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Hospital admission and readmission for acute exacerbation of COPD. A tough nut to crack

Reducing acute hospital care for people with long-term conditions has become a key element of health policy as governments strain every sinew to contain the escalating healthcare costs arising from ageing populations. Attention has been drawn to the problem of unscheduled hospitalisation for acute exacerbations of COPD (AECOPD) because it is such a common cause of emergency admission and because there is a high readmission rate following discharge. The latter has driven the perception in many quarters that admissions to hospital should be preventable and, with regards to readmission particularly, may be due to poor quality hospital care. Clinicians are frequently caught in the crossfire of these arguments—under pressure to discharge patients quickly to free up precious hospital bed capacity but also to ensure ‘safe’ discharge to reduce the risk of further presentation. Primary care physicians are experiencing similar pressures to avoid referral to hospital while at the same time providing safe management of the episode in the patient's home.

The impact of an AECOPD on an individual is determined by the composite effects of the severity of the acute event (eg, respiratory infection) and the underlying condition of the patient (the respiratory disease and other factors such as multimorbidity). In making clinical judgements about discharge from hospital clinicians need to also take into account the social and psychological circumstances, particularly the confidence of the patient and their carers that they are ready to leave hospital. It would be fair to say that currently, these judgements are largely subjective and do not routinely incorporate objective measurements of the risk of subsequent readmission to assist in shared decision-making.

Two papers published in this issue of Thorax are relevant to this debate and have the potential to impact on clinical care. Suh et al 1 used parasternal electromyography (EMG) to measure neural …