pulmonologist Follow-up Visit
Table Graphic Jump Location
TABLE 3 ]  Risk Factors Independently Associated With Readmission Within 90 d of Discharge

The model includes 166 patients; four patients were excluded because they attended their follow-up visit after they had been rehospitalized, and FEV1 data were missing for 25 patients.

a 

Patients who did not attend the follow-up visits with pulmonologists within 30 d of discharge.

Table Graphic Jump Location
TABLE 4 ]  Cox Proportional Hazard Model: Effect of Lack of Follow-up and Other Characteristics on Additional Hospitalization or Death

The model includes 166 patients; four patients were excluded because they attended their follow-up visit after they had been rehospitalized, and FEV1 data were missing for 25 patients. HR = hazard ratio.

a 

To prevent time interaction, the variables were modified as follows: previous hospitalizations, dichotomous division (none; ≥ 1); FEV1, dichotomous division (moderate-severe, 80 > FEV1 ≥ 30; very severe, FEV1 < 30); age, dichotomous division (≤ 70 y; > 70 y).

References

Halbert RJ, Isonaka S, George D, Iqbal A. Interpreting COPD prevalence estimates: what is the true burden of disease? Chest. 2003;123(5):1684-1692. [CrossRef] [PubMed]
 
Fauchi AS, Braunwald E, Kasper D, et al. Harrison’s Principles of Internal Medicine.17th ed. New York, NY: McGraw-Hill Medical; 2008:1635.
 
American Thoracic Society/European Respiratory Society Task Force. Standards for the Diagnosis and Management of Patients With COPD, Version 1.2. New York, NY: American Thoracic Society; 2004:166, 170-171, 174.
 
Groenewegen KH, Schols AMWJ, Wouters EFM. Mortality and mortality-related factors after hospitalization for acute exacerbation of COPD. Chest. 2003;124(2):459-467. [CrossRef] [PubMed]
 
Nie JX, Wang L, Upshur RE. Mortality of elderly patients in Ontario after hospital admission for chronic obstructive pulmonary disease. Can Respir J. 2007;14(8):485-489. [PubMed]
 
Roberts CM, Lowe D, Bucknall CE, Ryland I, Kelly Y, Pearson MG. Clinical audit indicators of outcome following admission to hospital with acute exacerbation of chronic obstructive pulmonary disease. Thorax. 2002;57(2):137-141. [CrossRef] [PubMed]
 
McGhan R, Radcliff T, Fish R, Sutherland ER, Welsh C, Make B. Predictors of rehospitalization and death after a severe exacerbation of COPD. Chest. 2007;132(6):1748-1755. [CrossRef] [PubMed]
 
Chan FW, Wong FY, Yam CH, et al. Risk factors of hospitalization and readmission of patients with COPD in Hong Kong population: analysis of hospital admission records. BMC Health Serv Res. 2011;11:186. [CrossRef] [PubMed]
 
Naylor MD, Brooten D, Campbell R, et al. Comprehensive discharge planning and home follow-up of hospitalized elders: a randomized clinical trial. JAMA. 1999;281(7):613-620. [CrossRef] [PubMed]
 
Lawlor M, Kealy S, Agnew M, et al. Early discharge care with ongoing follow-up support may reduce hospital readmissions in COPD. Int J Chron Obstruct Pulmon Dis. 2009;4:55-60. [PubMed]
 
Jack BW, Chetty VK, Anthony D, et al. A reengineered hospital discharge program to decrease rehospitalization: a randomized trial. Ann Intern Med. 2009;150(3):178-187. [CrossRef] [PubMed]
 
Ezekowitz JA, van Walraven C, McAlister FA, Armstrong PW, Kaul P. Impact of specialist follow-up in outpatients with congestive heart failure. CMAJ. 2005;172(2):189-194. [CrossRef] [PubMed]
 
Sharma G, Kuo YF, Freeman JL, Zhang DD, Goodwin JS. Outpatient follow-up visit and 30-day emergency department visit and readmission in patients hospitalized for chronic obstructive pulmonary disease. Arch Intern Med. 2010;170(18):1664-1670. [CrossRef] [PubMed]
 
Sin DD, Bell NR, Svenson LW, Man SF. The impact of follow-up physician visits on emergency readmissions for patients with asthma and chronic obstructive pulmonary disease: a population-based study. Am J Med. 2002;112(2):120-125. [CrossRef] [PubMed]
 
Global strategy for the diagnosis, management and prevention of COPD. Global Initiative for Chronic Obstructive Lung Disease (GOLD) website. http://www.goldcopd.org/. Published 2013. Accessed July 15, 2013.
 
NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

Find Similar Articles
CHEST Journal Articles
  • CHEST Journal
    Print ISSN: 0012-3692
    Online ISSN: 1931-3543