A taxonomy of seven‐day readmissions to an urban teaching hospital

Abstract

BACKGROUND Understanding the mechanism of unplanned hospital readmissions is necessary for accurate prediction and prevention. OBJECTIVE To identify specific mechanisms of unplanned readmissions through medical narratives obtained from chart reviews. DESIGN Retrospective chart review. SETTING Urban tertiary care hospital. PATIENTS Two hundred seventy patients accounted for 335 unplanned 7‐day readmissions between July 2010 and July 2011. MEASUREMENTS Readmissions were classified into 1 of 5 distinct categories. RESULTS Readmitted subjects were more likely to have had a longer length of stay during the first admission compared to nonreadmitted patients. Readmissions due to unpredictable/unpreventable complications or unrelated events constituted the highest percentage at 46%. Readmissions due to patient factors such as substance abuse, signing out against medical advice, or nonadherence to the treatment plan constituted 31%. Readmissions designated as preventable accounted for 24%. Among preventable readmissions, the most common cause was incomplete management of the index diagnosis. The interobserver level of agreement across the 5 major categories was substantial. CONCLUSIONS We found through detailed chart review of patients readmitted within 7 days to an urban teaching hospital that the majority of readmissions were not avoidable and were often due to unpredictable or unpreventable complications of the primary diagnosis from the index hospitalization or to patient behaviors that contradicted the treatment plan. These results question the value of readmissions as a valid metric of quality and support future interventions in hospital systems to reduce preventable readmissions. Journal of Hospital Medicine 2016;11:33–38. © 2015 Society of Hospital Medicine

How do studies assess the preventability of readmissions? A systematic review with narrative synthesis

“…Additional file 6 provides more information on the interviews with care providers and/or patients. In 7 studies the patient was approached [21–23, 25, 30–32] and in 5 studies the patient or caregiver was approached [14, 26–29]. In 4 studies it was mentioned that the results of the interview were available for the reviewers during their assessment of preventability, however, it was not specified if and how these results influenced the preventability assessment [14, 22, 26, 29].…”

“…The other 5 studies did not specify whether or not the additional patient/caregiver information was used to assess the preventability [25, 28, 30–32]. In the study of Burke et al [23], only 6 patients were interviewed during a pilot phase. After the pilot, they concluded that the interviews did not provide additional data to the patient’s medical record.…”

“…The majority of the studies did not report whether they assessed the causal relationship (i.e. whether the readmission is related to the care provided during index admission) explicitly, but ‘causative or causal’ could be extracted from the cause and/or preventability criteria [15, 16, 23, 32, 43, 44, 52, 53]. In addition, a few articles included information on ‘related readmissions’.…”

“…Four studies had ≥10 reviewers [17, 32, 36, 43]. The reviewers were most often physicians (specialists) or a combination hereof [5, 13, 15–18, 20–23, 25, 27, 28, 30–32, 35–39, 41, 42, 45, 47, 50, 51, 53–55, 57, 58]. A subset of studies included a multidisciplinary study team consisting of physicians, general practitioners, a medical officer, case managers, (specialized) nurses, medical record specialists, social workers and/or administrative staff [14, 24, 29, 33, 44, 46, 48].…”

“…As shown in Table 2 roughly three options for review were possible: a single reviewer without a double check [13, 17, 28, 38, 51, 59], a single reviewer double checked by a second reviewer [15, 18, 32, 36, 45] or a team [24, 40, 43] or a team of 3 to 4 persons which reviewed the readmissions directly [20, 25, 27, 33, 41, 49, 54]. Agreement and consensus regarding the preventability was handled differently: a double review of each readmission was performed meaning that both reviewers assessed the preventability of the readmissions and came to a mutual agreement [14, 16, 18, 19, 22, 23, 29–31, 35, 42, 44, 46, 47, 50, 52, 53, 57]. In some cases a team or panel was consulted when mutual agreement on the preventability was not achieved [5, 48, 55, 60].…”