A total of 62 746 hospitalizations for COPD exacerbation occurred between 1996 and 2006 for patients who had a PCP prior to hospitalization. Of these patients, 74.1% were exclusively treated by their PCP and 25.9% were cotreated with a pulmonary physician in the year prior to the hospitalization.
presents the patient and hospital characteristics of patients who did and did not have a follow-up visit with their PCP or pulmonologist and an adjusted HR of seeing either physician. Between 1996 and 2006, 66.9% of patients with COPD had an outpatient visit with their PCP or pulmonologist within 30 days of discharge. The percentage of patients with COPD with a postdischarge follow-up with their PCP or pulmonologist increased from 65.2% in 1996 to 71.0% in 2006 (P< .001). Among patients who had a follow-up visit, 86.7% were with their PCP, 6.7% with their pulmonary physician, and 6.6% with both.
Comparison of Patient- and Hospital-Level Characteristic of Patients With and Without a Follow-up Visit With Their Primary Care Physician (PCP) or Pulmonologist Following Hospitalization for COPD
Patients who did not have a follow-up visit with their PCP or pulmonologist were more likely to have a longer length of hospital stay, be older (>85 years), be black, have a low SES, have multiple comorbidities, and be admitted through the ER compared with those who had a follow-up visit within 30 days of discharge. Patients who lived in a large metropolitan area, received care at a major teaching hospital, or received care at a large hospital were also less likely to have a postdischarge follow-up visit. There were no differences between the groups in prior admissions for COPD, geographic region, admission day of the week, or type of hospital.
Also shown in are the multivariate analyses of patient- and hospital-level characteristics on the likelihood of an outpatient follow-up with their PCP or pulmonologist. The odds of a follow-up visit within 30 days of discharge increased 2% (95% CI, 1%–2%) per year from 1996 to 2006. Factors associated with a lower likelihood of outpatient follow-up were longer hospital stay, prior COPD hospitalization, older age, black race, lower SES, and emergency admission. Those receiving care at nonteaching, for-profit, and smaller sized hospitals were more likely to have a follow-up visit within 30 days of discharge. Censoring patients who had an ER visit or readmission prior to a follow-up visit with their PCP or pulmonologist did not change the adjusted HR for most of the variables listed in , except for low SES (HR, 0.92; 95% CI, 0.89–0.94) and 3 or more comorbidities (HR, 1.00; 95% CI, 0.97–1.03).
The shows the lag time from the date of discharge to the patient’s first follow-up visit with his or her PCP or pulmonologist. Of those seen, 75.2% were seen within 15 days of discharge.
Cumulative percentage of patients who had a follow-up visit with their primary care physician or pulmonologist from the day of discharge from a hospitalization for chronic obstructive pulmonary disease. Patients were censored at death (n=1419).
Patients who had a follow-up visit with their PCP or pulmonologist after discharge had fewer ER visits and lower readmission rates. The 30-day rates of postdischarge ER visits in patients with follow-up to their PCP or pulmonologist was 21.7% compared with 26.3% in those with no postdischarge follow-up (P < .001). Similarly, 30-day readmission rates were 18.9% and 21.4% for patients with and without a follow-up visit with their PCP or pulmonologist, respectively (P< .001). Of the 11 558 readmissions within 30 days, the top 3 reasons for readmission were COPD (24.1%), pneumonia or respiratory infection (12.9%), and heart failure (7.8%).
In a time-dependent analysis, controlling for patient-and hospital-level characteristics and excluding patients (n=1817) who died within 30 days of discharge, patients seen by their PCP or pulmonologist had lower 30-day adjusted rates of ER visits (HR, 0.86; 95% CI, 0.83–0.90] and readmission (HR, 0.91; 95% CI, 0.87–0.96) compared with those not seen by their PCP or pulmonologist (). The magnitude of the results did not change when we included patients who died within 30 days of discharge or restricted outcomes to hospitalization for pulmonary conditions or urgent or emergent admissions. Factors associated with increased 30-day risk of an ER visit or readmissions were length of initial hospitalization (>7 days), comorbidities, prior hospitalization for COPD, male sex, low SES, ICU stay, admission from the ER, and weekend hospital admission.
Hazard of ER Visit and Hospital Readmission 30 Days After Discharge in Patients With and Without a Follow-up Visit With Their PCP or a Pulmonologist