FROM JAMA INTERNAL MEDICINE
About one-quarter of hospital readmissions are potentially avoidable, new research indicates.
Further, gaps in care during the initial inpatient stay appear to account for half of those preventable readmissions, Dr. Andrew Auerbach, professor of medicine at the University of California, San Francisco, and his colleagues said in a research report published online March 7 in JAMA Internal Medicine.
In a second study, researchers found that a seven-factor HOSPITAL score identified patients at high risk for a potentially avoidable readmission.
The findings bring new evidence to the issues of whether, and how many readmissions are preventable.
Dr. Auerbach reported the results of an observational study of 1,000 general medicine patients readmitted within 30 days of discharge to 12 academic medical centers that make up the Hospital Medicine Reengineering Network ( HOMERuN ) during April 1, 2012, and March 31, 2013.
The researchers found that 26.9% (269 of 1,000) of readmissions “were considered potentially preventable, with half of these readmissions thought to represent gaps in care during the initial inpatient stay,” the researchers wrote.
Preventable readmissions were based on case reviews by at least two physicians who were extensively trained in the review process and had access to completed patient interviews, physician surveys, data derived from abstracted medical records, and the complete medical record. Each site had a pool of 3-10 physician adjudicators coordinated by a physician lead, who oversaw the process and resolved difficult cases.
Four factors were found to be “strongly associated” with potentially preventable readmissions: premature discharge during initial stay, failure to send information to the outpatient care team, lack of discussion about care goals with patients with serious illness, and emergency department decisions to admit patients who may not have required a return inpatient stay.
The researchers noted that readmissions related to gaps in care may not necessarily be a problem with emergency medicine per se, but something more broadly problematic (JAMA Intern Med. doi:10.1001/jamainternmed.2015.7863).
“Overcoming gaps in care in the attempt to avoid potentially unnecessary admissions from the emergency department may need to involve improved communications among primary care health professionals, hospital-based physicians, and emergency medicine physicians about criteria for admission and resources available in the community, in addition to providing greater access to urgent care for patients who would otherwise seek care in an emergency department and improving patients’ understanding of how and when to seek emergency care,” the authors wrote.
In a second study published the same day in JAMA Internal Medicine (2016 Mar 7. doi: 10.1001/jamainternmed.2015.8462 ), Dr. Jacques Donzé of the Bern University Hospital in Switzerland, and his colleagues in the United States, Canada, Israel, and Switzerland, found the HOSPITAL score “had good discriminative ability and excellent calibration for predicting the risk of 30-day potentially avoidable readmission.”
HOSPITAL scores seven factors to predict readmission risk, which include the following:
• Hemoglobin level at discharge.
• Discharge from an Oncology unit.
• Sodium level at discharge.
• Procedure conducted during stay.
• Index admission Type: urgent or emergent (nonelective).
• Number of hospital Admissions in the previous year.
• Length of stay.
The research looked at 121,136 adults discharged from nine large hospitals across four countries in 2011. Within 30 days after discharge, 15% (17,516) of patients were readmitted and 9.7% (11,307) had a potentially avoidable readmission. The HOSPITAL score had a C statistic of 0.72 for predicting potentially avoidable readmissions and identified the 14% of patients whose scores indicated that they were at high risk for a potentially avoidable readmission.
“The HOSPITAL score is the first risk prediction score to focus on potentially avoidable readmissions as opposed to all-cause readmissions, using readily available predictors at the time of discharge,” the authors wrote. “This score has the potential to reliably identify patients in need of more intensive transitional care interventions to prevent hospital readmissions.”
