BACKGROUND:The transition out of the hospital is a vulnerable time for patients, relying heavily on communication and coordination of resources across care settings. Understanding the perspectives of inpatient and outpatient physicians regarding factors contributing to readmission and potential preventive strategies is crucial in designing appropriately targeted readmission prevention efforts. OBJECTIVE: To examine and compare inpatient and outpatient physician opinions regarding reasons for readmission and interventions that might have prevented readmission. DESIGN: Cross-sectional multicenter study. PARTICIPANTS: We identified patients readmitted to general medicine services within 30 days of discharge at 12 US academic medical centers, and surveyed the primary care physician (PCP), discharging physician from the index admission, and admitting physician from the readmission regarding their endorsement of pre-specified factors contributing to the readmission and potential preventive strategies. MAIN MEASURES: We calculated kappa statistics to gauge agreement between physician dyads (PCP-discharging physician, PCP-admitting physician, and admitting-discharging physician). KEY RESULTS: We evaluated 993 readmission events, which generated responses from 356 PCPs (36 % of readmissions), 675 discharging physicians (68 % of readmissions), and 737 admitting physicians (74 % of readmissions). The most commonly endorsed contributing factors by both PCPs and inpatient physicians related to patient understanding and ability to self-manage. The most commonly endorsed preventive strategies involved providing patients with enhanced post-discharge instructions and/ or support. Although PCPs and inpatient physicians endorsed contributing factors and potential preventive strategies with similar frequencies, agreement among the three physicians on the specific factors and/or strategies that applied to individual readmission events was poor (maximum kappa 0.30). CONCLUSIONS: Differing opinions among physicians on factors contributing to individual readmissions highlights the importance of communication between inpatient and outpatient providers at discharge to share their different perspectives, and suggests that multi-faceted, broadly applied interventions may be more successful than those that rely on individual providers choosing specific services based on perceived risk factors.

Background Health policy debate commonly focuses on frequently hospitalized patients, but less research has examined trends in long-stay patients, despite their high cost, effect on availability of hospital beds, and physical and financial implications for patients and hospitals. Methods Using the National Inpatient Sample, a nationally-representative sample of acute care hospitalizations in the United States, we examined trends in long-stay hospitalizations from 2001–2012. We defined long stays as those 21 days or longer and evaluated characteristics and outcomes of those hospitalizations, including discharge disposition and length of stay and trends in hospital characteristics. We excluded patients under 18, and those with primary psychiatry, obstetric or rehabilitation diagnoses and weighted estimates to the U.S. population. Results Prolonged hospitalizations represented only 2% of hospitalizations, but approximately 14% of hospital days and incurred estimated charges of over $20 billion dollars annually. Over time, patients with prolonged hospitalizations were increasingly younger, male, and of minority status, and these hospitalizations occurred more frequently in urban, academic hospitals. Inhospital mortality for patients with prolonged stays progressively decreased over the 10-year period from 14.5 to 11.6% (p<0.001 for trend in grouped years), even accounting for changes in demographics and comorbidity. Conclusions The profile of patients with prolonged hospitalizations in the United States has changed, although their impact remains large, as they continue to represent one out of every 7 hospital days. Their large number of hospital days and expense increasingly falls upon urban academic medical centers, which will need to adapt to this vulnerable patient population.

BackgroundIt is unclear if the 30-day unplanned hospital readmission rate is a plausible accountability metric.ObjectiveCompare preventability of hospital readmissions, between an early period [0–7 days post-discharge] and a late period [8–30 days post-discharge]. Compare causes of readmission, and frequency of markers of clinical instability 24h prior to discharge between early and late readmissions.Design, setting, patients120 patient readmissions in an academic medical center between 1/1/2009-12/31/2010MeasuresSum-score based on a standard algorithm that assesses preventability of each readmission based on blinded hospitalist review; average causation score for seven types of adverse events; rates of markers of clinical instability within 24h prior to discharge.ResultsReadmissions were significantly more preventable in the early compared to the late period [median preventability sum score 8.5 vs. 8.0, p = 0.03]. There were significantly more management errors as causative events for the readmission in the early compared to the late period [mean causation score [scale 1–6, 6 most causal] 2.0 vs. 1.5, p = 0.04], and these errors were significantly more preventable in the early compared to the late period [mean preventability score 1.9 vs 1.5, p = 0.03]. Patients readmitted in the early period were significantly more likely to have mental status changes documented 24h prior to hospital discharge than patients readmitted in the late period [12% vs. 0%, p = 0.01].ConclusionsReadmissions occurring in the early period were significantly more preventable. Early readmissions were associated with more management errors, and mental status changes 24h prior to discharge. Seven-day readmissions may be a better accountability measure.