Effect of post-discharge transitional care in patients with COPD: a multicenter single-blind randomised controlled trial

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Abstract
Chronic obstructive pulmonary disease (COPD) significantly impairs patient quality of life and places a substantial burden on healthcare systems. However, the effectiveness of transitional care in reducing healthcare utilisation and improving symptom control remains uncertain. This study aimed to evaluate the effectiveness of an evidence-informed transitional care program for hospitalised patients with COPD. In this randomised controlled trial, 465 hospitalised patients with COPD from three South Korean university hospitals were block-randomised to intervention and control groups based on severity of airflow limitation (FEV1). The intervention involved a personalised care plan, including comprehensive assessment, patient education and training, telephone consultations, linkage to community services, home visits, and multidisciplinary case conferences. Participants were followed for 3 months after hospital discharge. Outcomes were analysed using an intention-to-treat approach. The primary outcome measures were readmission, respiratory symptoms, and treatment adherence. Mixed-effects models were used for repeated measures, and regression models were adjusted for baseline covariates. At 3 months post-discharge, all-cause readmission was numerically lower in the intervention group than in the control group, but the difference was not statistically significant (adjusted OR 0.84; 95% CI 0.48-1.47). In exploratory cause-specific analyses, COPD-related readmissions were numerically fewer in the TCG than in the UCG (2 vs. 9 patients), although the small event counts limit interpretation. The intervention group showed significantly greater improvement in respiratory symptoms compared with the control group (modified Medical Research Council scale scores: adjusted mean difference - 0.41, p < 0.001; chronic obstructive pulmonary disease assessment test scores: - 3.38, p < 0.001). Treatment adherence also improved in the intervention group at 1 month, although this difference was not statistically significant at 3 months. Post-discharge transitional care may improve short-term symptom control and early inhaler adherence in patients with COPD, while its effect on readmission remains uncertain and warrants evaluation in adequately powered studies with longer follow-up. Clinical Research Information Service (CRIS), No. KCT0007937, registered 24 November 2022-retrospectively registered.
Funding Information
  • Ministry of Health and Welfare, Republic of Korea (RS-2021-KH120369; RS-2025-02304587)

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