title: Preventability and Causes of Readmissions in a National Cohort of General Medicine Patients.
abstract: OBJECTIVE
  Readmission penalties have catalyzed efforts to improve care transitions, but few programs have incorporated viewpoints of patients and health care professionals to determine readmission preventability or to prioritize opportunities for care improvement.
  
  
  OBJECTIVE
  To determine preventability of readmissions and to use these estimates to prioritize areas for improvement.
  
  
  METHODS
  An observational study was conducted of 1000 general medicine patients readmitted within 30 days of discharge to 12 US academic medical centers between April 1, 2012, and March 31, 2013. We surveyed patients and physicians, reviewed documentation, and performed 2-physician case review to determine preventability of and factors contributing to readmission. We used bivariable statistics to compare preventable and nonpreventable readmissions, multivariable models to identify factors associated with potential preventability, and baseline risk factor prevalence and adjusted odds ratios (aORs) to determine the proportion of readmissions affected by individual risk factors.
  
  
  METHODS
  Likelihood that a readmission could have been prevented.
  
  
  RESULTS
  The study cohort comprised 1000 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 (aOR, 9.13; 95% CI, 5.23-15.95), failure to relay important information to outpatient health care professionals (aOR, 4.19; 95% CI, 2.17-8.09), discharge of patients too soon (aOR, 3.88; 95% CI, 2.44-6.17), and lack of discussions about care goals among patients with serious illnesses (aOR, 3.84; 95% CI, 1.39-10.64). The most common factors associated with potentially preventable readmissions included emergency department decision making (affecting 9.0%; 95% CI, 7.1%-10.3%), inability to keep appointments after discharge (affecting 8.3%; 95% CI, 4.1%-12.0%), premature discharge from the hospital (affecting 8.7%; 95% CI, 5.8%-11.3%), and patient lack of awareness of whom to contact after discharge (affecting 6.2%; 95% CI, 3.5%-8.7%).
  
  
  CONCLUSIONS
  Approximately one-quarter of readmissions are potentially preventable when assessed using multiple perspectives. High-priority areas for improvement efforts include improved communication among health care teams and between health care professionals and patients, greater attention to patients' readiness for discharge, enhanced disease monitoring, and better support for patient self-management.
authors.affiliation: Division of Hospital Medicine, Department of Medicine, University of California, San Francisco.
authors.forename: Andrew D
authors.initials: AD
authors.lastname: Auerbach
authors.affiliation: Section of Hospital Medicine at Vanderbilt, Department of Medicine, Vanderbilt University, Nashville, Tennessee3Center for Clinical Quality and Implementation Research, Vanderbilt University, Nashville, Tennessee.
authors.forename: Sunil
authors.initials: S
authors.lastname: Kripalani
authors.affiliation: Section of Hospital Medicine at Vanderbilt, Department of Medicine, Vanderbilt University, Nashville, Tennessee3Center for Clinical Quality and Implementation Research, Vanderbilt University, Nashville, Tennessee.
authors.forename: Eduard E
authors.initials: EE
authors.lastname: Vasilevskis
authors.affiliation: Division of Hospital Medicine, Department of Medicine, University of California, San Francisco.
authors.forename: Neil
authors.initials: N
authors.lastname: Sehgal
authors.affiliation: Center for Quality of Care Research, Baystate Medical Center, Department of Medicine, Tufts University School of Medicine, Boston, Massachusetts.
authors.forename: Peter K
authors.initials: PK
authors.lastname: Lindenauer
authors.affiliation: Division of General Internal Medicine, Massachusetts General Hospital, Boston.
authors.forename: Joshua P
authors.initials: JP
authors.lastname: Metlay
authors.affiliation: Division of General Internal Medicine, Harborview Medical Center, Seattle, Washington.
authors.forename: Grant
authors.initials: G
authors.lastname: Fletcher
authors.affiliation: Section of Hospital Medicine, Department of Medicine, The University of Chicago, Chicago, Illinois.
authors.forename: Gregory W
authors.initials: GW
authors.lastname: Ruhnke
authors.affiliation: Department of Internal Medicine, University of Michigan, Ann Arbor.
authors.forename: Scott A
authors.initials: SA
authors.lastname: Flanders
authors.affiliation: Department of Internal Medicine, University of Michigan, Ann Arbor.
authors.forename: Christopher
authors.initials: C
authors.lastname: Kim
authors.affiliation: Center for Health Services Research, University of Kentucky College of Medicine, Louisville.
authors.forename: Mark V
authors.initials: MV
authors.lastname: Williams
authors.affiliation: Division of General Internal Medicine, San Francisco General Hospital, San Francisco, California.
authors.forename: Larissa
authors.initials: L
authors.lastname: Thomas
authors.affiliation: Department of Medicine, California Pacific Medical Center, San Francisco.
authors.forename: Vernon
authors.initials: V
authors.lastname: Giang
authors.affiliation: Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, Boston, Massachusetts.
authors.forename: Shoshana J
authors.initials: SJ
authors.lastname: Herzig
authors.affiliation: Division of Geriatrics, Department of Medicine, University of California, San Francisco.
authors.forename: Kanan
authors.initials: K
authors.lastname: Patel
authors.affiliation: Department of Medicine, University of California, San Francisco15Department of Epidemiology and Biostatistics, University of California, San Francisco.
authors.forename: W John
authors.initials: WJ
authors.lastname: Boscardin
authors.affiliation: Value Institute and Department of Medicine, Christiana Care Health System, Wilmington, Delaware.
authors.forename: Edmondo J
authors.initials: EJ
authors.lastname: Robinson
authors.affiliation: Hospital Medicine Service, Division of General Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
authors.forename: Jeffrey L
authors.initials: JL
authors.lastname: Schnipper
mesh_terms: D000046:Academic Medical Centers; D000328:Adult; D000368:Aged; D000553:Ambulatory Care / Q000706:statistics & numerical data*; D015331:Cohort Studies; D003657:Decision Making; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D008297:Male; D059065:Medication Reconciliation / Q000706:statistics & numerical data*; D008875:Middle Aged; D015999:Multivariate Analysis; D016017:Odds Ratio; D010351:Patient Discharge / Q000706:statistics & numerical data*; D062209:Patient Handoff / Q000706:statistics & numerical data*; D010359:Patient Readmission / Q000706:statistics & numerical data*; D012307:Risk Factors; D014481:United States