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Poor communication, premature discharge linked to re-hospitalization

March 07, 2016

By Megan Brooks

NEW YORK (Reuters Health) - About a quarter of hospital readmissions are preventable, and about half of preventable readmissions are due to factors that occur after discharge, a new study shows.

"It's easy to complain about this, with (readmission) penalties only going to hospitals, but we can also be pragmatic," lead author Dr. Andrew Auerbach of the Division of Hospital Medicine, University of California, San Francisco, told Reuters Health by email. "Hospitals need to work with outpatient providers to improve communication and jointly come up with comprehensive programs to keep patients safe after discharge. This requires investment, but it's a better alternative than paying penalties."

The Affordable Care Act required the Department of Health and Human Services to establish a program to reduce what has been dubbed a "revolving door of rehospitalizations," Dr. Auerbach explained. Beginning in October 2012, 1% of every Medicare payment was deducted for a hospital that was determined to have excessive readmissions. This percentage has subsequently increased to up to 3%. Penalties apply to readmitted Medicare patients with some heart conditions, pneumonia, chronic lung disease, and hip and knee replacements.

"Unfortunately, few data exist to guide us in determining how many readmissions are preventable, and in those cases how they might have been prevented," he said.

As reported online March 7 in JAMA Internal Medicine, the study team reviewed 1000 readmissions occurring within 30 days of discharge from general medical services at 12 academic medical centers. Of these, 269 (27%) were considered potentially preventable.

In multivariable models, factors most strongly associated with potentially preventable readmissions included decisions made in the emergency department (ED) regarding the readmission, failure to relay key information to outpatient providers, discharge of patients too soon, and lack of discussions about care goals among patients with serious illnesses, with adjusted odds ratios of 9.13, 4.19, 3.88 and 3.84, respectively.

The most common factors associated with potentially preventable readmissions included ED decision making (9%), inability to keep appointments after discharge (8.3%), premature hospital discharge (8.7%) and the patient not knowing who to contact after discharge (6.2%).

Dr. Auerbach told Reuters Health, "We were most surprised by our finding that premature discharge from the hospital was a large contributor to readmission preventability. We have always been concerned that efforts to reduce length of stay might have had this effect, and most studies of reducing length of stay have not shown an increase in readmissions. Our study adds nuance to our understanding of the relationship between length of stay and readmission."

"We were also surprised by the large role which improving communication and confirmation of care plans between patients, acute care, and longitudinal care providers might provide in reducing readmissions. These efforts should focus on understanding whether a patient is truly able to care for himself after discharge, whether the care offered is consistent with his wishes, and on developing systems which can keep patients out of the hospital yet able to access certain aspects of hospital care (such as a blood transfusion, or intravenous fluids)," Dr. Auerbach added.

"The problems contributing to readmissions and care coordination gaps are complex and numerous," he noted, "but our research gives researchers a prioritized list of potential targets to study. Particularly, ways to ensure patients are not discharged too soon, and ways to create 'ideal' systems which can more effectively provide acute care services in ways that are useful and aligned with patients' needs."

The authors of an invited commentary say this study is "an important contribution to our understanding" of preventing readmissions.

"Over the last decade, reducing readmissions has been viewed as a goal in its own right, and our concerted efforts have yielded modest progress toward that goal. On the other hand, debate has grown over the value of readmissions as a measure of hospital quality because of the low rates of preventable readmissions, mixed success of interventions, problems with measurement, possible adverse effects on safety net hospitals, and questionable relationships between readmission rates and other measures of quality," write Dr. David Atkins of the Department of Veterans Affairs, Washington, DC, and Dr. Devan Kansagara of the VA Portland Healthcare System in Oregon.

In their view, "the real value in paying attention to readmissions is that it forces us to explore the interstitial spaces of our health care system - those areas where supporting structures need to be strengthened. Real improvement will not come from adding one new check box to the discharge form. Improvement requires creative ways to enable the complex array of professionals and caregivers involved in the care of very sick patients to work as a team across boundaries created by professional roles, geography, and time. The goal of reducing unnecessary hospitalization continues to beckon on the horizon, but we should not lose sight of the journey itself, which is just beginning and represents the real prize," conclude Dr. Atkins and Dr. Kansagara.

In a related study in JAMA Internal Medicine today, researchers report that the HOSPITAL score identified patients at high risk of a potentially avoidable readmission within 30 days of discharge with "moderately high discrimination and excellent calibration" when applied to more than 117,000 medical patients discharged by nine large hospitals across four different countries.

The HOSPITAL score includes the following predictors at discharge: hemoglobin, discharge from an oncology service, sodium level, procedure during the index admission, index type of admission (urgent), number of admissions during the last 12 months, and length of stay.

"This score has the potential to easily identify patients in need of more intensive transitional care interventions to prevent avoidable hospital readmissions," Dr. Jacques Donze from Bern University, Switzerland, and colleagues conclude in their paper.

Neither study had commercial funding.

SOURCE:, and

JAMA Intern Med 2016.

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