title: Preventable readmissions to surgical services: lessons learned and targets for improvement.
abstract: BACKGROUND
  Hospital readmissions are under intense scrutiny as a measure of health care quality. The Center for Medicare and Medicaid Services (CMS) has proposed using readmission rates as a benchmark for improving care, including targeting them as nonreimbursable events. Our study aim was to describe potentially preventable readmissions after surgery and to identify targets for improvement.
  
  
  METHODS
  Patients discharged from a general surgery service over 8 consecutive quarters (Q4 2009 to Q3 2011) were selected. A working group of attending surgeons defined terms and created classification schemes. Thirty-day readmissions were identified and reviewed by a 2-physician team. Readmissions were categorized as preventable or unpreventable, and by target for future quality improvement intervention.
  
  
  RESULTS
  Overall readmission rate was 8.3% (315 of 3,789). The most common indication for initial admission was elective general surgery. Among readmitted patients in our sample, 28% did not undergo an operation during their index admission. Only 21% (55 of 258) of readmissions were likely preventable based on medical record review. Of the preventable readmissions, 38% of patients were discharged within 24 hours and 60% within 48 hours. Dehydration occurred more frequently among preventable readmissions (p < 0.001). Infection accounted for more than one-third of all readmissions. Among preventable readmissions, targets for improvement included closer follow-up after discharge (49%), management in the outpatient setting (42%), and avoidance of premature discharge (9%).
  
  
  CONCLUSIONS
  A minority of readmissions may potentially be preventable. Targets for reducing readmissions include addressing the clinical issues of infection and dehydration as well as improving discharge planning to limit both early and short readmissions. Policies aimed at penalizing reimbursements based on readmission rates should use clinical data to focus on inappropriate hospitalization in order to promote high quality patient care.
authors.affiliation: Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA; Robert Wood Johnson Clinical Scholars Program, University of California, Los Angeles, CA; VA Greater Los Angeles Healthcare System, Los Angeles, CA. Electronic address: adawes@mednet.ucla.edu.
authors.forename: Aaron J
authors.initials: AJ
authors.lastname: Dawes
authors.affiliation: Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA; Robert Wood Johnson Clinical Scholars Program, University of California, Los Angeles, CA.
authors.forename: Greg D
authors.initials: GD
authors.lastname: Sacks
authors.affiliation: Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA; VA Greater Los Angeles Healthcare System, Los Angeles, CA.
authors.forename: Marcia M
authors.initials: MM
authors.lastname: Russell
authors.affiliation: Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA.
authors.forename: Anne Y
authors.initials: AY
authors.lastname: Lin
authors.affiliation: Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA; VA Greater Los Angeles Healthcare System, Los Angeles, CA.
authors.forename: Melinda
authors.initials: M
authors.lastname: Maggard-Gibbons
authors.affiliation: Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA.
authors.forename: Deborah
authors.initials: D
authors.lastname: Winograd
authors.affiliation: Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA.
authors.forename: Hallie R
authors.initials: HR
authors.lastname: Chung
authors.affiliation: Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA.
authors.forename: Areti
authors.initials: A
authors.lastname: Tillou
authors.affiliation: Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA.
authors.forename: Jonathan R
authors.initials: JR
authors.lastname: Hiatt
authors.affiliation: Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA; VA Greater Los Angeles Healthcare System, Los Angeles, CA.
authors.forename: Clifford
authors.initials: C
authors.lastname: Ko
mesh_terms: D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010359:Patient Readmission / Q000706:statistics & numerical data*; D011183:Postoperative Complications / Q000453:epidemiology / Q000517:prevention & control*; D012189:Retrospective Studies; D013503:Surgery Department, Hospital