Lawlor et al The study’s results are potentially confounded by a number of signiﬁcant biases. The inclusion criteria for early discharge care required patients to have good mobility, social support and performance status without other signiﬁcant co-morbidities. This well-performing sub-population would be expected to have a better chance of avoiding future admissions. Moreover, the self management subgroup’s selection, based on their demonstra- tion of a good disease understanding at a point in time, may itself have mitigated against re-hospitalization. Although it is a before and after investigation, the study fails to take into account possible improvements in treatment for COPD. Although these are unlikely to have had an effect of such magnitude, treatment changes in each subject were not recorded for the purposes of the study and can therefore not be out-ruled as a contributing factor. Notwithstanding the above, the highly signiﬁcant improvement in admission rates is still noteworthy and supports the possibility that a respiratory outreach programme could modify disease related behaviour in a large COPD population. Conclusion The current study suggests the possibility that provision of a nurse and physiotherapist-led respiratory outreach service comprising early discharge care followed by disease education, telephone support, and rapid access to respiratory outpatient clinics may reduce readmission rates in COPD patients. A randomized control trial of this prolonged approach would be worthwhile to substantiate this hypothesis. Acknowledgments The authors wish to acknowledge the help of the staff of the respiratory assessment unit, St. James’s Hospital. Disclosure This work was performed in St. James’s Hospital, Dublin, Ireland. None of the authors listed in this manuscript have any ﬁnancial or other conﬂicts of interest to disclose. References 1. Pauwels RA, Buist AS, Ma P, et al. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: National Heart, Lung, and Blood Institute and World Health Organization Global Initiative for Chronic Obstructive Lung Disease (GOLD): executive summary. Respir Care. 2001;46:798–825. 2. Murray CJ, Lopez AD. Evidence-based health policy–lessons from the Global Burden of Disease Study. Science. 1996;274:740–3. 3. Haughney J, Partridge MR, Vogelmeier C, et al. Exacerbations of COPD: quantifying the patient’s perspective using discrete choice modelling. Eur Respir J. 2005;26:623–9. 4. Kessler R, Stahl E, Vogelmeier C, et al. Patient understanding, detection, and experience of COPD exacerbations: an observational, interview- based study. Chest. 2006;30:133–42. 5. Cotton MM, Bucknall CE, Dagg KD, et al. Early discharge for patients with exacerbations of chronic obstructive pulmonary disease: a random- ized controlled trial. Thorax. 2000;55:902–6. 6. Hernandez C, Casas A, Escarrabill J, et al. Home hospitali- sation of exacerbated chronic obstructive pulmonary disease patients. Eur Respir J. 2003;21:58–67. 7. Ojoo JC, Moon T, McGlone S, et al. Patient’s and carer’s preferences in two models of care for acute exacerbations of COPD: results of a randomised controlled trial. Thorax. 2002;57:167–9. 8. Sala E, Alegre L, Carrera M, et al. Supported discharge shortens hospital stay in patients hospitalized because of an exacerbation of COPD. Eur Respir J. 2001;17:1138–42. 9. Skwarska E, Cohen G, Skwarski KM, et al. Randomized controlled trial of supported discharge in patients with exacerbations of chronic obstructive pulmonary disease. Thorax. 2000;55:907–12. 10. Sridhar M, Taylor R, Dawson S, et al. A nurse-led intermediate care package in patients who have been hospitalised with an acute exac- erbation of chronic obstructive pulmonary disease. Thorax Med J. 2008;38:334–40. 11. Bourbeau J, Julien M, Maltais F, et al. Reduction of hospital utilization in patients with chronic obstructive pulmonary disease: a disease-speciﬁc self-management intervention. Arch Intern Med. 2003;163:585–91. 12. Davies L, Wilkinson M, Bonner S, et al. 2000. “Hospital at home” versus hospital care in patients with exacerbations of chronic obstructive pulmonary disease: prospective randomised controlled trial. BMJ, 321:1265–8. 13. Monninkhof E, van der Valk P, van der Palen J, et al. Self-management education for patients with chronic obstructive pulmonary disease: a systematic review. Thorax. 2003;58:394–8. 14. Doll H, Grey-Amante P, Duprat-Lomon I, et al. Quality of life in acute exacerbation of chronic bronchitis: results from a German population study. Respir Med. 2002;96:39–51. 15. Seemungal TA, Donaldson GC, Paul EA, et al. Effect of exacerbation on quality of life in patients with chronic obstructive pulmonary dis- ease. Am J Respir Crit Care Med. 1998;157(5 Pt 1):1418–22. 16. Spencer S, Calverley PM, Burge PS, et al. Impact of preventing exacerbations on deterioration of health status in COPD. Eur Respir J. 2004;23:698–702. 17. Ram FS, Wedzicha JA, Wright J, et al. Hospital at home for patients with acute exacerbations of chronic obstructive pulmonary disease: systematic review of evidence. BMJ. 2004;329:315. 18. Efﬁng T, Monninkhof EM, van der Valk PD, et al. Self-management education for patients with chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2007;4:CD002990. 19. Monninkhof E, van der Valk P, Schermer T, et al. Economic evalua- tion of a comprehensive self-management programme in patients with moderate to severe chronic obstructive pulmonary disease. Chron Respir Dis. 2004;1:7–16. 60 International Journal of COPD 2009:4