Letters
trials to improve the evidence base for patient care as well as the professional society guidelines. Muhammad Rizwan Sardar, MD Marwan Badri, MBChB, MRCP Catherine T. Prince, DO, PhD, MPH Jonathan Seltzer, MD, MBA, MA Peter R. Kowey, MD Author Affiliations: Lankenau Medical Center and Lankenau Institute for Medical Research, Main Line Health System, Wynnewood, Pennsylvania (Sardar, Badri, Prince, Seltzer, Kowey); Cooper University Hospital, Camden, New Jersey (Sardar); Applied Clinical Intelligence, Bala Cynwyd, Pennsylvania (Seltzer); Jefferson Medical College, Philadelphia, Pennsylvania (Kowey). Corresponding Author: Marwan Badri, MBChB, MRCP, Lankenau Medical Center, 100 Lancaster Ave, Ste 558, Wynnewood, PA 19096 (marwanbadri @gmail.com). Published Online: September 29, 2014. doi:10.1001/jamainternmed.2014.4758. Author Contributions: Dr Badri had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Sardar, Badri, Seltzer, Kowey. Acquisition, analysis, or interpretation of data: Sardar, Badri, Prince. Drafting of the manuscript: Sardar, Badri. Critical revision of the manuscript for important intellectual content: Sardar, Prince, Seltzer, Kowey, Statistical analysis: Sardar, Prince. Administrative, technical, or material support: Badri, Seltzer. Study supervision: Sardar, Badri, Kowey. Conflict of Interest Disclosures: None of the authors are currently or have been involved in a guidelines-writing task force or recommendation and advisory board of such committees. Dr Kowey was a reviewer for the 2014 ACC/AHA guidelines for atrial fibrillation. No other disclosures are reported. 1. Fuster V, Rydén LE, Cannom DS, et al. 2011 ACCF/AHA/HRS focused updates incorporated into the ACC/AHA/ESC 2006 Guidelines for the management of patients with atrial fibrillation: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines developed in partnership with the European Society of Cardiology and in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society. J Am Coll Cardiol. 2011;57(11):e101-e198. 2. Hunt SA, Abraham WT, Chin MH, et al; American College of Cardiology Foundation; American Heart Association. 2009 Focused update incorporated into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines Developed in Collaboration With the International Society for Heart and Lung Transplantation. J Am Coll Cardiol. 2009;53(15):e1-e90. 3. Wright RS, Anderson JL, Adams CD, et al; American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. 2011 ACCF/AHA focused update incorporated into the ACC/AHA 2007 Guidelines for the Management of Patients with Unstable Angina/Non-ST-Elevation Myocardial Infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines developed in collaboration with the American Academy of Family Physicians, Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons. J Am Coll Cardiol. 2011;57(19):e215-e367. 4. Go AS, Mozaffarian D, Roger VL, et al; American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics–2013 update: a report from the American Heart Association. Circulation. 2013;127(1):e6-e245. 5. Fonarow GC, Heywood JT, Heidenreich PA, Lopatin M, Yancy CW; ADHERE Scientific Advisory Committee and Investigators. Temporal trends in clinical characteristics, treatments, and outcomes for heart failure hospitalizations, 2002 to 2004: findings from Acute Decompensated Heart Failure National Registry (ADHERE). Am Heart J. 2007;153(6):1021-1028. 6. Vavalle JP, Lopes RD, Chen AY, et al. Hospital length of stay in patients with non–ST-segment elevation myocardial infarction. Am J Med. 2012;125(11):1085-1094.
1870
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 enRelated article page 1872 gagement 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. Methods | 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. Results | 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).
JAMA Internal Medicine November 2014 Volume 174, Number 11
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a University of Georgia User on 06/08/2015
jamainternalmedicine.com
Letters
Table. Factors Associated With Readmission Preventability as Determined by Patient Opiniona No. (%) Total Sample (N = 98)
Preventable Readmission or Undecided (n = 30)
Nonpreventable Readmission (n = 68)
P Value
(n = 94)
(n = 28)
(n = 66)
.31
No
33 (35)
12 (43)
21 (32)
Yes
61 (65)
16 (57)
45 (68)
(n = 94)
(n = 28)
(n = 66)
No
34 (36)
13 (46)
21 (32)
Yes
60 (64)
15 (54)
45 (68)
(n = 94)
(n = 29)
(n = 65)
No
35 (37)
15 (52)
20 (31)
Yes
59 (63)
14 (48)
45 (69)
(n = 95)
(n = 29)
(n = 66)
Variable Attended ≥1 follow-up appointment
Follow-up appointment with PCP arranged or already scheduled on discharge
Follow-up appointment with specialist arranged or already scheduled on discharge
Follow-up appointment with PCP or specialist arranged or already scheduled on discharge No
17 (18)
9 (31)
8 (12)
Yes
78 (82)
20 (69)
58 (88)
(n = 96)
(n = 29)
(n = 67)
Felt they were discharged before ready No
67 (70)
9 (31)
Yes
29 (30)
20 (69)
(n = 94)
(n = 29)
Had medications reviewed before discharge
6 (21)
15 (23)
73 (78)
23 (79)
50 (77)
(n = 95)
(n = 27)
(n = 68)
No
83 (87)
23 (85)
60 (88)
Yes
12 (13)
4 (15)
8 (12)
(n = 27)
(n = 65)
No
14 (15)
4 (15)
10 (15)
Yes
78 (85)
23 (85)
55 (85)
(n = 96)
(n = 28)
(n = 68)
Had a PCP No
10 (10)
6 (21)
4 (6)
Yes
86 (90)
22 (79)
64 (94)
(n = 96)
(n = 29)
(n = 67)
No
30 (31)
10 (34)
20 (30)
Yes
66 (69)
19 (66)
47 (70)
(n = 93)
(n = 27)
(n = 66)
No
28 (30)
18 (67)
10 (15)
Yes
65 (70)
9 (33)
56 (85)
Reported improved overall health condition from index admission to index discharge
Felt all concerns were addressed before discharge
(n = 92)
(n = 26)
No
57 (62)
19 (73)
38 (58)
Yes
35 (38)
7 (27)
28 (42)
Contacted health care professional before readmission
Among patients who reported a nonpreventable readmission, physician reviewers agreed 54% of the time. Among patients who reported a preventable readmission or jamainternalmedicine.com
.99
.06
.65
Abbreviation: PCP, primary care physician. a
trials to improve the evidence base for patient care as well as the professional society guidelines. Muhammad Rizwan Sardar, MD Marwan Badri, MBChB, MRCP Catherine T. Prince, DO, PhD, MPH Jonathan Seltzer, MD, MBA, MA Peter R. Kowey, MD Author Affiliations: Lankenau Medical Center and Lankenau Institute for Medical Research, Main Line Health System, Wynnewood, Pennsylvania (Sardar, Badri, Prince, Seltzer, Kowey); Cooper University Hospital, Camden, New Jersey (Sardar); Applied Clinical Intelligence, Bala Cynwyd, Pennsylvania (Seltzer); Jefferson Medical College, Philadelphia, Pennsylvania (Kowey). Corresponding Author: Marwan Badri, MBChB, MRCP, Lankenau Medical Center, 100 Lancaster Ave, Ste 558, Wynnewood, PA 19096 (marwanbadri @gmail.com). Published Online: September 29, 2014. doi:10.1001/jamainternmed.2014.4758. Author Contributions: Dr Badri had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Sardar, Badri, Seltzer, Kowey. Acquisition, analysis, or interpretation of data: Sardar, Badri, Prince. Drafting of the manuscript: Sardar, Badri. Critical revision of the manuscript for important intellectual content: Sardar, Prince, Seltzer, Kowey, Statistical analysis: Sardar, Prince. Administrative, technical, or material support: Badri, Seltzer. Study supervision: Sardar, Badri, Kowey. Conflict of Interest Disclosures: None of the authors are currently or have been involved in a guidelines-writing task force or recommendation and advisory board of such committees. Dr Kowey was a reviewer for the 2014 ACC/AHA guidelines for atrial fibrillation. No other disclosures are reported. 1. Fuster V, Rydén LE, Cannom DS, et al. 2011 ACCF/AHA/HRS focused updates incorporated into the ACC/AHA/ESC 2006 Guidelines for the management of patients with atrial fibrillation: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines developed in partnership with the European Society of Cardiology and in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society. J Am Coll Cardiol. 2011;57(11):e101-e198. 2. Hunt SA, Abraham WT, Chin MH, et al; American College of Cardiology Foundation; American Heart Association. 2009 Focused update incorporated into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines Developed in Collaboration With the International Society for Heart and Lung Transplantation. J Am Coll Cardiol. 2009;53(15):e1-e90. 3. Wright RS, Anderson JL, Adams CD, et al; American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. 2011 ACCF/AHA focused update incorporated into the ACC/AHA 2007 Guidelines for the Management of Patients with Unstable Angina/Non-ST-Elevation Myocardial Infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines developed in collaboration with the American Academy of Family Physicians, Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons. J Am Coll Cardiol. 2011;57(19):e215-e367. 4. Go AS, Mozaffarian D, Roger VL, et al; American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics–2013 update: a report from the American Heart Association. Circulation. 2013;127(1):e6-e245. 5. Fonarow GC, Heywood JT, Heidenreich PA, Lopatin M, Yancy CW; ADHERE Scientific Advisory Committee and Investigators. Temporal trends in clinical characteristics, treatments, and outcomes for heart failure hospitalizations, 2002 to 2004: findings from Acute Decompensated Heart Failure National Registry (ADHERE). Am Heart J. 2007;153(6):1021-1028. 6. Vavalle JP, Lopes RD, Chen AY, et al. Hospital length of stay in patients with non–ST-segment elevation myocardial infarction. Am J Med. 2012;125(11):1085-1094.
1870
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 enRelated article page 1872 gagement 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. Methods | 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. Results | 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).
JAMA Internal Medicine November 2014 Volume 174, Number 11
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a University of Georgia User on 06/08/2015
jamainternalmedicine.com
Letters
Table. Factors Associated With Readmission Preventability as Determined by Patient Opiniona No. (%) Total Sample (N = 98)
Preventable Readmission or Undecided (n = 30)
Nonpreventable Readmission (n = 68)
P Value
(n = 94)
(n = 28)
(n = 66)
.31
No
33 (35)
12 (43)
21 (32)
Yes
61 (65)
16 (57)
45 (68)
(n = 94)
(n = 28)
(n = 66)
No
34 (36)
13 (46)
21 (32)
Yes
60 (64)
15 (54)
45 (68)
(n = 94)
(n = 29)
(n = 65)
No
35 (37)
15 (52)
20 (31)
Yes
59 (63)
14 (48)
45 (69)
(n = 95)
(n = 29)
(n = 66)
Variable Attended ≥1 follow-up appointment
Follow-up appointment with PCP arranged or already scheduled on discharge
Follow-up appointment with specialist arranged or already scheduled on discharge
Follow-up appointment with PCP or specialist arranged or already scheduled on discharge No
17 (18)
9 (31)
8 (12)
Yes
78 (82)
20 (69)
58 (88)
(n = 96)
(n = 29)
(n = 67)
Felt they were discharged before ready No
67 (70)
9 (31)
Yes
29 (30)
20 (69)
(n = 94)
(n = 29)
Had medications reviewed before discharge
6 (21)
15 (23)
73 (78)
23 (79)
50 (77)
(n = 95)
(n = 27)
(n = 68)
No
83 (87)
23 (85)
60 (88)
Yes
12 (13)
4 (15)
8 (12)
(n = 27)
(n = 65)
No
14 (15)
4 (15)
10 (15)
Yes
78 (85)
23 (85)
55 (85)
(n = 96)
(n = 28)
(n = 68)
Had a PCP No
10 (10)
6 (21)
4 (6)
Yes
86 (90)
22 (79)
64 (94)
(n = 96)
(n = 29)
(n = 67)
No
30 (31)
10 (34)
20 (30)
Yes
66 (69)
19 (66)
47 (70)
(n = 93)
(n = 27)
(n = 66)
No
28 (30)
18 (67)
10 (15)
Yes
65 (70)
9 (33)
56 (85)
Reported improved overall health condition from index admission to index discharge
Felt all concerns were addressed before discharge
(n = 92)
(n = 26)
No
57 (62)
19 (73)
38 (58)
Yes
35 (38)
7 (27)
28 (42)
Contacted health care professional before readmission
Among patients who reported a nonpreventable readmission, physician reviewers agreed 54% of the time. Among patients who reported a preventable readmission or jamainternalmedicine.com
.99
.06
.65
Abbreviation: PCP, primary care physician. a
