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Classifying general medicine readmissions

Are they preventable?

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Abstract

OBJECTIVES: To describe a new quality assessment method used to classify the preventability of hospitalization in terms of patient, clinician, or system factors.

DESIGN: The instrument was developed in two phases. Phase 1 was a prospective comparison of admitting residents’ and their attending physicians’ classifications of the perceived preventability of consecutive admissions to one Veterans Affairs Medical Center (VAMC) excluding admissions to the intensive care unit (ICU). In phase 2, a panel of 10 physicians rated 811 abstracted records of readmissions from nine VAMCs.

SETTING: Nine VAMCs across the United States with varying degrees of university hospital affiliation.

PATIENTS: Phase 1, 156 patients admitted to the general medicine service at the Durham VAMC. Phase 2, 514 patients accounting for 811 readmissions within 6 months of a general medicine service discharge at nine VAMCs.

MEASUREMENTS AND MAIN RESULTS: Physicians used a checklist to record the reason for hospitalization, the preventability of the hospitalization, and, if preventable, a reason defining preventability, which was classified in terms of system, clinician, and patient factors. In phase 2, two physician panelists assessed preventability for each chart. When two panelists disagreed on the preventability of hospitalization, a third panelist, blind to the original assessments, rated the chart. In phase 1, residents and attending physicians rated 33% and 34% of admissions as preventable (κ=0.41), respectively. In phase 2, 277 (34%) of 811 readmissions were deemed preventable. Intraobserver accuracy for the assessment of preventability was 96% (κ=0.89). Interobserver accuracy was 73% (κ=0.43). Hospital system factors accounted for 37% of preventable readmissions, clinician factors for 38%, and patient factors for 21%. The nine hospitals differed markedly in their profile of reasons for preventable readmissions (p=.005).

CONCLUSIONS: Using a new method of determining the preventability of hospitalizations, we identified several factors that might avert hospitalizations. Focusing efforts to identify preventable hospitalizations may yield better methods for managing patients’ total health care needs; however, the content of those efforts will vary by institution.

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Supported by a grant from the Department of Veterans Affairs Health Services Research and Development Program, Veterans Affairs Cooperative Studies in Health Services No. 8, and the Veterans Affairs Health Services Career Development Program. Dr. Oddone is also supported by the Robert Wood Johnson Generalist Physician Faculty Scholars Program.

The following investigators and institutions participated in the Health Services Trial on Primary Care and Readmissions: Data Monitoring Board,Thomas Meyer (chairman), Mary Foulkes, Mark Hlatky, Kristin Nichol; Executive Committee,Terry Adams, Carol Ashton, John Demakis, John Feussner, James Gibbs, William Henderson, Denise Hines, Charles Mengel; Brooklyn, NY,Rita Varano, Estelita Anteola; Cincinnati, Ohio,James Schultz, Virginia Hedger; Columbia, SC, Fodie Calkins, Grady Allen; Durham, NC,Marjorie Foy, Aileen Ward, Pamela Landsman; Fresno, Calif.,Kimberli Cox, Paula Hensley; Indianapolis, Ind.,Gayle Redmon, Terry Adams; Leavenworth, Kan.,Marie Cook, Lynn Carrel; Loma Linda, Calif.,Nalda Gordon, Elizabeth Wise; Philadelphia, Pa.,Joan Havey, Alice Cooney.

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Oddone, E.Z., Weinberger, M., Horner, M. et al. Classifying general medicine readmissions. J Gen Intern Med 11, 597–607 (1996). https://doi.org/10.1007/BF02599027

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