Abstract
This article has been corrected. The original version (PDF) is appended to this article as a Supplement.
Background:
Many experts believe that hospitals with more frequent readmissions provide lower-quality care, but little is known about how the preventability of readmissions might change over the postdischarge time frame.
Objective:
To determine whether readmissions within 7 days of discharge differ from those between 8 and 30 days after discharge with respect to preventability.
Design:
Prospective cohort study.
Setting:
10 academic medical centers in the United States.
Patients:
822 adults readmitted to a general medicine service.
Measurements:
For each readmission, 2 site-specific physician adjudicators used a structured survey instrument to determine whether it was preventable and measured other characteristics.
Results:
Overall, 36.2% of early readmissions versus 23.0% of late readmissions were preventable (median risk difference, 13.0 percentage points [interquartile range, 5.5 to 26.4 percentage points]). Hospitals were identified as better locations for preventing early readmissions (47.2% vs. 25.5%; median risk difference, 22.8 percentage points [interquartile range, 17.9 to 31.8 percentage points]), whereas outpatient clinics (15.2% vs. 6.6%; median risk difference, 10.0 percentage points [interquartile range, 4.6 to 12.2 percentage points]) and home (19.4% vs. 14.0%; median risk difference, 5.6 percentage points [interquartile range, −6.1 to 17.1 percentage points]) were better for preventing late readmissions.
Limitation:
Physician adjudicators were not blinded to readmission timing, community hospitals were not included in the study, and readmissions to nonstudy hospitals were not included in the results.
Conclusion:
Early readmissions were more likely to be preventable and amenable to hospital-based interventions. Late readmissions were less likely to be preventable and were more amenable to ambulatory and home-based interventions.
Primary Funding Source:
Association of American Medical Colleges.
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Author, Article, and Disclosure Information
Kelly L. Graham,
Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts (K.L.G., R.B.D., J.Y., E.R.M., S.J.H.)
University of California, San Francisco, San Francisco, California (A.D.A.)
Harvard Medical School and Brigham and Women's Hospital, Boston, Massachusetts (J.L.S.)
University of Michigan Medical School, Ann Arbor, Michigan (S.A.F.)
University of Washington, Seattle, Washington (C.S.K.)
Value Institute, Christiana Care Health System, Wilmington, Delaware (E.J.R.)
University of Chicago, Chicago, Illinois (G.W.R.)
University of California, San Francisco, at Zuckerberg San Francisco General Hospital, San Francisco, California (L.R.T.)
Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, Nashville, Tennessee (S.K.)
Center for Quality Aging at Vanderbilt University Medical Center and VA Tennessee Valley Healthcare System Geriatric Research Education and Clinical Center, Nashville, Tennessee (E.E.V.)
Harborview Medical Center, University of Washington, Seattle, Washington (G.S.F.)
University of Maryland School of Public Health, College Park, Maryland (N.J.S.)
Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School–Baystate, Springfield, Massachusetts (P.K.L.)
Center for Health Services Research, University of Kentucky, Lexington, Kentucky (M.V.W.)
Massachusetts General Hospital, Boston, Massachusetts (J.P.M.)
Disclaimer: The content is solely the responsibility of the authors and does not necessarily represent the official views of any of the funding agencies. Dr. Graham had full access to all of the study data and takes responsibility for its integrity and the accuracy of the data analysis.
Financial Support: By an unrestricted research grant from the Association of American Medical Colleges. This work was done with support from Harvard Catalyst, The Harvard Clinical and Translational Science Center, through award UL1 TR001102 from the National Institutes of Health and financial contributions from Harvard University and its affiliated academic health care centers. Dr. Graham is funded by the Eleanor and Miles Shore 50th Anniversary Fellowship Program for Scholars in Medicine at Beth Israel Deaconess Medical Center and Harvard Medical School. Dr. Herzig is funded by grant K23AG042459 from the National Institute on Aging. Dr. Marcantonio was supported in part by grants R01AG030618 and K24AG035075 from the National Institute on Aging. Dr. Vasilevskis was supported by National Institute on Aging award K23AG040157, the Veterans Affairs Clinical Research Center of Excellence, and the Geriatric Research Education and Clinical Center.
Disclosures: Dr. Schnipper reports grants from Mallinckrodt Pharmaceuticals outside the submitted work. Dr. Flanders has given expert testimony and reports grants from Blue Cross Blue Shield of Michigan and the Agency for Healthcare Research and Quality and personal fees from Wiley Publishing outside the submitted work. Dr. Kim reports grants from the Association of American Medical Colleges during the conduct of the study and personal fees from ZS Pharma and Actavis Pharma outside the submitted work. Dr. Kripalani reports personal fees from Verustat and SAI Interactive and equity from Bioscape Digital outside the submitted work. Dr. Lindenauer receives support from the Center for Outcomes Research & Evaluation at Yale New Haven Health System, under contract from the Centers for Medicare & Medicaid Services, to develop hospital outcome measures for pneumonia and chronic obstructive pulmonary disease. Dr. Williams reports consultancy for Telligen Technical Expert Panel and Medical College of Wisconsin; grants from the Patient-Centered Outcomes Research Institute, Agency for Healthcare Research and Quality, Centers for Medicare & Medicaid Services, and National Center for Advancing Translational Sciences; payment for lectures from Northwestern University and the Society of Hospital Medicine; royalties from Elsevier; and payment for development of educational presentations from Vizient outside the submitted work. Dr. Davis reports payments for service on the American Heart Association's editorial board outside the submitted work. Dr. Herzig reports grants from the National Institute on Aging during the conduct of the study. Authors not named here have disclosed no conflicts of interest. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M17-1724.
Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that her spouse has stock options/holdings with Targeted Diagnostics and Therapeutics. Darren B. Taichman, MD, PhD, Executive Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Deborah Cotton, MD, MPH, Deputy Editor, reports that she has no financial relationships or interest to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Catharine B. Stack, PhD, MS, Deputy Editor for Statistics, reports that she has stock holdings in Pfizer and Johnson & Johnson.
Reproducible Research Statement:Study protocol: Available from Dr. Herzig (e-mail, sherzig@bidmc.
Corresponding Author: Kelly L. Graham, MD, MPH, Instructor, Harvard Medical School, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, E/Shapiro 607D, Boston, MA 02215; e-mail, kgraham@bidmc.
Current Author Addresses: Dr. Graham: Beth Israel Deaconess Medical Center General Medicine/Primary Care, 330 Brookline Avenue, E/Shapiro 607D, Boston, MA 02215.
Dr. Auerbach: Division of Hospital Medicine, University of California, San Francisco, Room U131, 533 Parnassus Avenue, San Francisco, CA 94117.
Dr. Schnipper: Brigham and Women's Hospital General Medicine, BC3-2Y, 1620 Tremont Street, Boston, MA 02120.
Dr. Flanders: Division of General Medicine, University of Michigan Medical School, 1500 East Medical Center Drive #3, Ann Arbor, MI 48109.
Dr. Kim: Division of General Medicine, University of Washington, Seattle, WA 98195.
Dr. Robinson: Value Institute and Department of Medicine, Christiana Care Health System, 3301 Lancaster Pike, Wilmington, DE 19709.
Dr. Ruhnke: Section of Hospital Medicine, University of Chicago, 5841 South Maryland Avenue, MC 5000, Chicago, IL 60637.
Dr. Thomas: Division of Hospital Medicine, University of California, San Francisco, 533 Parnassus Avenue #L75, San Francisco, CA 94117.
Drs. Kripalani and Vasilevskis: Section of Hospital Medicine, Vanderbilt University Medical Center, 1215 21st Avenue South #6000, Nashville, TN 37212.
Dr. Fletcher: Division of General Internal Medicine, Harborview Medical Center, 325 9th Avenue, Seattle, WA 98104.
Dr. Sehgal: University of Maryland School of Public Health, 4200 Valley Drive #2242, Room 3310C, College Park, MD 20742.
Dr. Lindenauer: University of Massachusetts Medical School–Baystate, 759 Chestnut Street, Springfield, MA 01199.
Dr. Williams: Center for Health Services Research, University of Kentucky, 800 Rose Street, Lexington, KY 40536.
Dr. Metlay: Massachusetts General Hospital Department of Medicine, 55 Fruit Street, Boston, MA 02114.
Drs. Davis, Marcantonio, and Herzig: Beth Israel Deaconess Medical Center General Medicine, CO-1309, 330 Brookline Avenue, Boston, MA 02215.
Dr. Yang: Beth Israel Deaconess Medical Center General Medicine/Primary Care, W/PBS2, 330 Brookline Avenue, Boston, MA 02215.
Author Contributions: Conception and design: K.L. Graham, A.D. Auerbach, S.A. Flanders, E.J. Robinson, S. Kripalani, E.E. Vasilevskis, N.J. Sehgal, M.V. Williams, J.P. Metlay, J. Yang, S.J. Herzig.
Analysis and interpretation of the data: K.L. Graham, A.D. Auerbach, J.L. Schnipper, S.A. Flanders, G.W. Ruhnke, L.R. Thomas, S. Kripalani, E.E. Vasilevskis, N.J. Sehgal, P.K. Lindenauer, J.P. Metlay, R.B. Davis, E.R. Marcantonio, S.J. Herzig.
Drafting of the article: K.L. Graham, A.D. Auerbach, C.S. Kim, G.W. Ruhnke, E.E. Vasilevskis, J. Yang, S.J. Herzig.
Critical revision of the article for important intellectual content: K.L. Graham, A.D. Auerbach, J.L. Schnipper, S.A. Flanders, E.J. Robinson, G.W. Ruhnke, L.R. Thomas, S. Kripalani, E.E. Vasilevskis, G.S. Fletcher, P.K. Lindenauer, M.V. Williams, R.B. Davis, E.R. Marcantonio, S.J. Herzig.
Final approval of the article: K.L. Graham, A.D. Auerbach, J.L. Schnipper, S.A. Flanders, C.S. Kim, E.J. Robinson, G.W. Ruhnke, L.R. Thomas, S. Kripalani, E.E. Vasilevskis, G.S. Fletcher, N.J. Sehgal, P.K. Lindenauer, M.V. Williams, J.P. Metlay, R.B. Davis, J. Yang, E.R. Marcantonio, S.J. Herzig.
Provision of study materials or patients: A.D. Auerbach, C.S. Kim, E.J. Robinson, G.W. Ruhnke, L.R. Thomas, S. Kripalani, E.E. Vasilevskis, G.S. Fletcher, N.J. Sehgal.
Statistical expertise: N.J. Sehgal, R.B. Davis.
Obtaining of funding: A.D. Auerbach, J.L. Schnipper, C.S. Kim, G.W. Ruhnke, S. Kripalani, E.E. Vasilevskis, P.K. Lindenauer, J.P. Metlay, S.J. Herzig.
Administrative, technical, or logistic support: A.D. Auerbach, E.J. Robinson, G.W. Ruhnke, L.R. Thomas, S. Kripalani, P.K. Lindenauer, J.P. Metlay.
Collection and assembly of data: A.D. Auerbach, C.S. Kim, G.W. Ruhnke, L.R. Thomas, S. Kripalani, E.E. Vasilevskis, G.S. Fletcher, N.J. Sehgal, M.V. Williams, J.P. Metlay, S.J. Herzig.
This article was published at Annals.org 1 May 2018.
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