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May 20, 2026American Journal of Respiratory and Critical Care Medicine

B94-06 Hospital Readmission Among Patients Enrolled in a COPD Transitions of Care Program

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Why the study?

Chronic obstructive pulmonary disease is a leading cause of readmission, but few studies have evaluated the impact of inpatient inhaler teaching, education, and post-discharge appointments combined in a real-world clinical program.

Does outpatient follow-up as part of a comprehensive COPD transitions of care program reduce hospital readmission in patients admitted with a COPD exacerbation?

Population

928 patients with 4019 inpatient admissions for COPD exacerbations

Comparison

Post-discharge follow-up types vs no follow-up attended

Design

Retrospective cohort study

Follow-up

90 days post-discharge

Key result

Primary care follow-up within 30 days post-discharge reduced the odds of 30-day hospital readmission among patients in a COPD program (AOR 0.39; 95% CI 0.17-0.88; p=0.02).

Authors

MSM SunDRD RamaduraiSCS Chia

Discussion

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Overview

May support PCP follow-up to reduce readmissions; leaves open causal confirmation in randomized trials.

Key Points

  • This research aims to evaluate the effectiveness of a comprehensive COPD transitions of care program in reducing hospital readmissions.
  • Retrospectively identified patients who received an inpatient consult by the COPD program team during an exacerbation.
  • Implemented inpatient consultation, inhaler education, nurse phone follow-up, and outpatient appointments.
  • Analyzed odds of readmission at 30 and 90 days post-discharge using Generalized Estimating Equations.
  • Patients with PCP follow-up had 0.39 times adjusted odds of readmission within 30 days (95% CI 0.17-0.88, p = 0.02).
  • 140 out of 372 scheduled COPD-APN appointments were completed within 30 days (23.7%).
  • Attendance at both COPD-APN and PCP follow-up showed non-significant odds reductions in 30-day readmission.

Study Design

Type

Cohort (n=928)

Structured PICO

Does outpatient follow-up as part of a comprehensive COPD transitions of care program reduce hospital readmission in patients admitted with a COPD exacerbation?

P
Population
928 patients admitted with a COPD exacerbation who received an inpatient consult by the COPD program clinical team
I
Intervention
Comprehensive COPD clinical program including inpatient consultation by an advanced practice nurse (APN) or physician, pharmacist-led inhaler teaching, a post-discharge 48-hour nurse phone call, and an outpatient appointment with APN and pharmacy team
C
Comparator
No follow-up attended
O
Outcome
Hospital readmission at 30 and 90-days post-dischargehard clinical

Main Result

Effect estimate: AOR 0.39 (95% CI 0.17-0.88)

p-value: p=0.02

Post-discharge primary care follow-up within 30 days is associated with reduced 30-day hospital readmission among patients enrolled in a comprehensive COPD transitions of care program.

Limitations

  • Small sample size for combined follow-up groups
  • Possible confounding variables such as baseline health and social vulnerability
  • Small sample size in certain subgroups precluding estimation or significance

Cite This Study

Sun et al. (2026) conducted a cohort in COPD exacerbation (n=928). Primary care (PCP) follow-up vs. No follow-up attended was evaluated on Hospital readmission within 30 days (AOR 0.39, 95% CI 0.17-0.88, p=0.02). Primary care follow-up within 30 days post-discharge reduced the odds of 30-day hospital readmission among patients in a COPD program (AOR 0.39; 95% CI 0.17-0.88; p=0.02).

synapsesocial.com/papers/6a0d5040f03e14405aa9be45https://doi.org/10.1093/ajrccm/aamag162.1893
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Also Consider

Synapse has enriched 5 closely related papers on similar clinical questions. Consider them for comparative context:

  1. 1Impact of a Post-Discharge Integrated Disease Management Program on COPD Hospital Readmissions2017 · 20 citations
  2. 2Comprehensive and Collaborative Pharmacist Transitions of Care Service for Underserved Patients with Chronic Obstructive Pulmonary Disease2020 · 8 citations
  3. 3Effectiveness of structured planned post discharge support to patients with chronic obstructive pulmonary disease for reducing readmission rates: a systematic review2017 · 37 citations
  4. 4Factors associated with inpatient readmission among managed care enrollees with COPD2015 · 19 citations
  5. 5Risk assessment of readmissions following an initial COPD-related hospitalization2013 · 96 citations