Can we reduce the risk of readmission for a patient with an exacerbation of COPD?

We think so. Some strategies to reduce readmission rates, such as coordinating care and managing comorbidities, apply to chronic diseases in general, while others are disease-specific. To reduce the need for hospital readmission for chronic obstructive pulmonary disease (COPD), coordinated efforts involving both inpatient and outpatient care are necessary. This can be achieved by using a checklist before discharge (Table 1) and by implementing outpatient COPD programs that continue patient education and provide rapid access to medical support if needed.

See related commentary

There is room for improvement. COPD is common and expensive, with high rates of hospital readmission,¹ and up to 70% of the money we spend on it goes for hospital care.² No wonder then that the Centers for Medicare and Medicaid Services has now expanded its Readmissions Reduction Program to include acute COPD exacerbations.³ Yet in a retrospective study, Yip et al⁴ found that fewer than half of patients hospitalized with acute exacerbation of COPD received appropriate vaccinations, counseling on smoking cessation, and long-acting inhalers—all of which are on our checklist.⁴

The following interventions have been demonstrated to be useful in reducing COPD hospital admissions and the risk of death.

SMOKING CESSATION

Cigarette smoking is the most common and easily identifiable risk factor for COPD exacerbation.⁵

Au et al⁵ found that quitting smoking reduces the risk of COPD exacerbation (adjusted hazard ratio 0.78, 95% confidence interval [CI] 0.75–0.87), and the risk keeps decreasing the longer the patient stays off tobacco.⁵

Whether counseling hospitalized patients on smoking cessation reduces the COPD readmission rate has not been well studied. However, a meta-analysis of nine randomized controlled trials, two of which were done in the hospital, revealed higher abstinence rates in COPD patients who received extensive counseling on smoking cessation.⁷ For these reasons, hospitalized COPD patients who smoke should be strongly encouraged to quit.⁶

PNEUMOCOCCAL AND INFLUENZA VACCINATIONS

In a large retrospective study,⁸ pneumococcal vaccination was associated with a significantly lower risk of hospitalization for pneumonia in patients with chronic lung disease, including those with COPD (relative risk [RR] 0.57, 95% CI 0.38–0.84). The benefit was even greater with pneumococcal and influenza vaccinations during the influenza season (RR 0.28, 95% CI 0.14–0.58).

Randomized controlled trials indicate that influenza vaccination may reduce the rate of COPD exacerbations, especially in epidemic years when the proportion of exacerbations due to influenza is higher.⁹

Wongsurakiat et al¹⁰ found a significant reduction in the incidence of influenza-related acute respiratory illness in COPD patients in a well-designed randomized, placebo-controlled trial (RR 0.24, P = .005).¹⁰

Similarly, in another randomized controlled trial, pneumococcal vaccination was effective in preventing community-acquired pneumonia in COPD patients under age 65 and in those with severe airflow obstruction, although no statistically significant differences were found among other groups of patients with COPD.¹¹

Therefore, influenza and pneumococcal vaccinations are recommended by major COPD guidelines, such as GOLD (Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Lung Disease).⁶