title: Pathways to potentially preventable hospitalizations for diabetes and heart failure: a qualitative analysis of patient perspectives.
abstract: Potentially preventable hospitalizations (PPH) for heart failure (HF) and diabetes mellitus (DM) cost the United States over $14 billion annually. Studies about PPH typically lack patient perspectives, especially across diverse racial/ethnic groups with known PPH health disparities.
  
  
  
  English-speaking individuals with a HF or DM-related PPH (n = 90) at the largest hospital in Hawai'i completed an in-person interview, including open-ended questions on precipitating factors to their PPH. Using the framework approach, two independent coders identified patient-reported factors and pathways to their PPH.
  
  
  
  Seventy-two percent of respondents were under 65 years, 30 % were female, 90 % had health insurance, and 66 % had previously been hospitalized for the same problem. Patients' stories identified immediate, precipitating, and underlying reasons for the admission. Underlying background factors were critical to understanding why patients had the acute problems necessitating their hospitalizations. Six, non-exclusive, underlying factors included: extreme social vulnerability (e.g., homeless, poverty, no social support, reported by 54 % of respondents); health system interaction issues (e.g., poor communication with providers, 44 %); limited health-related knowledge (42 %); behavioral health issues (e.g., substance abuse, mental illness, 36 %); denial of illness (27 %); and practical problems (e.g., too busy, 6 %). From these findings, we developed a model to understand an individual's pathways to a PPH through immediate, precipitating, and underlying factors, which could help identify potential intervention foci. We demonstrate the model's utility using five examples.
  
  
  
  In a young, predominately insured population, factors well outside the traditional purview of the hospital, or even clinical medicine, critically influenced many PPH. Patient perspectives were vital to understanding this issue. Innovative partnerships and policies should address these issues, including linkages to social services and behavioral health.
authors.affiliation: Office of Public Health Studies, University of Hawai'i at Manoa, 1960 East-West Road, Biomed, Honolulu, HI, 96821, USA. tsentell@hawaii.edu.
authors.forename: Tetine L
authors.initials: TL
authors.lastname: Sentell
authors.affiliation: Queens Medical Center, 1301 Punchbowl Street, Honolulu, HI, 96813, USA.
authors.forename: Todd B
authors.initials: TB
authors.lastname: Seto
authors.affiliation: , 1301 Punchbowl Street, Honolulu, HI, 96813, USA.
authors.forename: Malia M
authors.initials: MM
authors.lastname: Young
authors.affiliation: , 1301 Punchbowl Street, Honolulu, HI, 96813, USA.
authors.forename: May
authors.initials: M
authors.lastname: Vawer
authors.affiliation: Office of Public Health Studies, University of Hawai'i at Manoa, 1960 East-West Road, Biomed, Honolulu, HI, 96821, USA.
authors.forename: Michelle L
authors.initials: ML
authors.lastname: Quensell
authors.affiliation: Office of Public Health Studies, University of Hawai'i at Manoa, 1960 East-West Road, Biomed, Honolulu, HI, 96821, USA.
authors.forename: Kathryn L
authors.initials: KL
authors.lastname: Braun
authors.affiliation: Daniel K. Inouye College of Pharmacy, University of Hawai'i at Hilo, 677 Ala Moana Boulevard, Suite 1025, Honolulu, HI, 96813, USA.
authors.forename: Deborah A
authors.initials: DA
authors.lastname: Taira
mesh_terms: D000328:Adult; D000368:Aged; D001208:Asia / Q000208:ethnology; D019091:Critical Pathways; D003920:Diabetes Mellitus / Q000208:ethnology / Q000628:therapy*; D005260:Female; D006254:Hawaii / Q000208:ethnology; D054625:Healthcare Disparities / Q000706:statistics & numerical data; D006333:Heart Failure / Q000208:ethnology / Q000628:therapy*; D006801:Humans; D008297:Male; D001523:Mental Disorders / Q000208:ethnology / Q000628:therapy; D008875:Middle Aged; D044468:Native Hawaiian or Pacific Islander / Q000208:ethnology; D036301:Qualitative Research; D019564:Unnecessary Procedures / Q000706:statistics & numerical data
keywords: Asians; Diabetes; Heart Failure; Hospitalization; Pacific Islanders; Readmissions