Randomised controlled trial of supported discharge in patients with exacerbations of chronic obstructive pulmonary disease

Background-A randomised trial was performed on patients presenting to hospi tal with an exacerbation of chronic obstructive pulmonary disease (COPD) to compare outcomes in those managed at home with support with those admitted to hospital in the standard manner. Methods-Over an 18 month period all patients presenting to the Royal Infirm ary of Edinburgh on weekdays (n=718) with a diagnosis of an exacerbation of COPD were assessed for inclusion in the trial. Patients with impaired leve l of consciousness, acute confusion, acute changes on radiography, or an ar terial pH of <7.35 or with other serious medical or social for admission we re excluded. Patients randomised to home support were discharged with an ap propriate treatment package (antibiotics, corticosteroids, nebulised bronch odilators and, if necessary, home oxygen). They were visited by a nurse the following day and thereafter at intervals of 2-3 days until recovery when they were discharged from follow up. Parallel observations were made on pat ients allocated to normal hospital admission up to the point of discharge, Patients in both groups were assessed at home eight weeks after the initial assessment. Results-Among weekday patients 353 (50%) were considered obligatory admissi ons, 140 (19%) were admitted because of co-morbidity, 17 (2%) because of po or social circumstances, and 24 (3%) did not consent to the trial. The rema ining 184 (26%) were randomised (2:1) either to home support or to a standa rd hospital admission. The median time to discharge was 7 days for the home support group and 5 days for the admitted group (p<0.01); 25% of the home support group and 34% of the admitted group were readmitted before the fina l assessment at eight weeks (p>0.05). There were no significant differences between the groups in attendances by GPs and carers or in health status me asured eight weeks after the initial assessment. Satisfaction with the serv ice was good. The mean total health service cost per patient was estimated as pound 877 for the home support group and pound 1753 for the admitted gro up. Conclusions-This study shows that home supported discharge is a well tolera ted, safe, and economic alternative to hospital admission for a proportion of patients referred to hospital for admission for an exacerbation of COPD.