Readmission in COPD patients: should we consider it a marker of quality of care or a marker of a more severe disease with a worse prognosis?

From the authors:

We thank Ernesto Crisafulli, Mónica Guerrero, Alfredo Chetta and Antoni Torres for their differentiated perspective on the topic of hospital readmission of chronic obstructive pulmonary disease (COPD).

We agree that hospital readmission is a complex surrogate parameter whereby the short period after dismission is related to a fragile health condition of the patient. The close correlation of readmission to increased mortality is another indicator of this vulnerable condition of the COPD patient, following acute exacerbation.

The pilot project of the European audit analysed only readmissions of the COPD patients due to respiratory reasons, in order to assess the risk related to the original hospital admitted exacerbation. This was also very well described in the data by Hurst et al. [1], who demonstrated that the first exacerbation is followed by a second in nearly one-third of patients within 8 weeks. Moreover, we found a correlation of the readmission rate and the severity of respiratory failure during the first admission and in line with other publications, a consecutive increase in mortality after readmission [2–4]. Guerrero et al. [5] reported a correlation with hypercapnia but not with the rate of ventilatory support, not even with admission to intensive care units. This is opposite to our study, which relates the risk of readmission to the severity of the exacerbation (respiratory acidosis, need of ventilation) and not only to disease severity. The need for ventilatory support is an expression of reduced ventilatory capacity in the acute situation and we know that muscle fatigue and overload in accordance with systemic corticosteroids have a potential for critical illness myopathy or neuropathy [6, 7]. Therefore, in the short course after exacerbation ventilatory support was identified as an indicator of an instable condition and a risk factor for readmission.

Due to the observational character of the European COPD Audit study we are not able to predict the potential for the prevention of readmission or death by a single measure of care. However we observed a huge variation of care within each participating country and between countries according to the treatment of acute respiratory failure and the referral to rehabilitation after discharge. The analysis of the level of adherence to management recommendations of acute exacerbation of COPD showed a disappointing result of only 15% of accordance with suggested standard procedures [8]. These findings mirror the ignorance towards the challenge of acute exacerbation of COPD on admission as well as a passive attitude towards ongoing COPD management after discharge. The complexity of COPD exacerbation and of COPD patients overall should not result in reduced treatment approaches.

Therefore, we think that it is high time to accept hospital admitted acute COPD-exacerbation as a risk profile that needs a strict acute care programme and a secured follow-up management starting with post-acute rehabilitation including noninvasive ventilation and long-term oxygen therapy for according patients.

Complexity management is requested as a holistic approach in knowledge-management driven programmes, according to the combination of each single evidence-based intervention that may be suitable to the patients’ risk profile as suggested by Kirschner et al. [9].

The assessment of quality of care is a powerful tool to monitor the changes in management and promote the discussion of care models. McCarthy et al. [10] showed a successful implementation of an improved COPD management at the emergency department after identification of weaknesses. The pilot of The European Audit intends to be a start for such activities.