IHE Journal Watch: Contributing Factors to Readmissions

Objectives

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

Methods

An observational study of 1,000 general medicine patients readmitted within 30 days of discharge to 12 U.S. academic medical centers between April 1, 2012, and March 31, 2013. Researchers surveyed patients and physicians, reviewed documentation, and performed two-physician case review to determine preventability of and factors contributing to readmission.

Results

The study cohort comprised 1,000 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, failure to relay important information to outpatient healthcare professionals, discharge of patients too soon and lack of discussions about care goals among patients with serious illnesses. The most common factors associated with potentially preventable readmissions included emergency department decision making (affecting 9.0%), inability to keep appointments after discharge (8.3%), premature discharge from the hospital (8.7%) and patient lack of awareness of whom to contact after discharge (6.2%).

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 healthcare teams and between healthcare professionals and patients, greater attention to patients’ readiness for discharge, enhanced disease monitoring and better support for patient self-management.

Discussion

Reducing penalties for readmissions continues to be a major focus for hospitals. CMS currently penalizes hospitals for all-cause readmissions for patients discharged from inpatient stays with diagnoses of myocardial infarction, CHF, pneumonia, COPD and hip and knee surgery. Starting in 2017, CMS is adding the DRG of coronary artery bypass graft to this list. Because the baseline for measurement is the national readmission rate for all reporting hospitals, if a hospital does not reduce its readmission rate as fast as (or preferably faster than) the national average, it runs the risk of increasing penalties.

Hospitals have made strides in improving care transitions, but few programs have incorporated viewpoints of patients and healthcare professionals to determine readmission preventability or prioritize opportunities for care improvement.

A major finding of the study is that 31% of readmissions could have been avoided if emergency departments had not admitted patients who did not need to be in the hospital. Other factors that played a role among the preventable readmissions included inability of patients to keep follow-up appointments, not knowing whom to contact if problems arose after they left the hospital, discharging patients too soon, and insufficient disease monitoring, such as blood draws and kidney function tests, postdischarge. 

Journal Source: Auerbach AD, Kripalani S, et al. Preventability and Causes of Readmissions in a National Cohort of General Medicine Patients. JAMA Intern Med, 2016 Mar 7; https://archinte.jamanetwork.com/article.aspx?articleid=2498846.

Matt Zavadsky, MS-HSA, EMT, is the public affairs director at MedStar Mobile Healthcare.