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.
To determine preventability of readmissions and to use these estimates to prioritize areas for improvement.
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.
Likelihood that a readmission could have been prevented.
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%).
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.
Identification of patients at a high risk of potentially avoidable readmission allows hospitals to efficiently direct additional care transitions services to the patients most likely to benefit.
To ...externally validate the HOSPITAL score in an international multicenter study to assess its generalizability.
International retrospective cohort study of 117 065 adult patients consecutively discharged alive from the medical department of 9 large hospitals across 4 different countries between January 2011 and December 2011. Patients transferred to another acute care facility were excluded.
The HOSPITAL score includes the following predictors at discharge: hemoglobin, discharge from an oncology service, sodium level, procedure during the index admission, index type of admission (urgent), number of admissions during the last 12 months, and length of stay.
30-day potentially avoidable readmission to the index hospital using the SQLape algorithm.
Overall, 117 065 adults consecutively discharged alive from a medical department between January 2011 and December 2011 were studied. Of all medical discharges, 16 992 of 117 065 (14.5%) were followed by a 30-day readmission, and 11 307 (9.7%) were followed by a 30-day potentially avoidable readmission. The discriminatory power of the HOSPITAL score to predict potentially avoidable readmission was good, with a C statistic of 0.72 (95% CI, 0.72-0.72). As in the derivation study, patients were classified into 3 risk categories: low (n = 73 031 62.4%), intermediate (n = 27 612 23.6%), and high risk (n = 16 422 14.0%). The estimated proportions of potentially avoidable readmission for each risk category matched the observed proportion, resulting in an excellent calibration (Pearson χ2 test P = .89).
The HOSPITAL score identified patients at high risk of 30-day potentially avoidable readmission with moderately high discrimination and excellent calibration when applied to a large international multicenter cohort of medical patients. This score has the potential to easily identify patients in need of more intensive transitional care interventions to prevent avoidable hospital readmissions.
Access to programs for high-needs patients depending on single-institution electronic health record data (EHR) carries risks of biased sampling. We investigate a statewide admission, discharge, and ...transfer feed (ADT) in assessing equity in access to these programs.
This is a retrospective cross-sectional study. We included high-need patients at Vanderbilt University Medical Center (VUMC) 18 years or older, with at least three emergency visits (ED) or hospitalizations in Tennessee from January 1 to June 30, 2021, including at least one at VUMC. We used the Tennessee ADT database to identify high-need patients with at least one VUMC ED/hospitalization. Then, we compared this population with high-need patients identified using VUMC's Epic® EHR database. The primary outcome was the sensitivity of VUMC-only criteria for identifying high-need patients compared to the statewide ADT reference standard.
We identified 2549 patients with at least one ED/hospitalization and assessed them as high-need based on the statewide ADT. Of those, 2100 had VUMC-only visits, and 449 had VUMC and non-VUMC visits. VUMC-only visit screening criteria showed high sensitivity (99.1%, 95% CI: 98.7 - 99.5%), showing that the high-needs patients admitted to VUMC infrequently access alternative systems. Results showed no meaningful difference in sensitivity when stratified by patient's race or insurance.
ADT allows examination for potential selection bias when relying upon single-institution utilization. In VUMC's high-need patients, there's minimal selection bias when depending on same-site utilization. Further research must understand how biases vary by site and durability over time.
Dual-eligible beneficiaries with Medicare and Medicaid coverage generally have greater utilization and spending levels than Medicare-only beneficiaries on postacute services, raising questions about ...how strategies to curb postacute spending will affect dual-eligible beneficiaries. We compared trends in postacute spending and use related to inpatient episodes at a population and episode level for dual-eligible and Medicare-only beneficiaries over the years 2009–2017. Although dual-eligible beneficiaries had consistently higher inpatient and postacute service use and spending than Medicare-only populations, both populations experienced similar declines in inpatient and postacute measures over time. Conditional on having an inpatient stay, most types of postacute service use increased regardless of dual-eligible status. These consistent patterns in episode-related postacute spending for Medicare-only and dual-eligible beneficiaries—decreased episode-related spending and use on a per beneficiary basis and increased use and spending on a per episode basis—suggest that changing patterns of care affect both populations.
Background
More than 30% of patients hospitalized for heart failure are rehospitalized or die within 90 days of discharge. Lower health literacy is associated with mortality among outpatients with ...chronic heart failure; little is known about this relationship after hospitalization for acute heart failure.
Methods and Results
Patients hospitalized for acute heart failure and discharged home between November 2010 and June 2013 were followed through December 31, 2013. Nurses administered the Brief Health Literacy Screen at admission; low health literacy was defined as Brief Health Literacy Screen ≤9. The primary outcome was all‐cause mortality. Secondary outcomes were time to first rehospitalization and, separately, time to first emergency department visit within 90 days of discharge. Cox proportional hazards models determined their relationships with health literacy, adjusting for age, gender, race, insurance, education, comorbidity, and hospital length of stay. For the 1379 patients, average age was 63.1 years, 566 (41.0%) were female, and 324 (23.5%) had low health literacy. Median follow‐up was 20.7 months (interquartile range 12.8 to 29.6 months), and 403 (29.2%) patients died. Adjusted hazard ratio for death among patients with low health literacy was 1.32 (95% CI 1.05, 1.66, P=0.02) compared to Brief Health Literacy Screen >9. Within 90 days of discharge, there were 415 (30.1%) rehospitalizations and 201 (14.6%) emergency department visits, with no evident association with health literacy.
Conclusions
Lower health literacy was associated with increased risk of death after hospitalization for acute heart failure. There was no evident relationship between health literacy and 90‐day rehospitalization or emergency department visits.
The effects of pictorial aids in medication instructions on medication recall, comprehension, and adherence are reviewed.
Many patients depend on medication labels and patient information leaflets ...for pertinent drug information, but these materials are often difficult for patients to understand. Research in psychology and marketing indicates that humans have a cognitive preference for picture-based, rather than text-based, information. Studies have shown that pictorial aids improve recall, comprehension, and adherence and are particularly useful for conveying timing of doses, instructions on when to take medicine, and the importance of completing a course of therapy. Other research has compared various techniques for using picture-based information and supports the use of integrative instructions, a combination of textual, oral, and pictorial communication, to promote comprehension and adherence. While pictures have generally proven useful for improving patient comprehension and adherence, not all picture-based interventions have produced successful results. Some icons, particularly clock icons, have been found to be too complex to enhance understanding and could not overcome the advantage provided by the familiarity of the textbased format, suggesting that patients be trained to use pictorial medication information before they are expected to use icons as an aid for medication administration. In addition to enhancing understanding, pictorial aids have been found to improve patients' satisfaction with medication instructions.
The use of pictorial aids enhances patients' understanding of how they should take their medications, particularly when pictures are used in combination with written or oral instructions.
Abstract Objectives Patient literacy affects many aspects of medication use and may influence the measurement of adherence. The aim of the study is to design and evaluate a medication adherence scale ...suitable for use across levels of patient literacy. Methods The Adherence to Refills and Medications scale (ARMS) was developed, pilot tested, and administered to 435 patients with coronary heart disease in an inner-city primary care clinic. Psychometric evaluation performed overall and by literacy level, included an assessment of internal consistency, test–retest reliability, and factor analysis. Criterion-related validity was evaluated by comparing scores with Morisky's self-reported measure of adherence, medication refill adherence, and blood pressure measurements. Lexile analysis was performed to assess the reading difficulty of the instrument. Results The final 12-item scale had high internal consistency overall (Cronbach's α = 0.814) and among patients with inadequate (α = 0.792) or marginal/adequate literacy skills (α = 0.828). Factor analysis yielded two subscales, which pertained to taking medications as prescribed and refilling medications on schedule. The ARMS correlated significantly with the Morisky adherence scale (Spearman's rho = −0.651, P < 0.01), and it correlated more strongly with measures of refill adherence than did the Morisky scale. Patients with low ARMS scores (which indicated better adherence) were significantly more likely to have controlled diastolic blood pressure ( P < 0.05), and tended to have better systolic blood pressure control. Lexile analysis demonstrated that the instrument had a favorable reading difficulty level below the eight grade. Conclusion The ARMS is a valid and reliable medication adherence scale when used in a chronic disease population, with good performance characteristics even among low-literacy patients.
Abstract Aims The Adherence to Refills and Medications Scale (ARMS) has been associated with objective measures of adherence and may address limitations of existing self-report measures of diabetes ...medication adherence. We modified the ARMS to specify adherence to diabetes medicines (ARMS-D), examined its psychometric properties, and compared its predictive validity with HbA1C against the most widely used self-report measure of diabetes medication adherence, the Summary of Diabetes Self-Care Activities medications subscale (SDSCA-MS). We also examined measurement differences by age (<65 vs. ≥65 years) and insulin status. Methods We administered self-report measures to 314 adult outpatients prescribed medications for type 2 diabetes and collected point-of-care HbA1C. Results One of the 12-item ARMS-D items was identified as less relevant to adherence to diabetes medications and removed. The 11-item ARMS-D had good internal consistency reliability ( α = 0.86), maintained its factor structure, and had convergent validity with the SDSCA-MS ( rho = −0.52, p < 0.001). Both the ARMS-D ( β = 0.16, p < 0.01) and the SDSCA-MS ( β = −0.12, p < 0.05) independently predicted HbA1C after adjusting for covariates, but this association did not hold among participants ≥65 years in subgroup analyses. There were no differences in ARMS-D or SDSCA-MS scores by insulin status, but participants on insulin reported more problems with adherence on two ARMS-D items (i.e., feeling sick and medicine costs). Conclusions The ARMS-D is a reliable and valid measure of diabetes medication adherence, and is more predictive of HbA1C than the SDSCA-MS, but takes more time to administer. The ARMS-D also identifies barriers to adherence, which may be useful in research and clinical practice.
Background
Hospital readmissions from skilled nursing facilities (SNFs) are common. Previous research has not examined how assessments of avoidable readmissions differ between hospital and SNF ...perspectives.
Objectives
To determine the percentage of readmissions from post‐acute care that are considered potentially avoidable from hospital and SNF perspectives.
Design
Prospective cohort study.
Setting
One academic medical center and 23 SNFs.
Participants
We included patients from a quality improvement trial aimed at reducing hospital readmissions among patients discharged to SNFs. We included Medicare patients who were discharged to one of 23 regional SNFs between January 2013 and January 2015, and readmitted to the hospital within 30 days.
Measurements
Hospital‐based physicians and SNF‐based staff performed structured root‐cause analyses (RCA) on a sample of readmissions from a participating SNF to the index hospital. RCAs reported avoidability and factors contributing to readmissions.
Results
The 30‐day unplanned readmission rate to the index hospital from SNFs was 14.5% (262 hospital readmissions of 1,808 discharges). Of the readmissions, 120 had RCA from both the hospital and SNF. The percentage of readmissions rated as potentially avoidable was 30.0% and 13.3% according to hospital and SNF staff, respectively. Hospital and SNF ratings of potential avoidability agreed for 73.3% (88 of the 120 readmissions), but readmission factors varied between settings. Diagnostic problems and improved management of changes in conditions were the most common avoidable readmission factors by hospitals and SNFs, respectively.
Conclusion
A substantial percentage of hospital readmissions from SNFs are rated as potentially avoidable. The ratings and factors underlying avoidability differ between hospital and SNF staff. These data support the need for joint accountability and collaboration for future readmission reduction efforts between hospitals and their SNF partners.
Objectives
To determine the prevalence, recognition, co‐occurrence, and recent onset of geriatric syndromes in individuals transferred from the hospital to a skilled nursing facility (SNF).
Design
...Quality improvement project.
Setting
Acute care academic medical center and 23 regional partner SNFs.
Participants
Medicare beneficiaries hospitalized between January 2013 and April 2014 and referred to SNFs (N = 686).
Measurements
Project staff measured nine geriatric syndromes: weight loss, lack of appetite, incontinence, and pain (standardized interview); depression (Geriatric Depression Scale); delirium (Brief Confusion Assessment Method); cognitive impairment (Brief Interview for Mental Status); and falls and pressure ulcers (hospital medical record using hospital‐implemented screening tools). Estimated prevalence, new‐onset prevalence, and common coexisting clusters were determined. The extent to which treating physicians commonly recognized syndromes and communicated them to SNFs in hospital discharge documentation was evaluated.
Results
Geriatric syndromes were prevalent in more than 90% of hospitalized adults referred to SNFs; 55% met criteria for three or more coexisting syndromes. The most‐prevalent syndromes were falls (39%), incontinence (39%), loss of appetite (37%), and weight loss (33%). In individuals who met criteria for three or more syndromes, the most common triad clusters were nutritional syndromes (weight loss, loss of appetite), incontinence, and depression. Treating hospital physicians commonly did not recognize and document geriatric syndromes in discharge summaries, missing 33% to 95% of syndromes present according to research personnel.
Conclusion
Geriatric syndromes in hospitalized older adults transferred to SNFs are prevalent and commonly coexist, with the most frequent clusters including nutritional syndromes, depression, and incontinence. Despite the high prevalence, this clinical information is rarely communicated to SNFs on discharge.
PDF
