IMPORTANCE Readmission penalties have catalyzed efforts to improve care transitions, but few programs have incorporated viewpoints of patients and health care professionals to determine readmission preventability or to prioritize opportunities for care improvement. OBJECTIVES To determine preventability of readmissions and to use these estimates to prioritize areas for improvement. DESIGN, SETTING, AND PARTICIPANTS An observational study was conducted of 1000 general medicine patients readmitted within 30 days of discharge to 12 US academic medical centers between April 1, 2012, and March 31, 2013. We surveyed patients and physicians, reviewed documentation, and performed 2-physician case review to determine preventability of and factors contributing to readmission. We used bivariable statistics to compare preventable and nonpreventable readmissions, multivariable models to identify factors associated with potential preventability, and baseline risk factor prevalence and adjusted odds ratios (aORs) to determine the proportion of readmissions affected by individual risk factors. MAIN OUTCOME AND MEASURE Likelihood that a readmission could have been prevented. RESULTS The study cohort comprised 1000 patients (median age was 55 years). Of these, 269 (26.9%) were considered potentially preventable. In multivariable models, factors most strongly associated with potential preventability included emergency department decision making regarding the readmission (aOR, 9.13; 95% CI, 5.23–15.95), failure to relay important information to outpatient health care professionals (aOR, 4.19; 95% CI, 2.17–8.09), discharge of patients too soon (aOR, 3.88; 95% CI, 2.44–6.17), and lack of discussions about care goals among patients with serious illnesses (aOR, 3.84; 95% CI, 1.39–10.64). The most common factors associated with potentially preventable readmissions included emergency department decision making (affecting 9.0%; 95% CI, 7.1%−10.3%), inability to keep appointments after discharge (affecting 8.3%; 95% CI, 4.1%−12.0%), premature discharge from the hospital (affecting 8.7%; 95% CI, 5.8%–11.3%), and patient lack of awareness of whom to contact after discharge (affecting 6.2%; 95% CI, 3.5%–8.7%). CONCLUSIONS AND RELEVANCE Approximately one-quarter of readmissions are potentially preventable when assessed using multiple perspectives. High-priority areas for improvement efforts include improved communication among health care teams and between health care professionals and patients, greater attention to patients’ readiness for discharge, enhanced disease monitoring, and better support for patient self-management.

Background: Many experts believe that hospitals with more frequent hospital readmissions provide lower quality of care, but little is known about how the preventability of readmissions might change over the post-discharge timeframe. Objective: To determine whether readmissions within 7 days of discharge are different from readmissions between 8 and 30 days after discharge with respect to preventability. Design: Prospective cohort study. Setting: 10 US academic medical centers. Patients: 822 adults readmitted to a general medicine service. Measurements: At each site, 2 physician assessors used a structured survey instrument to determine whether each readmission was preventable and to measure other characteristics of the readmission. Results: 36.2% of early readmissions versus 23.0% of late readmissions were preventable (median risk difference 13.0%, 25th, 75th percentile 5.5, 26.4). The hospital was identified as a better location to prevent an early readmission than a late readmission (47.2% vs. 25.5%, [median risk difference 22.8%, 25th, 75th percentile 17.9, 31.8]). In contrast, the outpatient clinic (15.2% vs. 6.6%, [median risk difference 10%, 25th, 75th percentile 4.6, 12.2]) and home (19.4% vs. 14%, [median risk difference 5.6%, 25th, 75th percentile −6.1, 17.1]) were identified as better locations to prevent late readmissions than early readmissions. Limitations: Physician assessors were not blinded to readmission timing. In addition, community hospitals were not included in the study, and readmissions to non-study hospitals were not included in the results. Conclusions: 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.

ImportancePatient concerns at or before discharge inform many transitional care interventions; few studies examine patients’ perceptions of self-care and other factors related to readmission.ObjectivesTo characterise patient-reported or caregiver-reported factors contributing to readmission.Design, setting and participantsCross-sectional, national study of general medicine patients readmitted within 30 days at 12 US hospitals. Interviews included multiple-choice survey and open-ended survey questions of patients or their caregivers.MeasurementsMultiple-choice survey quantified post-discharge difficulty in seven domains of self-care: medication use, contacting providers, transportation, basic needs (eg, food and shelter), diet, social support and substance abuse. Open-ended responses were coded into themes that added depth to the domains above or captured additional patient-centred concerns.ResultsWe interviewed 1066 readmitted patients. 91% reported understanding their discharge plan; however, only 37% reported that providers asked about barriers to carrying out the plan. 52% reported experiencing difficulty in ≥1 self-care domains ranging in frequency from 22% (diet) to 7% (substance use); 26% experienced difficulty in two or more domains. Among 508 patients (48% overall) who reported no difficulties in these domains, two-thirds either could not attribute their readmission to any specific difficulty (34%) or attributed their readmission to progression or persistence of their disease despite following their discharge plan (31%). Only 20% attributed their readmission to early discharge (8%), poor-quality hospital care (6%) or issues such as inadequate discharge instructions or follow-up care (6%).LimitationsThe study population included only patients readmitted at academic medical centres and may not be representative of community-based care.ConclusionPatients readmitted within 30 days reported understanding their discharge plans, but frequent difficulties in self-care and low anticipatory guidance for resolving these issues after discharge.

Accountable Care Organizations (ACOs) have incentives to meet quality and expenditure targets and share in resulting savings. Achieving these goals will require ACOs to engage more actively with patients and their families. The extent to which ACOs do so is currently unknown. Using mixed-methods including a national survey, phone interviews and site-visits; we examine the extent to which ACOs actively engage patients and their families, explore challenges involved; and consider approaches for dealing with those challenges. Results indicate that greater ACO use of patient activation and engagement (PAE) activities at the point-of-care may influence more positive leadership perceptions of the impact of PAE investments on ACO costs, quality, and outcomes of care. We identify a number of important practices associated with greater PAE, including high-level leadership commitment, goal-setting supported by adequate resources, extensive provider training and use of inter-disciplinary care teams, and frequent monitoring and reporting on progress.