Background:

Early readmission is considered to be an indicator of healthcare quality as well as of utilization. Characterizing sub–groups among readmitted patients can guide quality improvement efforts.

Methods:

We conducted an IRB–approved mixed–methods study of readmitted adults at a 365 bed teaching hospital. 1) We prospectively screened all admissions to identify patients who had been discharged from the hospitalist service within 30 days. 2) A trained research assistant reviewed the index admission and readmission records to collect demographic and health information. 3) Patients were then interviewed using a brief structured questionnaire to ask why they returned to the hospital, whether they felt ready for the index discharge, and whether they had unmet needs after the index discharge. Patients were also asked to rate the patient–centeredness of the index discharge using the Care Transitions Measure and to explain the reason for their rating. 4) We asked hospitalists who had cared for a patient to comment on the preventability of the readmission. 5) We followed patients for 6 months after the index discharge to categorize the episode as an isolated readmission (IR, 1 readmission/6 mos) or part of serial readmissions (SR, >1 readmission/6 mos). All abstracted data and interview responses were transcribed and coded. We used a grounded theory approach to identify emergent themes.

Results:

We identified 82 readmissions involving 76 patients. Median time to readmission was 14.5 days (range 0–30 days). In the 6 months after index discharge, 23 (30.3%) were readmitted once and 53 (69.7%) were readmitted >1 time (range 2–12 times). Only (23.7%) patients rated their index discharge as not patient–centered. Emerging themes related to lack of patient–centeredness include perceptions of poor communication, unmet expectations (for discharge and for service), and non–improvement of clinical condition. These themes were expressed by both IR and SR patients. Hospitalists provided comments for 66 (80.5%) encounters involving 64 patients. Emerging themes related to the etiology and preventability of readmission include new medical problem, suboptimal quality of care (e.g., fall at skilled nursing facility), care coordination issues (e.g., lack of PCP), disease progression, patient non–adherence, psychiatric illness, and substance abuse. IR patients appeared to be readmitted for suboptimal quality of care and care coordination issues, whereas SR patients were readmitted for disease progression, psychiatric illness and substance abuse.

Conclusions:

Isolated readmissions may be reduced by improving care coordination and quality of care. Communication and expectation management can improve patient–centeredness of discharge processes. In contrast, serial rehospitalizations often result from advanced physiologic or psychiatric disease that only complex systems–wide interventions can modify. Hospitals should apply different targeted interventions for IR and SR populations.