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Editor's Note
November 2014

Preventable Readmission—Is It in the Eye of the Beholder?

JAMA Intern Med. 2014;174(11):1872-1873. doi:10.1001/jamainternmed.2014.3105

Despite the emphasis on delivering patient-centered medicine, patients are rarely asked directly what they want or think. That is why I liked this study by Howard-Anderson et al.1 In the context of major national policy initiatives and hospital quality initiatives focused on preventing readmission, the authors asked patients who were readmitted whether the admission, in their view, was preventable. Only 27% said yes. To make the case for objective determination of preventable readmissions even more challenging, physicians agreed with the judgment of patients as to whether the admission was preventable in fewer cases than you would expect by chance.

Preventing readmissions is a sensible aim. Not only does it save money, but patients benefit from tight coordination of the transition between inpatient and outpatient care (eg, providing sufficient in-home services and assuring that there will be a follow-up appointment). However, tying financial penalties to phenomena as complex as readmissions is problematic because, as demonstrated by this study, we do not all agree on which hospitalizations are preventable. Indeed, the Centers for Medicare and Medicaid Services in their policies on readmissions (http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Readmissions-Reduction-Program.html) do not differentiate between preventable and nonpreventable admissions, a situation that penalizes hospitals that have higher-than-expected readmission rates, regardless of whether they are considered preventable.

Of note, 69% of patients who reported preventable readmissions or who were undecided felt that they were discharged before they were ready. As an attending in a safety-net hospital, it is common for patients to request to stay an extra day or 2 after their acute illness has abated. Often, I know that it is because they have limited social support to care for them at home, because they have no home, or because they still feel unwell. However, a different set of financial rules results in my hospital not getting paid if the patient has no acute need for the hospital day. Although great emphasis is placed on being patient centered, we need better alignment between payments and our patients’ values and needs.

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Conflict of Interest Disclosures: None reported.

References
1.
Howard-Anderson  J, Lonowski  S, Vangala  S, Tseng  C-h, Busuttil  A, Afsar-manesh  N.  Readmissions in the era of patient engagement [published online September 29, 2014].  JAMA Intern Med. doi:10.1001/jamainternmed.2014.4782.
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