Lawlor et al Comparisons of emergency department presentation and hospital admissions before and after inclusion in the respiratory outreach programme are given in Table 3. In the 6-month period immediately post-early discharge 7 of the original 246 patients died. Among the remaining 239 patients, mean emergency department presentations and hospital admissions were reduced 48% (p 0.001) and 51% (p 0.001), respectively compared to the 6-month period preceding early discharge. By 1-year post-early discharge, a total of 20 patients had died. Among the remaining 226 patients, mean emergency department presentations and hospital admissions were reduced by 40% (p 0.001) and 42% (p 0.001), respectively compared to the 1-year period preceding early discharge. Comparisons of emergency department presentation and hospital admissions before and after inclusion in the respiratory outreach programme for the 60 patients who also received formal self-management education are given in Table 4. In the 6-month period immediately post-early discharge emergency department presentations and hospital admissions were reduced 62% (p 0.001) and 69% (p 0.001), respectively compared to the 6-month period preceding early discharge. At 1-year post-early discharge, emergency department presentations and hospital admissions were reduced by 61% (p 0.001) and 62% (p 0.001), respectively compared with the 1-year period preceding early discharge. Comparison of the change in emergency department presentations and admissions between the 60 self-management patients and the remaining 186 patients included in the respiratory outreach programme showed no significant difference at 6 or 12 months. Comparisons of hospital admissions for all COPD patients admitted in 2004, but not included in the respiratory outreach programme, are given in Table 5. There was no reduction in admissions at 6 or 12 months after, compared with prior to, this index hospitalization. Discussion The current study shows that patients enrolled in a respiratory outreach service comprising early discharge care, education, telephone support and rapid-access to respiratory outpatient clinics, with and without self-management education, experi- ence fewer emergency department presentations and hospital readmissions for acute exacerbations of COPD than prior to enrolment. For patients with COPD, health-related quality of life is related to exacerbation frequency14–16 while avoidance of hospital admission is a highly valued outcome.3 Early dis- charge and hospital in the home interventions, widely used in the management of exacerbations, are safe,8 cost effective.6,9 preferential to patients7 and save hospital bed days.5 How- ever, readmission rates for patients in these programmes have not differed to those for patients receiving normal hospital care. 5,8,9,12 Similarly, although there have been many studies of self-management education in COPD, only one, by Bour- beau and colleagues11 has been associated with a signiﬁcant reduction in hospital readmissions. These results are under- standable given that most of the interventions studied were not designed to reduce readmission rates speciﬁcally. In many studies, early discharge care addressed the exacerbation only, with interventions that included clinical assessment, blood testing, provision of medication and access to an oxygen concentrator, and patients were subsequently discharged from the service.17 Most reported self-management education programmes, meanwhile, did not include self-treatment of exacerbations, therefore a key factor in the prevention of hospital admissions was not examined.18 Others, moreover, Table 3 Comparisons of admissions and emergency department presentations in the 6 month and 1 year period before and after the early discharge programme.Values are shown as medians and interquartile ranges (IQR) 12 months before 6 months before 6 months 12 months early discharge early discharge post-early discharge post-early discharge N 246 246 239 226 Total Admissions 462 359 173 264 Rate per patient 1.88 1.45 0.72 1.16 Median (IQR) admissions per patient 1 (1,2) 1 (1,2) 0 (0,1)* 0 (0,2)† Emergency dept presentations 523 401 208 309 Emergency dept presentations per patient 2.1 1.63 0.87 1.36 Median (IQR) emergency dept 1 (1,3) 1 (1,2) 0 (0,1) * 0 (0,2)† presentations per patient Notes: *p 0.001 compared to 6 months prior to early discharge; †p 0.001 compared to 1 year prior to early discharge. 58 International Journal of COPD 2009:4