OBJECTIVES: To evaluate the impact of the use of guideline recommended care on the risk of subsequent moderate to severe COPD exacerbation requiring hospitalization or emergency department (ED) visit following discharge from COPD in a privately insured population in Texas METHODS: Retrospective population-based cohort study design using Blue Cross Blue Shield of Texas (BCBSTX) enrollment and claims data (years 2008 to 2011) was employed. All COPD-related hospitalizations and ED visits were extracted. Patients were identified as adherence to guideline recommended care if within 30 days of discharge, had at least one claim of prescription fills for any maintenance medications and had at least one follow up visit with a primary care physician or pulmonologist. The presence of a subsequent COPD-related exacerbation requiring hospitalization or an ED visit was assessed for one year post-discharge and compared between cohorts who receive and did not receive guideline recommended care using a probit regression model with instrumental variables. RESULTS: One-fourth (29%) of the patients with COPD-related hospitalizations/ED visits were identified as recipients of the guideline recommended care. Receiving guideline recommended care was associated with a reduction of 4.4 percentage points in the probability of having subsequent COPD exacerbation requiring hospital admission/ED visits (p-value = 0.837). Analysis focusing on the follow up visit alone shows that having follow up visits were significantly associated (p-value = 0.018) with a reduction in the probability (32.8 percentage points) of having subsequent COPD exacerbation requiring hospital admission/ED visits, while the use of maintenance medication was associated with an increase in the probability (19.5 percentage points) of having subsequent COPD exacerbation requiring hospital admission/ED visits (p-value = 0.337). CONCLUSIONS: The use of guideline recommended care, especially in the use of follow up care, was significantly associated with the reduction in the probability of having subsequent COPD exacerbation requiring hospital admission/ED.