FIG: 7: Once a patient is discharged following hospitalization for an acute exacerbation of COPD, what are risk factors for readmission?  This question was investigated about 8 years ago by Jencks et al[6] for different medical illnesses in the Medicare population.  They found that, overall, Medicare recipients who were hospitalized and then needed to be readmitted tended to be suffering from poorly-coordinated transition of care.  These patients had poor knowledge of their disease, they had gaps in their medical regimen, they were unaware of earlier signs of disease worsening, and they had poor use of evidence-based medicine.  They were also less likely to have a hospital outpatient evaluation within 30 days of discharge (shown on the right side of this Figure), with less than half or three-quarters of them having an office visit to review their care by their community physician within 30 days of discharge from the hospital. 

This poor coordination of care could have caused by lack of a system-based planned outpatient visit after they were discharged from the hospital to make sure they were on the proper medications, or at least responding to the medications that were given to them at hospital discharge.