Why Do Readmissions Happen?

Hospital readmissions are considered a quality and cost issue not just in the US, but in other developed countries.  The British Medical journal carries research which examined patient and provider perceptions of the avoidability of  such readmissions.  (BMJ Article)   The researchers examined perceptions about readmissions in a prospective trial of unplanned readmissions in four countries–the Netherlands, Ireland, the UK and Denmark.  Patients, nurses and physicians were asked their opinion about the predictability and preventability of the readmission, as well as contributing factors to a readmission.  These perceptions were deemed important because there is a lack of rigor in the notion of a “preventable” readmission and doctors’ perceptions are viewed as the gold standard, although doctors aren’t homogenous in their views on what is and isn’t “preventable”.  The researchers decided that if a majority of the people interviewed about a specific readmission, including doctors, patients, caregivers, the researcher and other clinicians, thought it was preventable or predictable, it would be labeled as such.  A total of almost 1400 patients were involved, with a median age of 70.

Using the majority decides rule, 28% of the readmissions were viewed as predictable and only 14% as avoidable.  There was poor agreement across interviewees for a specific readmission, and particularly between patients and clinicians.  Factors relating to predictability included having five or more hospital admissions in the prior year (duh); higher frailty and higher comorbidity scores and having a non-elective initial admission.  Patients who had followup planned and who reported being ready for discharge had readmissions that were deemed less preventable.  Conversely, when a patient reported feeling less ready for discharge, the subsequent readmissions were deemed less preventable and more predictable.    The root causes of most readmissions were disease-related while a few were viewed as health care worker or patient-related.  The ones that were disease-related were perceived as least predictable or preventable, but again there was little agreement among interviewees.  Pretty obvious that more attention should be paid to what a patient says, but in the US and in many other countries, hospitals are incented to move patients out quickly, ready or not.  This study just points out again the bad design of most readmission reduction programs.