Gaps in the care of patients admitted to hospital with an exacerbation of chronic obstructive pulmonary disease

Background: Patients admitted to hospital because of an exacerbation of chronic obstructive pulmonary disease (COPD) are at high risk of adverse events. We evaluated the association between gaps in care and adverse events during the hospital stay and after discharge. Methods: We retrospectively reviewed the charts of 105 consecutive patients discharged from hospial between Jan. 1 and Dec. 31, 2001, with a diagnosis of COPD exacerbation. On the basis of published guidelines, prior studies and discussions with colleagues, we defined a care gap as having occurred if any of 9 important inpatient and 7 discharge-related processes of care did not take place correctly. Inpatient adverse events included worsening of condition after admission, transfer to a higher level of care, cardiac arrest and death. Discharge related adverse events were defined as including readmission to the hospital, revisit to the emergency department or death within 30 days after discharge. Results: Of the 105 patients studied, 88 (84%) had at least 1 inpatient gap in care and 16 (15%) an inpatient adverse event; 2 of the 16 died. Patients who had an inpatient adverse event had more gaps in their care (2.0 v. 1.3 gaps, p = 0.004) and longer stays (16.4 v. 8.6 days, p = 0.007). There were 6 adverse events (frequency 38%) among the 16 patients with 3 or more gaps in their care, 6 adverse events (28%) among the 21 patients with 2 gaps, 1 adverse event (2%) among the 51 patients with 1 gap and 3 adverse events (18%) among the 17 patients with no gaps in their care (p = 0.001 for trend). Of the 103 patients discharged alive, 102 (99%) had at least 1 gap in discharge-related care, but we found no association between these gaps and adverse events within 30 days after discharge. Interpretation: Gaps in the inpatient care of patients with COPD exacerbation were common and were associated with inpatient adverse events. Gaps in discharge-related care were also common but were not associated with postdischarge adverse events.