More than 25 percent of hospital readmissions may be preventable

More than one-quarter of hospital readmissions were considered potentially preventable, according to an observational study of 1,000 general medicine patients readmitted within 30 days of discharge to 12 U.S. academic medical centers.

Physician adjudicators categorized readmissions as preventable if they rated the likelihood of preventability as 50 percent or more.

Lead researcher Andrew D. Auerbach, MD, MPH, of the University of California, San Francisco, and colleagues published their results online in JAMA Internal Medicine on March 7.

They evaluated 1,000 patients who were part of the Hospital Medicine Reengineering Network of hospital medicine investigators at 12 academic medical centers. They were all 18 years or older, spoke English as their primary language and were readmitted within 30 days of discharge between April 1, 2012 and March 31, 2013. The median age of patients was 55 years old.

The researchers collected data from interviews with patients, reviews of inpatient and outpatient medical records and surveys from patients’ physicians. Trained research assistants conducted interviews with patients about their perceptions of care during their previous hospital admission and their experiences since discharge.

The researchers then sent emails or faxed up to five surveys to each patient’s primary care physician, physician from the index hospital admission and the current attending physician. Research assistants followed with a structured medical record review, collected information regarding patients’ comorbidities and medications and recorded medical record-based measures of care transition processes.

To determine preventability, the researchers used a scale that had been used previously when assessing care transitions. At each site, two physician adjudicators reviewed available information for each case and developed initial assessments and worked together to make a final decision. Physician leads at each site resolved challenging cases.

Of the patients, 26.9 percent had a potentially preventable readmission. Further, of the preventable readmissions, 52.0 percent were potentially preventable with efforts made during the index admission.

Patients with and without preventable readmissions had similar inpatient care processes and their ability to manage care after discharge. However, the researchers noted that patients who reported problems with drugs or alcohol were less likely to have their readmission considered preventable. In addition, patients who could not reach their physicians after discharge were more likely to have a preventable readmission.

Multivariable models found the following four factors were most strongly associated with potentially preventable readmissions: premature discharge from the index hospitalization; failure to relay important information to outpatient healthcare professionals; lack of discussions about care goals among patients with serious illnesses; and emergency department decision making to admit a patient who may not have required an inpatient stay.

The following factors were also associated with potentially preventable readmissions: emergency department decision making; inability to keep appointments after discharge; premature dis- charge from the hospital and patient lack of awareness of whom to contact after discharge.

The results were similar when the researchers performed multivariable models that excluded data from sites with fewer than 50 patients and when they excluded sites whose aggregate estimates of preventability were in the top or lower two of sites.

The analysis had a few limitations, according to the researchers, including that the case review process featured a subjective view to determine preventability of readmissions. They also did not retain patient factors in their final models. Further, most patients were from large academic medical centers, which could limit the generalizability of the findings.

“Because our study cannot ascribe causality to the factors we have identified, our results cannot support the conclusion that eliminating the factors we identified will surely reduce readmissions,” they wrote. “The answer to that question will require further studies. Our study formulates a potential approach for prioritizing local efforts, as well as monitoring the effectiveness of programs in place. Finally, our results suggest a potential approach to focus interventions in ways that span the continuum of care, prioritize efforts to prepare patients more effectively for discharge, and provide better ability for patients, caregivers, and healthcare professionals to support patients and improve outcomes during the period after hospitalization.”