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Original Investigation |

Preventability and Causes of Readmissions in a National Cohort of General Medicine Patients

Andrew D. Auerbach, MD, MPH1; Sunil Kripalani, MD, MSc2,3; Eduard E. Vasilevskis, MD, MPH2,3; Neil Sehgal, PhD, MPH1; Peter K. Lindenauer, MD, MSc4; Joshua P. Metlay, MD, PhD5; Grant Fletcher, MD6; Gregory W. Ruhnke, MD, MS, MPH7; Scott A. Flanders, MD8; Christopher Kim, MD8; Mark V. Williams, MD9; Larissa Thomas, MD10; Vernon Giang, MD11; Shoshana J. Herzig, MD, MPH12; Kanan Patel, MBBS, MPH13; W. John Boscardin, PhD14,15; Edmondo J. Robinson, MD, MBA, MS16; Jeffrey L. Schnipper, MD, MPH17
[+] Author Affiliations
1Division of Hospital Medicine, Department of Medicine, University of California, San Francisco
2Section of Hospital Medicine at Vanderbilt, Department of Medicine, Vanderbilt University, Nashville, Tennessee
3Center for Clinical Quality and Implementation Research, Vanderbilt University, Nashville, Tennessee
4Center for Quality of Care Research, Baystate Medical Center, Department of Medicine, Tufts University School of Medicine, Boston, Massachusetts
5Division of General Internal Medicine, Massachusetts General Hospital, Boston
6Division of General Internal Medicine, Harborview Medical Center, Seattle, Washington
7Section of Hospital Medicine, Department of Medicine, The University of Chicago, Chicago, Illinois
8Department of Internal Medicine, University of Michigan, Ann Arbor
9Center for Health Services Research, University of Kentucky College of Medicine, Louisville
10Division of General Internal Medicine, San Francisco General Hospital, San Francisco, California
11Department of Medicine, California Pacific Medical Center, San Francisco
12Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, Boston, Massachusetts
13Division of Geriatrics, Department of Medicine, University of California, San Francisco
14Department of Medicine, University of California, San Francisco
15Department of Epidemiology and Biostatistics, University of California, San Francisco
16Value Institute and Department of Medicine, Christiana Care Health System, Wilmington, Delaware
17Hospital Medicine Service, Division of General Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
JAMA Intern Med. 2016;176(4):484-493. doi:10.1001/jamainternmed.2015.7863.
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Importance  Readmission penalties have catalyzed efforts to improve care transitions, but few programs have incorporated viewpoints of patients and health care professionals to determine readmission preventability or to prioritize opportunities for care improvement.

Objectives  To determine preventability of readmissions and to use these estimates to prioritize areas for improvement.

Design, Setting, and Participants  An observational study was conducted of 1000 general medicine patients readmitted within 30 days of discharge to 12 US academic medical centers between April 1, 2012, and March 31, 2013. We surveyed patients and physicians, reviewed documentation, and performed 2-physician case review to determine preventability of and factors contributing to readmission. We used bivariable statistics to compare preventable and nonpreventable readmissions, multivariable models to identify factors associated with potential preventability, and baseline risk factor prevalence and adjusted odds ratios (aORs) to determine the proportion of readmissions affected by individual risk factors.

Main Outcome and Measure  Likelihood that a readmission could have been prevented.

Results  The study cohort comprised 1000 patients (median age was 55 years). Of these, 269 (26.9%) were considered potentially preventable. In multivariable models, factors most strongly associated with potential preventability included emergency department decision making regarding the readmission (aOR, 9.13; 95% CI, 5.23-15.95), failure to relay important information to outpatient health care professionals (aOR, 4.19; 95% CI, 2.17-8.09), discharge of patients too soon (aOR, 3.88; 95% CI, 2.44-6.17), and lack of discussions about care goals among patients with serious illnesses (aOR, 3.84; 95% CI, 1.39-10.64). The most common factors associated with potentially preventable readmissions included emergency department decision making (affecting 9.0%; 95% CI, 7.1%-10.3%), inability to keep appointments after discharge (affecting 8.3%; 95% CI, 4.1%-12.0%), premature discharge from the hospital (affecting 8.7%; 95% CI, 5.8%-11.3%), and patient lack of awareness of whom to contact after discharge (affecting 6.2%; 95% CI, 3.5%-8.7%).

Conclusions and Relevance  Approximately one-quarter of readmissions are potentially preventable when assessed using multiple perspectives. High-priority areas for improvement efforts include improved communication among health care teams and between health care professionals and patients, greater attention to patients’ readiness for discharge, enhanced disease monitoring, and better support for patient self-management.

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