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Federal law permits physicians to 'opt out' of Medicare. When a radiation oncologist chooses this option, he or she may neither bill nor collect from Medicare, but may legally attempt to charge and collect what he or she considers the value of services provided to Medicare-eligible patients. Many academic faculty practice plans permit members to opt out. Even if it is permissible for a radiation oncologist to opt out of Medicare, is it appropriate? The question raises significant ethical and economic issues as one attempts to balance the good of the individual faculty member against the good of the clinical faculty as a whole. In this commentary, the authors offer the principal arguments in favor of and against permitting a faculty radiation oncologist to opt out. They conclude by recommending broad faculty oversight over such decisions. [ABSTRACT FROM AUTHOR]

Objective: To examine the association between the use of right heart catheterization (RHC) during the first 24 hours of care in the intensive care unit (ICU) and subsequent survival, length of stay, intensity of care, and cost of care.Design: Prospective cohort study.Setting: Five US teaching hospitals between 1989 and 1994.Subjects: A total of 5735 critically ill adult patients receiving care in an ICU for 1 of 9 prespecified disease categories.Main Outcome Measures: Survival time, cost of care, intensity of care, and length of stay in the ICU and hospital, determined from the clinical record and from the National Death Index. A propensity score for RHC was constructed using multivariable logistic regression. Case-matching and multivariable regression modeling techniques were used to estimate the association of RHC with specific outcomes after adjusting for treatment selection using the propensity score. Sensitivity analysis was used to estimate the potential effect of an unidentified or missing covariate on the results.Results: By case-matching analysis, patients with RHC had an increased 30-day mortality (odds ratio, 1.24; 95% confidence interval, 1.03-1.49). The mean cost (25th, 50th, 75th percentiles) per hospital stay was $49 300 ($17 000, $30 500, $56 600) with RHC and $35 700 ($11 300, $20 600, $39 200) without RHC. Mean length of stay in the ICU was 14.8 (5, 9, 17) days with RHC and 13.0 (4, 7, 14) days without RHC. These findings were all confirmed by multivariable modeling techniques. Subgroup analysis did not reveal any patient group or site for which RHC was associated with improved outcomes. Patients with higher baseline probability of surviving 2 months had the highest relative risk of death following RHC. Sensitivity analysis suggested that a missing covariate would have to increase the risk of death 6-fold and the risk of RHC 6-fold for a true beneficial effect of RHC to be misrepresented as harmful.Conclusion: In this observational study of critically ill patients, after adjustment for treatment selection bias, RHC was associated with increased mortality and increased utilization of resources. The cause of this apparent lack of benefit is unclear. The results of this analysis should be confirmed in other observational studies. These findings justify reconsideration of a randomized controlled trial of RHC and may guide patient selection for such a study. [ABSTRACT FROM AUTHOR]

The Duke Institute for Health Innovation (DIHI) was launched in 2013. Frontline staff members submit proposals for innovation projects that align with strategic priorities set by organizational leadership. Funded projects receive operational and technical support from institute staff members and a transdisciplinary network of collaborators to develop and implement solutions as part of routine clinical care, ranging from machine learning algorithms to mobile applications. DIHI's operations are shaped by four guiding principles: build to show value, build to integrate, build to scale, and build responsibly. Between 2013 and 2021, more than 600 project proposals have been submitted to DIHI. More than 85 innovation projects, both through the application process and other strategic partnerships, have been supported and implemented. DIHI's funding has incubated 12 companies, engaged more than 300 faculty members, staff members, and students, and contributed to more than 50 peer-reviewed publications. DIHI's practices can serve as a model for other health systems to systematically source, develop, implement, and scale innovations., Competing Interests: M.P.S. and S.B. are co-inventors of software licensed from Duke University to Clinetic, Inc. M.P.S. and S.B. hold equity in Clinetic, Inc. M.P.S., W.R., and S.B. are co-inventors of software licensed from Duke University to Cohere Med, Inc., (© 2023 The Author(s).)

The rapidly changing field of medicine demands that future physician-leaders excel not only in clinical medicine but also in the management of complex health care enterprises. However, many physicians have become leaders "by accident," and the active cultivation of future leaders is required. Addressing this need will require multiple approaches, targeting trainees at various stages of their careers, such as degree-granting programs, residency and fellowship training, and career and leadership development programs. Here, the authors describe a first-of-its-kind graduate medical education pathway at Duke Medicine, the Management and Leadership Pathway for Residents (MLPR). This program was developed for residents with both a medical degree and management training. Created in 2009, with its first cohort enrolled in the summer of 2010, the MLPR is intended to help catalyze the emergence of a new generation of physician-leaders. The program will provide physicians-in-training with rigorous clinical exposure along with mentorship and rotational opportunities in management to accelerate the development of critical leadership and management skills in all facets of medicine, including care delivery, research, and education. To achieve this, the MLPR includes 15 to 18 months of project-based rotations under the guidance of senior leaders in many disciplines including finance, patient safety, health system operations, strategy, and others. Developing both clinical and management skill sets during graduate medical education holds the promise of engaging future leaders of health care at an early career stage, keeping more MD-MBA graduates within health care, and creating a bench of talented future physician-executives., (Copyright © by the Association of American medical Colleges.)

The aim of this study was to determine the effect of diet, energy balance and milk production on oxidative stress in early-lactating, Holstein-Friesian dairy cows fed to produce either low or high levels of milk. Indicators of energy balance (non-esterified fatty acids, β-hydroxybutyrate, glucose and insulin-like growth factor-1) and indicators of oxidative stress (reactive oxygen metabolites and biological antioxidants) were measured in the first 5 weeks of lactation. Energy balance indicators showed that high producing animals had a lower degree of negative energy balance. Diet was found to have an indirect effect on the level of oxidative stress. Factors associated with a high level of oxidative stress were severe negative energy balance (mean -71 ± 6.85 27 MJ/cow/day, P < 0.05) and lower levels of milk production (mean 26.4 ± 0.07 28 L/cow/day, P < 0 .05). Further studies will be required to more precisely determine the specific effects of diet, energy balance and milk production on such stress in dairy cows and to establish normal ranges for these biomarkers., (Copyright © 2009 Elsevier Ltd. All rights reserved.)

The purpose of this study was to test whether supplementation with K improves bone mineral density (BMD) in older cows so that by parturition their bone is better able to mobilize Ca. Twenty-four Holstein Friesian cows (6 mo pregnant, lactating, and in their third or later lactation) were allocated to 2 equal groups and individually fed twice daily a total diet comprising low K oaten hay plus a pelleted concentrate fortified with or without K(2)CO(3) to achieve 3.12% K/kg of DM in the total diet of the K-supplemented (KS) cows compared with 1.50% K/kg of DM for the control cows. The cows were fed their respective diets from the beginning of their sixth month of pregnancy until 2 wk before the expected date of parturition. The strategy was to use K to stimulate a mild increase in extracellular pH to potentially improve BMD well before parturition, when high K contents in the diet are considered safe, but cease supplementing in the few weeks prepartum, when high intakes of K are known to be problematic. The expectation was that the effect of the denser bone would carry through to benefit the cow's plasma Ca, P, and Mg status at parturition. Prior to the period of K supplementation, the cows were part of a commercial pasture-based herd, to which they were returned at the end of the supplementation period and treated as 1 group from at least 11 d prepartum until the end of the study at d 42 of the next lactation. Supplementation with K successfully induced a sustained increase of urinary pH throughout late lactation and into the dry period, as expected. The KS cows consistently averaged a urine pH 0.25+/-0.10 U higher than the controls. However, there was no significant effect of K supplementation on BMD, bone mineral concentrations, plasma osteocalcin, urinary deoxypyridinoline:creatinine plasma Ca, or plasma P concentrations during or immediately after the cessation of supplementation, nor where there any carryover effects during parturition or by d 42 of lactation. Instead, there was an unexpected decrease in the concentration of Mg in plasma of the KS cows compared with the control cows that extended from 0.5 to 2.5 d postpartum. The timing of the decline in plasma Mg was paralleled by declines in plasma concentrations of 1,25 dihydroxy-vitamin D(3) and urinary excretion of Ca and Mg, whereas urinary excretion of P increased; all changes were consistent with a hypomagnesemia that could increase the risk of hypocalcemia. These data suggest that, in addition to the well-documented negative effects of K when fed immediately at parturition, the effects of high dietary K diets can carry over for at least 11 d to trigger a mild hypomagnesemia at parturition. Because K supplementation did not improve BMD prepartum, it was not possible to conclude for or against an ability of denser bone to reduce the risk of hypocalcemia in older cows at parturition., (Copyright 2010 American Dairy Science Association. Published by Elsevier Inc. All rights reserved.)

This study investigated the energy balance, metabolic changes, reproduction, and health in Australian Holstein-Friesian cows of average genetic merit fed to produce 6,000 L of milk/cow per lactation (restricted production; Rp) on a predominantly grazed pasture diet, or 9,000 L of milk/cow per lactation (high production: Hp) on a more intensive feeding regimen by using a partial mixed ration to supplement pasture. The mean 4% fat-corrected milk (FCM) and standard deviation achieved was 8,466 +/- 1,162 L/cow per lactation for the Hp herd and 6,748 +/- 787 L/cow per lactation for the Rp herd. During early lactation, the degree of estimated negative energy balance was less in the Hp cows than in the Rp cows (-16.1 vs. -29.1 MJ/cow per day, respectively). Consequently, the mobilization of body reserves was also lower in the Hp cows, and this was reflected in lower concentrations of nonesterified fatty acids (0.70 vs. 0.84 mmol/L) and beta-hydroxybutyrate (0.51 vs. 0.69 mmol/L) and greater concentrations of glucose (3.51 vs. 3.34 mmol/L) and insulin-like growth factor-I (78.9 vs. 58.7 ng/mL) for Hp and Rp cows, respectively. After calving, body condition score and body weight decreased to a similar extent in both herds and did not reflect the differences in mobilization of body reserves between the 2 herds. Reproductive performance was not significantly related to level of milk yield. The mean interval from calving to first active corpus luteum was 33 (SD = 20) d postpartum, and there were 1.4 (SD = 0.8) estrus cycles before the beginning of the breeding period (>50 d postpartum). The interval from calving to pregnancy was 114 d, and the pregnancy rate after 12 wk of mating was 74%. The number of cows with ovarian abnormalities was also similar between the 2 herds. Cows with a long postpartum anestrus had the lowest concentration of insulin-like growth factor-I. The number of health-related disorders was also similar between the herds, with the exception of mastitis, for which the incidence was significantly greater in the Hp cows. The results indicate that the production per cow could be increased from 6,748 L of FCM/cow per lactation for cows grazing pasture and supplemented with concentrates only at milking to 8,466 L of FCM/ cow per lactation, in one lactation, by supplementing pasture with a partial mixed ration. Despite the fact that production per cow increased substantially, the degree of estimated negative energy balance and the metabolic changes in early lactation were lower and reproductive performance was maintained.

Economic viability of automatic milking systems (AMS) within an Australian pasture-based farming system will be largely determined by the throughput (cows milked/h), which is the result of processes occurring while the cow is in the AMS milking crate. Premilking udder preparation is automated and optional on all AMS. Yet, very few conventional farms in Australia conduct premilking teat preparation regimens, with the majority (78%) strategically washing only visibly dirty teats before milking cup attachment. The objective was to determine the impact of udder preparation in an AMS on the total time spent by cows in the AMS milking unit (crate time). An experiment was conducted with 80 lactating Holstein-Friesian cows in a crossover design over two 5-wk periods to determine the effect of premilking teat preparation (no wash vs. wash) on milk yield, milk harvest rates, and total crate time per milking session in an AMS. Within this study there was no significant effect of treatment on quarter milk conductivity (no wash = 4,858 vs. wash = 4,829 +/- SE = 17 microS/cm), milk blood concentration (no wash = 115.7 vs. wash = 112.3 +/- 7.3 ppm) or test-day somatic cell counts (no wash = 2.044 vs. wash = 2.039 +/- 0.025 log(10) SCC). There was similar total daily milk yield for the 2 treatments (no wash = 20.5 vs. wash = 20.1 +/- 0.2 kg of milk), but a greater mean quarter milk flow rate resulting from the wash treatment (no wash = 0.950 vs. wash = 0.981 +/- 0.013 kg of milk/min). The faster milking was not sufficient to counter the time associated with washing, resulting in longer crate time (no wash = 6.02 vs. wash = 7.12 +/- 0.08 min/milking session) and therefore, lower harvest rate (no wash = 2.08 vs. wash = 1.74 +/- 0.02 kg of milk/min crate time). Not washing teats would allow more efficient AMS utilization by potentially allowing more cows to be milked per machine, which would likely have a positive effect on the economic viability of this technology. The results indicate that a longer term study, investigating the effect of washing teats on udder health and milk quality, is warranted.

A 5 yr whole-system study, beginning in June 1994, compared the productivity of high [HGM; Australian Breeding Value (ABV) of 49.1 kg of fat plus protein] and low [LGM; ABV of 2.3 kg of fat plus protein] genetic merit cows. Cows from both groups were fed at 3 levels of concentrate (C): 0.34 (low C), 0.84 (medium C), and 1.71 (high C) t of DM/cow per lactation. Thus, there were 6 treatments (farmlets) composed of 18 cows each. The 30 blocks of pasture on each farmlet were matched between farmlets for pasture growth before the study (and soil characteristics and aspect). Cows were culled, and pasture and feed use were managed so as not to bias any one treatment. Genetic merit, level of feeding, and their interaction were significant effects for protein content, protein/cow, and milk and protein/ha. For fat and milk yield/cow, genetic merit and level of feeding were significant, whereas there was no significant effect of genetic merit on fat content. The difference of 46.8 kg of fat plus protein yield between the ABV of HGM and LGM cows and the actual difference in production between the 2 groups was not significantly different except for low C (27 kg) cows. This was due to a 3-fold lower protein yield difference (6 kg/cow) compared with an ABV difference for protein yield of 17.9 kg/cow. The dramatic effect of treatment on protein is in line with differences in the mean protein content (2.89% for the HGM - low C cows compared with a mean of 3.02% for the remaining groups) and mean body condition score [4.3 for HGM - low C cows compared with 4.8 for the mean of the remaining groups (scale 1 to 8)], both indicators reflecting a higher negative energy balance in the HGM - low C cows. When individual cow production was plotted against ABV for production of milk or protein yield all relationships were quadratic, but the slope was relatively flat (low response to ABV) for the low C cows, steeper for the medium C cows and steepest (but not linear) for the high C cows. The relationship between ABV for fat yield and actual fat yield was linear for all levels of concentrate. The mean milk yield/ha from pasture for the 6 farmlets over the 5 yr was 11,868 L, 11,417 L, or 7,761 L for the HGM cows fed at low C, medium C, or high C, respectively, and 10,579 L, 9,800 L, or 5,812 L for LGM cows, fed at low C, medium C, or high C, respectively. The response to concentrates fed was very high for the HGM - medium C cows at 0.115 kg fat plus protein or 1.75 L milk/kg of concentrate fed, with comparable figures of 0.083 kg and 1.0 L, 0.86 kg and 1.47 L and 0.066 and 0.92 L/kg of concentrate fed for the HGM - high C, LGM - medium C, and LGM - high C, respectively. The results show a significant genetic merit by environment (level of feeding) interaction for reproduction and most production parameters when considered in terms of the individual cow and the whole farm system.

This cross-sectional survey examined the prevalence of ruminal acidosis and the effects of acidosis on the production of dairy cattle. Eight fresh cows, 3 primiparous and 5 multiparous (< 100 d in milk), were selected randomly from each of 100 dairy herds in 5 regions of Australia. Rumen fluid was obtained from each cow by rumenocentesis and a stomach tube, and samples were tested for pH. Stomach tube rumen fluid samples were analyzed for volatile fatty acid, ammonia, and D-lactate concentrations. On the basis of the results of all assays, cows were categorized into 3 distinct categories (categories 1, 2, and 3) by cluster analysis. The percentages of cattle in categories 1, 2, and 3 were 10.2, 29.9, and 59.9%, respectively. Mean rumen pH for categories 1, 2, and 3 were 5.74 +/- 0.47, 6.18 +/- 0.44, and 6.33 +/- 0.43, respectively. Biochemically, categories 1, 2, and 3 were characterized, respectively, as follows: mean total VFA concentration (mM), 100.74 +/- 23.22, 94.79 +/- 18.13, and 62.81 +/- 15.65; mean ammonia concentration (mM), 2.46 +/- 2.02, 7.79 +/- 3.75, and 3.64 +/- 2.03; and mean D-lactate concentration (mM), 0.34 +/- 0.86, 0.28 +/- 0.97, and 0.12 +/- 0.51. Category 1 cows had higher propionate, valerate, isovalerate, and caproate concentrations and were of lower parity than cows in other categories. Cows in category 1 had higher milk production but lower milk fat content than category 2 cows. Herds were assigned to 1 of 3 groups according to the numbers of cows assigned to each category. Herds with > or = 3 of the 8 cows in category 1 were classified as acidotic. Herds with > or = 3 of the 8 cows in category 2 were classified as having suboptimal rumen function, and herds with > or = 3 of the 8 cows in category 3 were classified as normal. Herds that had 3 or more of the 8 cows in category 1 (acidotic herds) had diets with higher energy and nonfiber carbohydrate contents and a lower neutral detergent fiber content than herds with a high prevalence of category 2 or 3 cows. The lack of significance of a herd effect in the statistical models developed suggests that the categories were robust across production systems, in which diets varied from all pasture to total mixed rations. A point prevalence of 10% (95% credible interval, 8 to 12%) of cows with an acidotic profile indicates a high risk for acidosis in the cattle sampled. The higher nonfiber carbohydrate and lower neutral detergent fiber contents of diets for herds with a high prevalence of category 1 cows (acidotic herds) indicates that there may be opportunities to reduce the risk of acidosis by dietary manipulation.

Although several forage species such as perennial ryegrass are predominant, there is a wide range of forage species that could be grown in subtropical and temperate regions in Australia as dairy pastures. These species have differing seasonal patterns of growth, nutrient quality, and water-use efficiency, as demonstrated in a large experiment evaluating over 30 species at the University of Sydney (Camden, New South Wales, Australia). Some species can be grazed, whereas others require mechanical harvesting, which incurs a further cost. Previous comparisons of species that relied on yield of dry matter per unit of some input (typically land or water) did not simultaneously take into account the season in which forage is produced, or other factors related to the costs of production and delivery to the cows. To effectively compare the profitability of individual species, or combinations of species, requires the use of a whole-farm, multiperiod model. Linear programming was used to find the most profitable mix of forage species for an irrigated dairy farm in a warm temperate irrigation region of New South Wales, Australia. It was concluded that for a typical farmer facing the prevailing milk and purchased feed prices with average milk production per cow, the most profitable mix of species would include a large proportion of perennial ryegrass (Lolium perenne) and prairie grass (Bromus willdenowii). The result was robust to changes in seasonal milk pricing and a move from year-round to a more seasonal calving pattern.

This study was conducted to determine the effects of genetic merit for milk production and concentrate feeding on the intervals to the onset of postpartum cyclic ovarian activity, first insemination, and establishment of pregnancy. Other factors considered included biochemical measures of energy balance, liveweight, and measures of production. A farmlet study was conducted with two lines of cattle that differed in Australian Breeding Value by 735 L milk and 47 kg of fat plus protein that were fed 300 or 2000 kg of concentrate per cow per year in a subtropical grazing system based on ryegrass, clover, and kikuyu pasture. Milk yield was higher in cows fed 2000 kg of concentrate per cow per year (23.6 L/d) than those fed 300 kg/cow per year (18.2 L/d), and cows of medium genetic merit (19.6 L/d) produced less milk than those of high genetic merit (22.2 L/d). Plasma glucose concentration was lower in the cows of high genetic merit (3.11 mmol/L), than in the cows of medium genetic merit (3.39 mmol/L). The cumulative probabilities of ovulation, insemination, and establishment of pregnancy by any day postpartum were determined by a Weibull distribution. Medium genetic merit cows in winter were more likely to ovulate by any day postpartum than in summer and more likely than high genetic merit cows in either summer or winter. The cumulative probability of insemination was lower in primipara than multipara and in summer than in winter. Primiparous cattle had a lower cumulative probability of pregnancy by any day postpartum.

Objective: To determine if body mass Index (BMI = weight [kg]/height [m]2), predictive of mortality in longitudinal epidemiologic studies, was also predictive of mortality in a sample of seriously ill hospitalized subjects., Design: Prospective, multicenter study., Setting: Five tertiary care medical centers in the United States., Patients: Patients > or = 18 yrs of age who had one of nine illnesses of sufficient severity to anticipate a 6-month mortality rate of 50% were enrolled at five participating sites in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT)., Interventions: None., Measurements and Main Results: Patients were asked their current height and weight as part of the demographic data. Stratifying body mass index by percentile rank (< or = 15, 15 to 85, and > or = 85th percentiles), risk ratios for mortality were calculated by Cox Proportional Hazards using the 15th to 85th percentile of body mass index as the reference group while controlling for multiple variables such as prior weight loss, albumin, and Acute Physiology Score. A body mass index in the < or = 15th percentile was associated with an excess risk of mortality (risk ratio = 1.23; p < .001) within 6 months. High body mass index (> or = 85th percentile) was not significantly related to risk of mortality., Conclusions: Body mass index, a simple anthropometric measure of nutrition employed in community epidemiologic studies, has now been demonstrated to be a predictor of mortality in an acutely ill population of adults at five different tertiary centers. Even when controlling for multiple disease states and physiologic variables and removing from the analysis all patients with significant prior weight loss, a body mass index below the 15th percentile remained a significant and independent predictor of mortality. Examination of patient vs. proxy data did not change the results. Future studies examining variables predictive of mortality should include body mass index, even in acutely ill populations with a poor probability of survival.

Objective: To review the literature addressing the use of the pulmonary artery catheter (PAC) in patients with respiratory failure., Data Source: All pertinent English language articles dealing with pulmonary artery catheterization in patients with respiratory failure were retrieved from 1983 through 1996., Study Selection: Articles were chosen for review if the use of pulmonary artery catheterization in patients with respiratory failure was studied or reviewed., Data Extraction: From the articles selected, information was obtained about changes in therapy and changes in outcome associated with PAC use in patients with respiratory failure., Data Synthesis: Evidence exists to suggest that use of the PAC in patients with respiratory failure often results in a change in diagnosis and therapy. Inadequate evidence exists to accurately determine benefit or harm from PAC use in patients with respiratory failure., Conclusion: The optimal role of the PAC as a diagnostic and monitoring device in different types of respiratory failure has not been clearly defined. Research is needed to determine the role of the PAC in very carefully defined groups of patients with respiratory failure.

Objective: To evaluate whether the lack of effect of advance directives (ADs) on decision-making in SUPPORT might arise, in part, from the content of the actual documents., Design: Advance directives placed in the medical records were abstracted for date of completion and content of additional written instructions. We examined directives with instructions to forgo life-sustaining treatment in the current state of health to determine whether care given was consistent with preferences noted in those directives., Settings: Five teaching hospitals in the United States., Patients: A total of 4804 patients with at least one of nine serious illnesses were admitted to five teaching hospitals in the 2 years following implementation of the Patient Self-Determination Act. Patients were part of a randomized controlled trial to improve decision-making and outcomes., Results: From the medical records of 4804 patients, a total of 688 directives were collected from 569 patients. The majority of these directives (66%) were durable powers of attorney; in addition, 31% were standard living wills or other forms of written instructions (3%). Only 90 documents (13%) provided additional instructions for medical care beyond naming a proxy or stating the preferences of a standard living will. Only 36 contained specific instructions about the use of life-sustaining medical treatment, and only 22 of these directed forgoing life-sustaining treatment in the patient's current situation. For these, the treatment course was consistent with the instruction for nine patients. In two cases, patients may have changed an inconsistent directive after discussion with hospital staff., Conclusion: Advance directives placed in the medical records of seriously ill patients often did not guide medical decision-making beyond naming a healthcare proxy or documenting general preferences in a standard living will format. Even when specific instructions were present, care was potentially inconsistent in half of the cases.

In order to describe the outcomes of patients hospitalized with an acute exacerbation of severe chronic obstructive pulmonary disease (COPD) and determine the relationship between patient characteristics and length of survival, we studied a prospective cohort of 1,016 adult patients from five hospitals who were admitted with an exacerbation of COPD and a PaCO2 of 50 mm Hg or more. Patient characteristics and acute physiology were determined. Outcomes were evaluated over a 6 mo period. Although only 11% of the patients died during the index hospital stay, the 60-d, 180-d, 1-yr, and 2-yr mortality was high (20%, 33%, 43%, and 49%, respectively). The median cost of the index hospital stay was $7,100 ($4,100 to $16,000; interquartile range). The median length of the index hospital stay was 9 d (5 to 15 d). After discharge, 446 patients were readmitted 754 times in the next 6 mo. At 6 mo, only 26% of the cohort were both alive and able to report a good, very good, or excellent quality of life. Survival time was independently related to severity of illness, body mass index (BMI), age, prior functional status, PaO2/FI(O2), congestive heart failure, serum albumin, and the presence of cor pulmonale. Patients and caregivers should be aware of the likelihood of poor outcomes following hospitalization for exacerbation of COPD associated with hypercarbia.