Abstract

Objectives: Readmissions are an increasing area of focus for quality improvement initiatives. Widely variable estimates exist on preventability and impact of multipronged readmission interventions. Given the rotating nature of attending physicians in academic centers, physicians often are unaware of readmissions. We present a before-and-after (uncontrolled) trial evaluating timely feedback of readmissions to hospitalist physicians.

Methods: A daily list of patients (inpatient, observation, procedure, or emergency department) who are registered as receiving care within University of North Carolina hospitals was filtered to include only inpatients within the last 30 days and cared for by a faculty member from the hospital medicine program, and readmissions were tracked. A hospitalist physician performed an in-depth review of readmissions using a readmission diagnostic worksheet developed by the Institute for Healthcare Improvement STate Action on Avoidable Rehospitalizations Initiative. Physicians were surveyed on their perception of readmissions in general and their preventability. Outcomes of interest were 30-day readmission rates, physician perspectives and estimates of preventability, patient factors from the STate Action on Avoidable Rehospitalizations tool, and length of stay.

Results: Compared with the previous 18 months, the readmission rate was reduced modestly during the 6 months of our intervention (12% to 10%, t test + 0.071). The average length of stay increased from 4.73 days during the prior 18 months to 5.01 for the 4 months since the intervention ( t test 0.1). Based on the attending physician survey, 13% of attending physicians believed that fewer than 10% of readmissions were preventable; this increased to 30% after 6 months of timely notification and chart reviews. At baseline, the top three contributors to readmissions were believed to be patient understanding, medication nonadherence, and substance abuse/addiction. After 6 months of the intervention, the top three contributors were believed to be substance abuse/addiction, medication nonadherence, and lack of primary care.

Conclusions: Our intervention of real-time feedback regarding readmissions and enforced chart review led to a modest reduction in readmission rates without significant changes in length of stay. Physicians continued to believe that a readmission event was multifactorial and largely not preventable. Real-time notification did increase physician involvement in prevention initiatives, in particular with high-use patients.