Early discharge with follow-up support in COPD Table 4 Comparisons of admissions and emergency department presentations in the 6 month and 1 year period before and after the early discharge programme for those patients receiving additional formal self-management education.Values are shown as median and interquartile ranges (IQR) N Admissions Admission rate per patient Median (IQR) admissions per patient Emergency dept presentations Emergency dept presentations per patient Median (IQR) emergency dept presentations per patient 12 months before early discharge 60 98 1.63 1 (1,2) 107 1.78 1 (1,2) 6 months before early discharge 60 84 1.4 1 (1,2) 91 1.51 1 (1,2) 6 months post-early discharge 60 26 0.43 0 (0,1)* 34 0.56 0 (0,1)* 12 months post-early discharge 60 37 0.61 0 (0,1)† 41 0.68 0 (0,1)† Notes: *p 0.001 compared to 6 months prior to early discharge; †p 0.001 compared to 1 year prior to early discharge. did not examine the effect on hospital admissions at all. A Cochrane analysis of 14 such studies concluded that because of the heterogeneity in interventions, study populations, follow-up time, and outcome measures, the data generated was insufﬁcient to form recommendations.18 The current study, also, has signiﬁcant limitations. It was not a randomized control trial, but a retrospective analysis, therefore limiting extrapolation of the results to the COPD population at large and preventing us from drawing conclu- sions as to whether early discharge care actually reduces readmissions. Features in common with other studies do allow us to speculate regarding factors of possible impor- tance to the observed reduction in admission rates. Patient selection and the timing of recruitment are among these. All participants had been recently admitted and, similar to the study by Bourbeaue and colleagues,11 were active presenters to the emergency department with an average rate of 1.8 admissions over the preceding year. In contrast in other self-management studies there were lower preced- ing admission rates,10,19 that would be difﬁcult to further reduce. For example, 20% of the patients studied by Sridhar and colleagues10 had not been admitted at all in the 2 years prior to recruitment. In addition, similar to the work by Bourbeau and colleagues11 the current study included both a written management plan to address exacerbations (the vast majority of trials of self-management did not), and a formal exercise programme. Less speciﬁcally, the prolonged contact between the patients and the respiratory depart- ment could, equally, have been important, as the success of self-management education is believed to be reliant on the accompanying ongoing communication with health care personnel.11 In the current study, patient/department contact persisted for at least 3, and up to 36, months with a strategy that addressed the exacerbation initially, with after-care that included education and smoking cessation advice, followed by encouragement to contact the department thereafter for support if they experienced further respiratory difﬁculties. However, which, if any, aspect of the outreach programme’s interventions contributed most to reduced readmissions cannot be determined from the results, not only because the study was not designed to examine the impact of the individual interventions, but also because self management education did not signiﬁcantly reduce admissions compared to the outreach programme on its own. Table 5 Comparisons of admissions in the 6 month and 1 year period before and after admission for COPD for those patients admitted in 2004 but not included in the respiratory outreach programme.Values are shown as median and interquartile range (IQR) 12 months 6 months 6 months 12 months before admission before admission before admission before admission N 267 267 259 244 Admissions 139 70 103 165 Median (IQR) admissions 0 (0,1) 0 (0,0) 0 (0,1)* 0 (0,1)† per patient Notes: *p 0.05 compared to 6 months prior to early discharge, but showing a signiﬁcant increase in admissions; †p = 0.102 compared to 1 year prior to early discharge. International Journal of COPD 2009:4 59