Classifying general medicine readmissions. Are they preventable? Veterans Affairs Cooperative Studies in Health Services Group on Primary Care and Hospital Readmissions.
OBJECTIVE
To describe a new quality assessment method used to classify the preventability of hospitalization in terms of patient, clinician, or system factors.


METHODS
The instrument was developed in two phases. Phase 1 was a prospective comparison of admitting residents' and their attending physicians' classifications of the perceived preventability of consecutive admissions to one Veterans Affairs Medical Center (VAMC) excluding admissions to the intensive care unit (ICU). In phase 2, a panel of 10 physicians rated 811 abstracted records of readmissions from nine VAMCs.


METHODS
Nine VAMCs across the United States with varying degrees of university hospital affiliation.


METHODS
Phase 1, 156 patients admitted to the general medicine service at the Durham VAMC. Phase 2, 514 patients accounting for 811 readmissions within 6 months of a general medicine service discharge at nine VAMCs.


RESULTS
Physicians used a checklist to record the reason for hospitalization, the preventability of the hospitalization, and, if preventable, a reason defining preventability, which was classified in terms of system, clinician, and patient factors. In phase 2, two physician panelists assessed preventability for each chart. When two panelists disagreed on the preventability of hospitalization, a third panelist, blind to the original assessments, rated the chart. In phase 1, residents and attending physicians rated 33% and 34% of admissions as preventable (kappa = 0.41), respectively. In phase 2, 277 (34%) of 811 readmissions were deemed preventable. Intraobserver accuracy for the assessment of preventability was 96% (kappa = 0.89). interobserver accuracy was 73% (kappa = 0.43). Hospital system factors accounted for 37% of preventable readmissions, clinician factors for 38%, and patient factors for 21%. The nine hospitals differed markedly in their profile of reasons for preventable readmissions (p = .005).


CONCLUSIONS
Using a new method of determining the preventability of hospitalizations, we identified several factors that might avert hospitalizations. Focusing efforts to identify preventable hospitalizations may yield better methods for managing patients' total health care needs; however, the content of those efforts will vary by institution.
Oddone
E Z
EZ
Center for Health Services Research in Primary Care, Veterans Affairs Medical Center, Durham, NC 27705, USA.
Weinberger
M
M
Horner
M
M
Mengel
C
C
Goldstein
F
F
Ginier
P
P
Smith
D
D
Huey
J
J
Farber
N J
NJ
Asch
D A
DA
Loo
L
L
Mack
E
E
Hurder
A G
AG
Henderson
W
W
Feussner
J R
JR
D000328:Adult; D000368:Aged; D002983:Clinical Competence; D003625:Data Collection; D005260:Female; D006757:Hospital Units; D006787:Hospitals, Veterans; D006801:Humans; D007388:Internal Medicine; D008297:Male; D008875:Middle Aged; D015588:Observer Variation; D010359:Patient Readmission / Q000639:trends; D010865:Pilot Projects; D011446:Prospective Studies; D011787:Quality of Health Care / Q000639:trends