When do patients with chronic obstructive lung disease need hospital admission? Reflections based on a VA experience

Over a two-year period, the management of patients with chronic obstructive lung disease was observed in the walk-in clinic of a Veterans Administration Medical Center. Of 794 visits, 279 (35%) resulted in immediate hospitalization. Of 515 patients sent home, 229 (44%) relapsed, and of these, 165 (72%) eventually required admission. The clinical and laboratory data routinely obtained, including arterial blood gas values in 69% of the visits, could not distinguish the inappropriate discharges unless acidosis or severe hypoxemia was present. About 10% of the patients accounted for 30% of the admissions. Severity of disease, especially the development of cor pulmonale, accounted only partially for high demand by a subset of patients. Psychosocial factors and inadequacy of facilities for continuing home care play an essential, though poorly defined, role in precipitating hospital admissions.