- Correction(s) for this article:
This article has been corrected. The original version (PDF) is appended to this article as a Supplement.
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.
To determine whether readmissions within 7 days of discharge differ from those between 8 and 30 days after discharge with respect to preventability.
Prospective cohort study.
10 academic medical centers in the United States.
822 adults readmitted to a general medicine service.
For each readmission, 2 site-specific physician adjudicators used a structured survey instrument to determine whether it was preventable and measured other characteristics.
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.
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.
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.
Gerhart G, Yemane A, Hickman P, Oelschlaeger A, Rollins E, Brennan N; Centers for Medicare & Medicaid Services. Medicare readmission rates showed meaningful decline in 2012. Medicare Medicaid Res Rev. 2013;3:E1-12. CrossrefGoogle Scholar
Lavenberg JG, Leas B, Umscheid CA, Williams K, Goldmann DR, Kripalani S. Assessing preventability in the quest to reduce hospital readmissions. J Hosp Med. 2014;9:598-603. [PMID: 24961204] doi:10.1002/jhm.2226 CrossrefMedlineGoogle Scholar
Centers for Medicare and Medicaid Services (CMS), HHS. Medicare program; hospital inpatient prospective payment systems for acute care hospitals and the long-term care hospital prospective payment system and FY 2012 rates; hospitals' FTE resident caps for graduate medical education payment. Final rules. Fed Regist. 2011;76:51476-846. [PMID: 21894648] MedlineGoogle Scholar
Joynt KE, Jha AK. Thirty-day readmissions—truth and consequences. N Engl J Med. 2012;366:1366-9. [PMID: 22455752] doi:10.1056/NEJMp1201598 CrossrefMedlineGoogle Scholar
Fontanarosa PB, McNutt RA. Revisiting hospital readmissions [Editorial]. JAMA. 2013;309:398-400. [PMID: 23340644] doi:10.1001/jama.2013.42 CrossrefMedlineGoogle Scholar
Joynt KE, Jha AK. A path forward on Medicare readmissions. N Engl J Med. 2013;368:1175-7. [PMID: 23465069] doi:10.1056/NEJMp1300122 CrossrefMedlineGoogle Scholar
Chin DL, Bang H, Manickam RN, Romano PS. Rethinking thirty-day hospital readmissions: shorter intervals might be better indicators of quality of care. Health Aff (Millwood). 2016;35:1867-75. [PMID: 27702961] CrossrefMedlineGoogle Scholar
Stefan MS, Pekow PS, Nsa W, Priya A, Miller LE, Bratzler DW, et al. Hospital performance measures and 30-day readmission rates. J Gen Intern Med. 2013;28:377-85. [PMID: 23070655] doi:10.1007/s11606-012-2229-8 CrossrefMedlineGoogle Scholar
Tsai TC, Joynt KE, Orav EJ, Gawande AA, Jha AK. Variation in surgical-readmission rates and quality of hospital care. N Engl J Med. 2013;369:1134-42. [PMID: 24047062] doi:10.1056/NEJMsa1303118 CrossrefMedlineGoogle Scholar
Gorodeski EZ, Starling RC, Blackstone EH. Are all readmissions bad readmissions? [Letter]. N Engl J Med. 2010;363:297-8. [PMID: 20647209] doi:10.1056/NEJMc1001882 CrossrefMedlineGoogle Scholar
Krumholz HM, Lin Z, Keenan PS, Chen J, Ross JS, Drye EE, et al. Relationship between hospital readmission and mortality rates for patients hospitalized with acute myocardial infarction, heart failure, or pneumonia. JAMA. 2013;309:587-93. [PMID: 23403683] doi:10.1001/jama.2013.333 CrossrefMedlineGoogle Scholar
Parina RP, Chang DC, Rose JA, Talamini MA. Is a low readmission rate indicative of a good hospital? J Am Coll Surg. 2015;220:169-76. [PMID: 25529903] doi:10.1016/j.jamcollsurg.2014.10.020 CrossrefMedlineGoogle Scholar
Graham KL, Wilker EH, Howell MD, Davis RB, Marcantonio ER. Differences between early and late readmissions among patients: a cohort study. Ann Intern Med. 2015;162:741-9. [PMID: 26030632]. doi:10.7326/M14-2159 LinkGoogle Scholar
Kahlon S, Pederson J, Majumdar SR, Belga S, Lau D, Fradette M, et al. Association between frailty and 30-day outcomes after discharge from hospital. CMAJ. 2015;187:799-804. [PMID: 26009583] doi:10.1503/cmaj.150100 CrossrefMedlineGoogle Scholar
Wijlaars LP, Hardelid P, Woodman J, Allister J, Cheung R, Gilbert R. Contribution of recurrent admissions in children and young people to emergency hospital admissions: retrospective cohort analysis of hospital episode statistics. Arch Dis Child. 2015;100:845-9. [PMID: 25987359] doi:10.1136/archdischild-2014-307771 CrossrefMedlineGoogle Scholar
Goodwin AJ, Rice DA, Simpson KN, Ford DW. Frequency, cost, and risk factors of readmissions among severe sepsis survivors. Crit Care Med. 2015;43:738-46. [PMID: 25746745] doi:10.1097/CCM.0000000000000859 CrossrefMedlineGoogle Scholar
Kind AJ, Jencks S, Brock J, Yu M, Bartels C, Ehlenbach W, et al. Neighborhood socioeconomic disadvantage and 30-day rehospitalization: a retrospective cohort study. Ann Intern Med. 2014;161:765-74. [PMID: 25437404]. doi:10.7326/M13-2946 LinkGoogle Scholar
Odonkor CA, Hurst PV, Kondo N, Makary MA, Pronovost PJ. Beyond the hospital gates: elucidating the interactive association of social support, depressive symptoms, and physical function with 30-day readmissions. Am J Phys Med Rehabil. 2015;94:555-67. [PMID: 25299530] doi:10.1097/PHM.0000000000000213 CrossrefMedlineGoogle Scholar
Lindenauer PK, Lagu T, Rothberg MB, Avrunin J, Pekow PS, Wang Y, et al. Income inequality and 30 day outcomes after acute myocardial infarction, heart failure, and pneumonia: retrospective cohort study. BMJ. 2013;346:f521. [PMID: 23412830] doi:10.1136/bmj.f521 CrossrefMedlineGoogle Scholar
Calvillo-King L, Arnold D, Eubank KJ, Lo M, Yunyongying P, Stieglitz H, et al. Impact of social factors on risk of readmission or mortality in pneumonia and heart failure: systematic review. J Gen Intern Med. 2013;28:269-82. [PMID: 23054925] doi:10.1007/s11606-012-2235-x CrossrefMedlineGoogle Scholar
Joynt KE, Orav EJ, Jha AK. Thirty-day readmission rates for Medicare beneficiaries by race and site of care. JAMA. 2011;305:675-81. [PMID: 21325183] doi:10.1001/jama.2011.123 CrossrefMedlineGoogle Scholar
Herzig SJ, Schnipper JL, Doctoroff L, Kim CS, Flanders SA, Robinson EJ, et al. Physician perspectives on factors contributing to readmissions and potential prevention strategies: a multicenter survey. J Gen Intern Med. 2016;31:1287-93. [PMID: 27282857] CrossrefMedlineGoogle Scholar
Herrin J, St Andre J, Kenward K, Joshi MS, Audet AM, Hines SC. Community factors and hospital readmission rates. Health Serv Res. 2015;50:20-39. [PMID: 24712374] doi:10.1111/1475-6773.12177 CrossrefMedlineGoogle Scholar
van Walraven C, Bennett C, Jennings A, Austin PC, Forster AJ. Proportion of hospital readmissions deemed avoidable: a systematic review. CMAJ. 2011;183:E391-402. [PMID: 21444623] doi:10.1503/cmaj.101860 CrossrefMedlineGoogle Scholar
Auerbach AD, Kripalani S, Vasilevskis EE, Sehgal N, Lindenauer PK, Metlay JP, et al. Preventability and causes of readmissions in a national cohort of general medicine patients. JAMA Intern Med. 2016;176:484-93. [PMID: 26954564] doi:10.1001/jamainternmed.2015.7863 CrossrefMedlineGoogle Scholar
Kripalani S, Roumie CL, Dalal AK, Cawthon C, Businger A, Eden SK, et al; PILL-CVD (Pharmacist Intervention for Low Literacy in Cardiovascular Disease) Study Group. Effect of a pharmacist intervention on clinically important medication errors after hospital discharge: a randomized trial. Ann Intern Med. 2012;157:1-10. [PMID: 22751755]. doi:10.7326/0003-4819-157-1-201207030-00003 LinkGoogle Scholar
Schnipper JL, Kirwin JL, Cotugno MC, Wahlstrom SA, Brown BA, Tarvin E, et al. Role of pharmacist counseling in preventing adverse drug events after hospitalization. Arch Intern Med. 2006;166:565-71. [PMID: 16534045] CrossrefMedlineGoogle Scholar
Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW. The incidence and severity of adverse events affecting patients after discharge from the hospital. Ann Intern Med. 2003;138:161-7. [PMID: 12558354] LinkGoogle Scholar
Burke RE, Kripalani S, Vasilevskis EE, Schnipper JL. Moving beyond readmission penalties: creating an ideal process to improve transitional care. J Hosp Med. 2013;8:102-9. [PMID: 23184714] doi:10.1002/jhm.1990 CrossrefMedlineGoogle Scholar
O'Neil AC, Petersen LA, Cook EF, Bates DW, Lee TH, Brennan TA. Physician reporting compared with medical-record review to identify adverse medical events. Ann Intern Med. 1993;119:370-6. [PMID: 8338290] LinkGoogle Scholar
Graham KL, Dike O, Doctoroff L, Jupiter M, Vanka A, Davis RB, et al. Preventability of early vs. late readmissions in an academic medical center. PLoS One. 2017;12:e0178718. [PMID: 28622384] doi:10.1371/journal.pone.0178718 CrossrefMedlineGoogle Scholar
Localio AR, Weaver SL, Landis JR, Lawthers AG, Brenhan TA, Hebert L, et al. Identifying adverse events caused by medical care: degree of physician agreement in a retrospective chart review. Ann Intern Med. 1996;125:457-64. [PMID: 8779457] LinkGoogle Scholar
Joynt KE, Jha AK. Characteristics of hospitals receiving penalties under the Hospital Readmissions Reduction Program. JAMA. 2013;309:342-3. [PMID: 23340629] doi:10.1001/jama.2012.94856 CrossrefMedlineGoogle Scholar
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.