Early readmissions to the department of medicine as a screening tool for monitoring quality of care problems.
With growing awareness of medical fallibility, researchers need to develop tools to identify and study medical mistakes. We examined the utility of hospital readmissions for this purpose in a prospective case-control study in a large academic medical center in Israel. All patients with nonelective readmissions to 2 departments of medicine within 30 days of discharge were interviewed, and their medical records were carefully examined with emphasis on the index admission. Patient data were compared to data for age- and sex-matched controls (n = 140) who were not readmitted. Medical records of readmitted and control patients were blindly evaluated by 2 senior clinicians who independently identified potential quality of care (QOC) problems during the index admission. Inhospital and late mortality was determined 6 months after discharge.Over a period of 3 months there were 1988 urgent admissions; 1913 discharges and subsequently 271 unplanned readmissions occurred (14.1% of discharges). Readmissions occurred an average of 10 days after discharge, and readmitted patients were sicker than controls (mean, 4.3 vs. 3.3 diagnoses per patient), although their length of stay was similarly short (3.4 +/- 2.8 d). Analysis of all readmissions revealed QOC problems in 90/271 (33%) of readmissions, 4.5% of hospitalizations. All were deemed preventable. Interobserver agreement was good (83%, kappa = 0.67). Among matched controls, only 8/140 admissions revealed QOC problems (6%, p < 0.001) (k = 0.77). The preventable readmissions mostly involved a vascular event or congestive heart failure; they occurred within a mean of 10 +/- 8 days of the index admission, and their inpatient mortality was 6.7% vs. 1.7% among readmissions that had no QOC problems (odds ratio, 4.1; 95% confidence interval, 1.0-16.7). The main pitfalls identified during the index admission included incomplete workup (33%), too short hospital stay (31%), inappropriate medication (44%), diagnostic error (16%), and disregarding a significant laboratory result (12%). In many patients more than 1 pitfall was identified (mean, 1.5 per patient). Risk factors for preventable readmission include older age and living in an institution (p < 0.05). Almost two-thirds of the readmitted patients with QOC problems were discharged after spending 2 days or fewer at the hospital. In conclusion, unplanned readmissions within 30 days of discharge are frequent, more prevalent in sicker patients, and possibly associated with increased mortality. In a third of readmitted patients a QOC problem can be identified, and these problems are preventable. Thus, readmission may be used as a screening tool for potential QOC problems in the department of medicine. Routine monitoring of all readmissions may provide a simple cost-effective means of identifying and addressing medical mistakes.
Balla
Uri
U
From Department of Medicine, Kaplan Medical Centre, Rehovot; Hebrew University Hadassah Medical School, Jerusalem, Israel.
Malnick
Stephen
S
Schattner
Ami
A
D000368:Aged; D016022:Case-Control Studies; D005260:Female; D006801:Humans; D007557:Israel; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D008403:Mass Screening / Q000706:statistics & numerical data*; D010351:Patient Discharge / Q000706:statistics & numerical data; D010359:Patient Readmission / Q000706:statistics & numerical data*; D011446:Prospective Studies; D011787:Quality of Health Care / Q000706:statistics & numerical data*; D016037:Single-Blind Method; D013997:Time Factors
Ashton CM, Kuykendall DH, Johnson ML, Wray NP, Wu L. The association between the quality of inpatient care and early readmission. Ann Intern Med. 1995;122:415-421.
Ashton CM, Del Junco DJ, Souchek J, Wray NP, Manssyur CL. The association between the quality of inpatient care and early readmission: a meta-analysis of the evidence. Med Care. 1997;35:1044-1059.
Auerbach AD, Wachter RM, Katz P, Showstack J, Baron RB, Goldman L. Implementation of a voluntary hospitalist service at a community teaching hospital: improved clinical efficiency and patient outcomes. Ann Intern Med. 2002;137:859-865.
Beck CA, Richard H, Tu JV, Pilote L. Administrative data feedback for effective cardiac treatment. AFFECT, a cluster randomized trial. JAMA. 2005;294:309-317.
Benbassat J, Taragin M. Hospital readmissions as a measure of quality of health care. advantages and limitations. Arch Intern Med. 2000;160:1074-1081.
Burns R, Nichols LO. Factors predicting readmission of older general medicine patients. J Gen Intern Med. 1991;6:389-393.
Clark A. Are readmissions avoidable? BMJ. 1990;301:1136-1138.
Corrigan JM, Martin JB. Identification of factors associated with hospital readmission and development of a predictive model. Health Serv Res. 1992;27:82-101.
Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW. The incidence and severity of adverse events affecting patients after discharge from the hospital. Ann Intern Med. 2003;138:161-167.
Frankl SE, Breeling JL, Goldman L. Preventability of emergent hospital readmission. Am J Med. 1991;90:667-674.
Gautam P, Macduff C, Brown I, Squair J. Unplanned readmissions of elderly patients. Health Bull (Edinb). 1996;54:449-457.
Gregory D, Baigelman W, Wilson IB. Hospital economics of the hospitalist. Health Serv Res. 2003;38:905-918.
Halfon P, Eggli Y, van Melle G, Chevalier J, Wasserfallen J-B, Burnard B. Measuring potentially avoidable hospital readmissions. J Clin Epidemiol. 2002;55:573-587.
Halfon P, Eggli Y, Pretre-Rohrbach I, Meylan D, Marazzi A, Burnand B. Validation of the potentially avoidable hospital readmission rate as a routine indicator of the quality of hospital care. Med Care. 2006;44:972-981.
Hayward RA, Bernard AM, Rosevear JS, Anderson JE, McMahon LF Jr. An evaluation of generic screens for poor quality of hospital care on a general medical service. Med Care. 1993;31:394-402.
Heggerstadt T. Do hospital length of stay and staffing ratio affect elderly patients' risk of readmission? A nation-wide study of Norwegian hospitals? Health Serv Res. 2002;37:647-665.
Iezzoni LI, Mackiernan YD, Cahalane MJ, Phillips RS, Davis RB, Miller K. Screening inpatient quality using post-discharge events. Med Care. 1999;37:384-398.
Jimenez-Puente A, Garcia-Alegria J, Gomez-Aracena J, Hidalgo-Rojas I, Lorenzo-Nogueiras L, Perea-Milla-Lopez E, Fernandez-Crehuet-Navajas J. Readmission rate as an indicator of hospital performance: the case of Spain. Int J Technol Assess Health Care. 2004;20:385-391.
Kossovsky MP, Perneger TV, Sarasin FP, Bolla F, Borst F, Gaspoz J. Comparison between planned and unplanned readmissions to a department of internal medicine. J Clin Epidemiol. 1999;52:151-156.
Kossovsky MP, Sarasin FP, Perneger TV, Chopard PP, Sigaud P, Gaspoz J-M. Unplanned readmissions of patients with congestive heart failure: do they reflect in-hospital quality of care or patient characteristics. Am J Med. 2000;109:386-390.
Leape LL. Error in medicine? JAMA. 1994;272:1851-1857.
Leng GC, Walsh D, Fowkes FG, Swainson CP. Is the emergency readmission rate a valid outcome indicator. Qual Health Care. 1999;8:234-238.
Marcantonio ER, McKeans S, Goldfinger M, Kleefield S, Yurksofsky M, Brennan TA. Factors associated with unplanned hospital readmission among patients 65 years of age and older in a Medicare managed care plan. Am J Med. 1999;107:13-17.
Maurer PP, Ballmer PE. Hospital readmissions-are they predictable and avoidable? Swiss Med Wkly. 2004;134:606-611.
Palmer HC, Armistead NS, Elnicki DM, Halperin AK, Ogershok PR, Manivannan S, Hobbs GR, Evans K. The effect of hospitalist service with nurse discharge planner on patient care in an academic teaching hospital. Am J Med. 2001;111:627-632.
Phillips RS, Safran C, Cleary PD, Delbanco TL. Predicting emergency readmissions for patients discharged from medical service of a teaching hospital. J Gen Intern Med. 1987;2:400-405.
Pierluissi E, Fischer MA, Campbell AR, Landefeld CS. Discussion of medical errors in morbidity and mortality conferences. JAMA. 2003;290:2838-2842.
Schattner A, Gilad A. Primary care physician's awareness and implementation of colorectal cancer prevention guidelines. Prev Med. 2002;35:447-452.
Schattner A, Fletcher RH. Pearls and pitfalls in patient care: need to revive traditional clinical values. Am J Med Sci. 2004;372:79-85.
Thomas DR, Brahan R, Haywood BP. Inpatient community-based geriatric assessment reduces subsequent mortality. J Am Geriatr Soc. 1993;41:101-104.
Tsuchihashi M, Tsutsui H, Kodama K, Kasagi F, Setoguchi S, Mohr M, Kubota T, Takeshita A. Medical and socioenvironmental predictors of hospital readmission in patients with congestive heart failure. Am Heart J. 2001;142(4):E7.
Weinberger M, Oddone EZ, Henderson WG. Does increased access to primary care reduce hospital readmissions? Veterans Affairs Cooperative Study Group on Primary Care and Hospital Readmission. N Engl J Med. 1996;334:1441-1447.
Westert GP, Lagoe RJ, Keskimaki I, Leyland A, Murphy M. An international study of hospital readmissions and related utilization in Europe and the USA. Health Policy. 2002;61:269-278.