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      Examining 30-day COPD readmissions through the emergency department

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          Thirty-day readmission in COPD is common and costly, but potentially preventable. The emergency department (ED) may be a setting for COPD readmission reduction efforts.


          To better understand COPD readmission through the ED, ascertain factors associated with 30-day readmission through the ED, and identify subgroups of patients with COPD for readmission reduction interventions.

          Patients and methods

          A retrospective cohort study was conducted from January 2009 to September 2015 in patients with COPD of age ≥18 years. Electronic health record data were abstracted for information available to admitting providers in the ED. The primary outcome was readmission through the ED within 30 days of discharge from an index admission for COPD. Logistic regression was used to examine the relationship between potential risk factors and 30-day readmission.


          The study involved 1,574 patients who presented to the ED within 30 days on an index admission for COPD. Of these, 82.2% were readmitted through the ED. Charlson score (odds ratio [OR]: 3.6; 95% CI: 2.9–4.4), a chief complaint of breathing difficulty (OR: 1.6; 95% CI: 1.1–2.6), outpatient utilization of albuterol (OR: 4.1; 95% CI: 2.6–6.4), fluticasone/salmeterol (OR: 2.3; 95% CI: 1.3–4.2), inhaled steroids (OR: 3.8; 95% CI: 1.3–10.7), and tiotropium (OR: 1.8; 95% CI: 1.0–3.2), as well as arterial blood gas (OR: 4.4; 95% CI: 1.3–15.1) and B-type natriuretic peptide (OR: 2.2; 95% CI: 1.4–3.5) testing in the ED were associated with readmission (c-statistic =0.936). Seventeen-point-eight percent of patients with COPD presented to the ED and were discharged home; 56% presented with a complaint other than breathing difficulty; and 16% of those readmitted for breathing difficulty had a length of stay <48 hours.


          Intensive outpatient monitoring, evaluation, and follow-up after discharge are needed to help prevent re-presentation to the ED, as practically all patients with COPD who represent to the ED within 30 days are readmitted to the hospital and for a variety of clinical complaints. Among those patients with COPD who present with breathing difficulty, improved decision support algorithms and alternative management strategies are needed to identify and intervene on the subgroup of patients who require <48-hour length of stay.

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          Most cited references 23

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          The impact of confounder selection criteria on effect estimation.

           R Mickey,  S Greenland (1988)
          Much controversy exists regarding proper methods for the selection of variables in confounder control. Many authors condemn any use of significance testing, some encourage such testing, and other propose a mixed approach. This paper presents the results of a Monte Carlo simulation of several confounder selection criteria, including change-in-estimate and collapsibility test criteria. The methods are compared with respect to their impact on inferences regarding the study factor's effect, as measured by test size and power, bias, mean-squared error, and confidence interval coverage rates. In situations in which the best decision (of whether or not to adjust) is not always obvious, the change-in-estimate criterion tends to be superior, though significance testing methods can perform acceptably if their significance levels are set much higher than conventional levels (to values of 0.20 or more).
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            Risk factors for hospitalization for a chronic obstructive pulmonary disease exacerbation. EFRAM study.

            Although exacerbation of chronic obstructive pulmonary disease (COPD) is important in terms of health and costs, there is little information about which are the risk factors. We estimated the association between modifiable and nonmodifiable potential risk factors of exacerbation and the admission for a COPD exacerbation, using a case-control approach. Cases were recruited among admissions for COPD exacerbation during 1 yr in four tertiary hospitals of the Barcelona area. Control subjects were recruited from hospital's register of discharges, having coincided with the referent case in a previous COPD admission but being clinically stable when the referent case was hospitalized. All patients completed a questionnaire and performed spirometry, blood gases, and physical examination. Information about potential risk factors was collected, including variables related to clinical status, characteristics of medical care, medical prescriptions, adherence to medication, lifestyle, quality of life, and social support. A total of 86 cases and 86 control subjects were included, mean age 69 yr, mean FEV(1) 39% of predicted. Multivariate logistic regression showed the following risk (or protective) factors of COPD hospitalization: three or more COPD admissions in the previous year (odds ratio [OR] 6.21, p = 0.008); FEV(1) (OR 0.96 per percentual unit, p < 0.0005); underprescription of long-term oxygen therapy (LTOT) (OR 22.64, p = 0.007); and current smoking (OR 0.30, p = 0.022). Among a wide range of potential risk factors we have found that only previous admissions, lower FEV(1), and underprescription of LTOT are independently associated with a higher risk of admission for a COPD exacerbation.
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              Risk factors of hospitalization and readmission of patients with COPD exacerbation – systematic review

              Background: Chronic obstructive lung disease (COPD) exacerbations are a significant cause of morbidity and mortality. Data regarding factors which causes or prevents exacerbations is very limited. The aim of this systematic review is to summarize the results from available studies to identify potential risk factors for hospital admission and/or re-admission among patients experiencing COPD exacerbations. Methods: We undertook a systematic review of the literature. Potential studies were identified by searching the electronic databases: PubMed, EMBASE, BIOSIS, CINAHL, PsycINFO, Cochrane library, reference lists in trial reports, and other relevant articles. Results: Seventeen articles that met the predefined inclusion criteria were identified. Heterogeneity of study designs, risk factors and outcomes restrict the result to only a systematic review and precluded a formal meta-analysis. In this review, three predictive factors: previous hospital admission, dyspnea and oral corticosteroids were all found to be significant risk factors of readmissions and variables including using long term oxygen therapy, having low health status or poor health related quality of life and not having routine physical activity were all associated with an increased risk of both admission and readmission to hospital. Conclusions: There are a number of potential modifiable factors that are independently associated with a higher risk of COPD exacerbation requiring admission/readmission to the hospital. Identifying these factors and the development of targeted interventions could potentially reduce the number and severity of such exacerbations.

                Author and article information

                Int J Chron Obstruct Pulmon Dis
                Int J Chron Obstruct Pulmon Dis
                International Journal of COPD
                International Journal of Chronic Obstructive Pulmonary Disease
                Dove Medical Press
                27 December 2017
                : 13
                : 109-120
                [1 ]Oakland University William Beaumont School of Medicine, Rochester, MI
                [2 ]Center for Healthcare Studies, Feinberg School of Medicine, Northwestern University
                [3 ]Center for Health Statistics, University of Chicago, Chicago, IL
                [4 ]Primary Care, Brigham and Women’s Hospital, Boston, MA
                [5 ]Emergency Medicine
                [6 ]Internal Medicine, Beaumont Health, Royal Oak, MI, USA
                Author notes
                Correspondence: Alexandra Halalau, Oakland University William Beaumont School of Medicine, 3535 W. 13 Mile Road, Royal Oak, MI 48073, USA, Tel +1 248 551 0457, Fax +1 248 551 1245, Email alexandra.halalau@
                © 2018 Rezaee et al. This work is published and licensed by Dove Medical Press Limited

                The full terms of this license are available at and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License ( By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed.

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