Abstract Introduction Chronic hypercapnic respiratory failure (CHRF), commonly due to chronic obstructive pulmonary disease (COPD), obesity hypoventilation syndrome (OHS), or neuromuscular disease, carries high readmission (23% at 30 days) and mortality (30–49% at 1 year) despite noninvasive ventilation (NIV). While NIV therapy can be effective in reducing complications, the role of timely outpatient follow-up in preventing readmissions remains insufficiently understood. Methods We conducted a retrospective cohort study of adult patients discharged on new NIV for CHRF from a tertiary hospital (Dec 2023–Oct 2024), assessing demographics, prior hospitalizations, timely follow-up, and readmission rates 6 months post discharge. Subsequently, a quality improvement initiative (Nov 2024–Apr 2025) assigned a telehealth pulmonary follow-up within 4 weeks, using four standardized adherence questions. Electronic health data were analyzed; primary outcome was 30-day readmission rates. Descriptive and comparative statistics were performed. Results Of 71 patients discharged on new NIV for CHRF, 45 comprised the pre-intervention cohort and 26 the post-intervention cohort. Pre-intervention, only 26.7% had follow-up within 30 days (readmission rate 8.3%); 73.3% had no follow-up (readmission rate 45.5%). Post-intervention, 65.4% completed timely telehealth follow-up (readmission rate 11.8%); 34.6% did not (readmission rate 44.4%). Overall, patients with timely follow-up had a 10.3% 30-day readmission rate versus 45.2% without follow-up (p 0.001). Of 71 patients, 32 (45%) had ≥1 hospitalization in the year preceding NIV initiation, with an average of 2.37 hospitalizations per readmitted patient. Conclusion In patients with chronic hypercapnic respiratory failure newly initiated on NIV, timely outpatient follow-up within 4 weeks was associated with markedly lower 30-day readmission rates (10.3% vs 45.2%). Despite high risk, many patients discharged on PAP therapy for hypoventilation syndromes do not receive timely follow-up—a critical care gap strongly linked to early readmissions. This QI initiative with structured discharge planning and early specialty follow-up significantly improved outcomes. Healthcare systems should prioritize comprehensive transitional care, expanded telehealth, and transitional care models to ensure consistent, timely access to specialty care, reduce preventable readmissions, and improve survival in this vulnerable population. Support (if any)
Kuruppu et al. (Fri,) studied this question.