Readmissions in the Era of Patient Engagement

The patient perspective on readmissions is lacking in the literature despite evidence that improved patient satisfaction is associated with decreased 30-day readmission rates¹ and that patient-centered communication may improve health outcomes and reduce expenditures.^2,3 In the emerging era of patient engagement in which patients increasingly desire to participate in their medical care,⁴ patient perspectives on readmissions warrant further investigation. We aimed to illuminate the patient voice on readmissions, focusing on factors that patients associate with preventable readmissions and the extent to which patients and physicians agree on readmission preventability.

The UCLA Institutional Review Boards approved the study. During 5 weeks (December 4, 2012, through December 23, 2012, and January 7, 2013, through January 20, 2013), all patients readmitted within 30 days to general medicine and cardiology services at Ronald Reagan UCLA Medical Center and UCLA Medical Center, Santa Monica were identified. Patients who provided oral consent were interviewed within 72 hours of readmission. The interview script addressed the reason for readmission, preventability, discharge processes, health status, and follow-up care. Independent physicians concurrently reviewed interviewed patients’ medical records for readmission preventability using research electronic data capture for medical record abstraction.⁵

Our analysis classified each readmission as preventable or not preventable as determined by the patient. We identified factors associated with patient assessments of preventability using Pearson χ² test and Fisher exact test for categorical variables and using t test and 1-way analysis of variance for continuous variables. We analyzed the concordance between patient and physician opinions of readmission preventability using a 95% CI for Cohen κ.

Among 143 eligible patients, 98 (69%) participated and 45 (31%) refused or were unavailable; no significant demographic differences were observed between participants and nonparticipants. The mean (SD) age of participants was 59 (18) years. Fifty-two percent were male; 57% of participants were of white race/ethnicity, and 28% were African American. The mean (SD) length of the index admission was 5.6 (4.9) days, and the mean (SD) time between discharge and readmission was 14.4 (8.4) days.

Sixty-eight patients reported that their readmission was not preventable, 26 reported that it was preventable, and 4 were undecided. Compared with patients reporting nonpreventable readmissions, patients who reported preventable readmissions or who were undecided were more likely to report being discharged before being ready (69% vs 13%, P < .001), not having all concerns addressed before discharge (67% vs 15%, P < .001), being less satisfied with the discharge team on a scale of 1 to 10 (mean, 6.3 vs 8.0; P = .01), and not having a follow-up appointment with the primary care physician or a specialist scheduled at discharge (31% vs 12%, P = .03) (Table).

Among patients who reported a nonpreventable readmission, physician reviewers agreed 54% of the time. Among patients who reported a preventable readmission or were undecided, physician reviewers agreed 30% of the time. The overall agreement was 47% (Cohen κ = −0.14; 95% CI, −0.33 to −0.04).

This study provides novel insights into factors that patients associate with preventable readmissions. Almost one-third of patients believed that their readmission was preventable, and this assessment seemed to be significantly linked to readiness for discharge, follow-up appointment scheduling, and patient satisfaction. Limitations of the study include the single-center study design and the timing of interviews at readmission, potentially introducing recall bias. Nevertheless, the results highlight the importance of incorporating patient viewpoints on readmissions into hospital efforts to create patient-centered interventions.

In addition, patient and physician opinions regarding preventability often did not match. This gap bolsters the argument that focusing solely on physician assessments of readmissions will not necessarily improve patient satisfaction and may not be maximally effective in achieving higher-quality care. The disagreement between patient and physician opinions may also indicate that patients are not adequately educated during discharge. This notion is supported in a recent study by Horwitz et al⁶ that found significant discordance between actual and perceived comprehension among patients at discharge. Health care systems should continue to actively engage and educate patients during this vulnerable care transition period, incorporating patient and physician priorities into intervention strategies.

Corresponding Author: Nasim Afsar-manesh, MD, Division of General Internal Medicine, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, PO Box 957417, Ronald Reagan UCLA Medical Center, Ste 7501A, Los Angeles, CA 90095-7417 (nafsarmanesh@mednet.ucla.edu).

Published Online: September 29, 2014. doi:10.1001/jamainternmed.2014.4782.

Author Contributions: Dr Howard-Anderson and Ms Lonowski have shared first authorship. Dr Howard-Anderson and Ms Lonowski had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Howard-Anderson, Lonowski, Busuttil, Afsar-manesh.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Howard-Anderson, Lonowski, Vangala, Tseng.

Critical revision of the manuscript for important intellectual content: Busuttil, Afsar-manesh.

Statistical analysis: Vangala, Tseng.

Study supervision: Howard-Anderson, Lonowski, Busuttil, Afsar-manesh.

Conflict of Interest Disclosures: Drs Howard-Anderson, Busuttil, and Afsar-manesh and Ms Lonowski reported receiving a grant from the Beryl Institute to obtain additional patient interviews after the patient interviews and data analysis were completed for the article. This grant provided no support for the data or analysis in this article. No other disclosures were reported.

Previous Presentation: An earlier version of this work was presented as a poster at the 25th Annual National Forum on Quality Improvement in Health Care; December 9, 2013; Orlando, Florida.