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

Abstract Rationale Chronic obstructive pulmonary disease (COPD) is a leading cause of hospital readmission. Interventions including inpatient inhaler teaching, multidisciplinary patient education, and COPD-specific post-discharge appointments may mitigate the risk of readmission. However, few studies have examined the impact of these interventions in a combined, real-world clinical program. We investigated risk of hospital readmission among patients enrolled in a comprehensive COPD clinical program that spanned inpatient and transition to outpatient care for patients admitted with a COPD exacerbation. Methods We retrospectively identified patients who received an inpatient consult by the COPD program clinical team during an exacerbation. Interventions included inpatient in-person consultation for COPD management 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 our APN and pharmacy team for multidisciplinary review of COPD symptoms and to address care gaps and inhaler education. We used Generalized Estimating Equations to determine odds of hospital readmission at 30 and 90-days post-discharge, adjusting for attendance of follow-up prior to hospital readmission, sociodemographic, and clinical variables. Results Among 928 patients, there were 4019 inpatient admissions for COPD exacerbations and 952 outpatient appointments from February 2019 to December 2024. Of 372 scheduled COPD-APN appointments, 140 (23.7%) appointments were completed within 30 days post-discharge versus 580 scheduled and 342 (59.0%) completed primary care (PCP) appointments. Patients with primary care (PCP) follow-up (versus no follow-up attended) had 0.39 times adjusted odds of hospital readmission within 30 days (0.17-0.88, p = 0.02), with a loss of effect at 90 days. No patients received COPD-APN follow-up only within 30 days post-discharge, precluding estimation of the adjusted odds. Patients who attended both COPD-APN and PCP follow-up (AOR 0.52; 0.20-1.31, p = 0.2) and patients who attended pulmonary follow-up (AOR 0.54; 0.22-1.29, p = 0.2) within 30 days post-discharge had non-significant adjusted odds reductions of 30-day readmission. (See Table for patient characteristics and visit and intervention data). Conclusions Our findings demonstrate that post-discharge PCP follow-up may be protective against 30-day hospital readmission among patients enrolled in a comprehensive COPD program. Absence of significance at later time points and in the COPD-APN and PCP combined follow-up group suggest that further analysis with a larger sample may benefit the analysis and investigation into possible confounding variables (e.g., baseline health, social vulnerability) is needed. Attendance of outpatient follow-up within 30 days of discharge likely enhances the COPD program effects. This abstract is funded by: None