Understanding Why Patients With COPD Get Readmitted

A Large National Study to Delineate the Medicare Population for the Readmissions Penalty Expansion


      The Hospital Readmissions Reduction Program (HRRP) penalizes hospitals for 30-day readmissions and was extended to COPD in October 2014. There is limited evidence available on readmission risk factors and reasons for readmission to guide hospitals in initiating programs to reduce COPD readmissions.


      Medicare claims data from 2006 to 2010 in seven states were analyzed, with an index admission for COPD defined by discharge International Classification of Diseases, Ninth Revision, codes as stipulated in the HRRP guidelines. Rates of index COPD admission and readmission, patient demographics, readmission diagnoses, and use of post-acute care (PAC) were investigated.


      Over the study period, there were 26,798,404 inpatient admissions, of which 3.5% were index COPD admissions. At 30 days, 20.2% were readmitted to the hospital. Respiratory-related diseases accounted for only one-half of the reasons for readmission, and COPD was the most common diagnosis, explaining 27.6% of all readmissions. Patients discharged home without home care were more likely to be readmitted for COPD than patients discharged to PAC (31.1% vs 18.8%, P < .001). Readmitted beneficiaries were more likely to be dually enrolled in Medicare and Medicaid (30.6% vs 25.4%, P < .001), have a longer median length of stay (5 days vs 4 days, P < .0001), and have more comorbidities ( P < .001).


      Medicare patients with COPD exacerbations are usually not readmitted for COPD, and these reasons differ depending on PAC use. Readmitted patients are more likely to be dually enrolled in Medicare and Medicaid, suggesting that the addition of COPD to the readmissions penalty may further worsen the disproportionately high penalties seen in safety net hospitals.


      AECOPD ( acute exacerbation of COPD), AMI ( acute myocardial infarction), CCS ( Clinical Classifications Software), CHF ( congestive heart failure), CMS ( Centers for Medicare & Medicaid Services), HRRP ( Hospital Readmissions Reduction Program), ICD-9 ( International Classification of Diseases, Ninth Revision), IPPS ( inpatient prospective payment system), LOS ( length of stay), PAC ( post-acute care), SNF ( skilled nursing facility)
      To read this article in full you will need to make a payment
      Subscribe to CHEST
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


      1. (Centers for Medicare & Medicaid Services website Accessed October 4, 2014 International Union Against Cancer)
        • Grosso L
        • Lundenaur PK
        • Wang C
        • et al.
        Hospital-Level 30-Day Readmission Following Admission for an Acute Exacerbation of Chronic Obstructive Pulmonary Disease. Yale-New Haven Health Services Corporation/Center for Outcomes Research and Evaluation, New Haven, CT2011
        • Blum J
        Delivery System Reform: Progress Report from CMS. Hearing Before the Committee on Finance United States Senate. Centers for Medicare & Medicaid Services, Washington, DC2013: 1-16
        • Ross JS
        • Mulvey GK
        • Stauffer B
        • et al.
        Statistical models and patient predictors of readmission for heart failure: a systematic review.
        Arch Intern Med. 2008; 168: 1371-1386
        • Prieto-Centurion V
        • Markos MA
        • Ramey NI
        • et al.
        Interventions to reduce rehospitalizations after chronic obstructive pulmonary disease exacerbations. A systematic review.
        Ann Am Thorac Soc. 2014; 11: 417-424
        • Newhouse JP
        • Garber AM
        Geographic variation in health care spending in the United States: insights from an Institute of Medicine report.
        JAMA. 2013; 310: 1227-1228
      2. COPD Management in the Long-Term Care Setting. American Medical Directors Association, Columbia, MD2010 (International Union Against Cancer)
        • Charlson ME
        • Pompei P
        • Ales KL
        • MacKenzie CR
        A new method of classifying prognostic comorbidity in longitudinal studies: development and validation.
        J Chronic Dis. 1987; 40: 373-383
      3. (Clinical Classifications Software (CCS) for ICD-9-CM. Healthcare Cost and Utilization Project website Accessed January 10, 2014)
      4. (The Medicare Payment Advisory Commission website Published 2013. Accessed October 4, 2014 International Union Against Cancer)
      5. (Medicare Payment Advisory Commission; Medicaid and CHIP Payment and Access Commission Medicare Payment Advisory Committee website Data Book: Beneficiaries Dually Eligible for Medicare and Medicaid, 2013 Accessed March 15, 2014)
        • Jencks SF
        • Williams MV
        • Coleman EA
        Rehospitalizations among patients in the Medicare fee-for-service program.
        N Engl J Med. 2009; 360: 1418-1428
        • Dharmarajan K
        • Hsieh AF
        • Lin Z
        • et al.
        Diagnoses and timing of 30-day readmissions after hospitalization for heart failure, acute myocardial infarction, or pneumonia.
        JAMA. 2013; 309: 355-363
        • Hansen LO
        • Greenwald JL
        • Budnitz T
        • et al.
        Project BOOST: effectiveness of a multihospital effort to reduce rehospitalization.
        J Hosp Med. 2013; 8: 421-427
        • Coleman EA
        • Parry C
        • Chalmers S
        • Min SJ
        The care transitions intervention: results of a randomized controlled trial.
        Arch Intern Med. 2006; 166: 1822-1828
        • Voss R
        • Gardner R
        • Baier R
        • Butterfield K
        • Lehrman S
        • Gravenstein S
        The care transitions intervention: translating from efficacy to effectiveness.
        Arch Intern Med. 2011; 171: 1232-1237
        • Stein BD
        • Bautista A
        • Schumock GT
        • et al.
        The validity of International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes for identifying patients hospitalized for COPD exacerbations.
        Chest. 2012; 141: 87-93
        • Skull SA
        • Andrews RM
        • Byrnes GB
        • et al.
        ICD-10 codes are a valid tool for identification of pneumonia in hospitalized patients aged ≥ 65 years.
        Epidemiol Infect. 2008; 136: 232-240
        • Kiyota Y
        • Schneeweiss S
        • Glynn RJ
        • Cannuscio CC
        • Avorn J
        • Solomon DH
        Accuracy of Medicare claims-based diagnosis of acute myocardial infarction: estimating positive predictive value on the basis of review of hospital records.
        Am Heart J. 2004; 148: 99-104
        • Wedzicha JA
        • Seemungal TA
        COPD exacerbations: defining their cause and prevention.
        Lancet. 2007; 370: 786-796
        • Antman E
        • Bassand JP
        • Klein W
        • et al.
        Myocardial infarction redefined—a consensus document of The Joint European Society of Cardiology/American College of Cardiology Committee for the redefinition of myocardial infarction.
        J Am Coll Cardiol. 2000; 36 (The Joint European Society of Cardiology/American College of Cardiology Committee): 959-969
        • Silver MA
        • Maisel A
        • Yancy CW
        • et al.
        BNP Consensus Panel 2004: a clinical approach for the diagnostic, prognostic, screening, treatment monitoring, and therapeutic roles of natriuretic peptides in cardiovascular diseases.
        Congest Heart Fail. 2004; 10 (BNP Consensus Panel): 1-30
        • Januzzi JL
        • van Kimmenade R
        • Lainchbury J
        • et al.
        NT-proBNP testing for diagnosis and short-term prognosis in acute destabilized heart failure: an international pooled analysis of 1256 patients: the International Collaborative of NT-proBNP Study.
        Eur Heart J. 2006; 27: 330-337
        • Volkova NB
        • Kodani A
        • Hilario D
        • Munyaradzi SM
        • Peterson MW
        Spirometry utilization after hospitalization for patients with chronic obstructive pulmonary disease exacerbations.
        Am J Med Qual. 2009; 24: 61-66
        • Han MK
        • Kim MG
        • Mardon R
        • et al.
        Spirometry utilization for COPD: how do we measure up?.
        Chest. 2007; 132: 403-409
        • Seemungal TA
        • Donaldson GC
        • Bhowmik A
        • Jeffries DJ
        • Wedzicha JA
        Time course and recovery of exacerbations in patients with chronic obstructive pulmonary disease.
        Am J Respir Crit Care Med. 2000; 161: 1608-1613
        • Hurst JR
        • Vestbo J
        • Anzueto A
        • et al.
        Susceptibility to exacerbation in chronic obstructive pulmonary disease.
        N Engl J Med. 2010; 363 (Evaluation of COPD Longitudinally to Identify Predictive Surrogate Endpoints (ECLIPSE) Investigators): 1128-1138
        • Berenson J
        • Shih A
        Higher readmissions at safety-net hospitals and potential policy solutions.
        Issue Brief (Commonw Fund). 2012; 34: 1-16
        • Joynt KE
        • Jha AK
        Characteristics of hospitals receiving penalties under the Hospital Readmissions Reduction Program.
        JAMA. 2013; 309: 342-343
        • Press VG
        • Arora VM
        • Shah LM
        • et al.
        Misuse of respiratory inhalers in hospitalized patients with asthma or COPD [published correction appears in J Gen Intern Med. 2011;26(4):458].
        J Gen Intern Med. 2011; 26: 635-642
        • Konetzka RT
        • Brauner DJ
        • Shega J
        • Werner RM
        The effects of public reporting on physical restraints and antipsychotic use in nursing home residents with severe cognitive impairment.
        J Am Geriatr Soc. 2014; 62: 454-461
        • Drye E
        • Lindenaurer PK
        • Wang C
        • et al.
        2013 Measure Updates and Specifications Report: Hospital-Level 30-day Readmission Following Admission for an Acute Exacerbation of Chronic Obstructive Pulmonary Disease (Version 2.0). Yale-New Haven Health Services Corporation/Center of Outcomes Research and Evaluation, New Haven, CT2013