Preventable Admissions on a General Medicine Service: Prevalence, Causes and Comparison with AHRQ Prevention Quality Indicators—A Cross-Sectional Analysis

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Abstract

<div class="section"> <a class="named-anchor" id="d586127e194">  </a> <h5 class="section-title" id="d586127e195">Background</h5> <p id="d586127e197">Rates of preventable admissions will soon be publicly reported and used in calculating performance-based payments. The current method of assessing preventable admissions, the Agency of Healthcare Research and Quality (AHRQ) Preventable Quality Indicators (PQI) rate, is drawn from claims data and was originally designed to assess population-level access to care. </p> </div><div class="section"> <a class="named-anchor" id="d586127e199">  </a> <h5 class="section-title" id="d586127e200">Objective</h5> <p id="d586127e202">To identify the prevalence and causes of preventable admissions by attending physician review and to compare its performance with the PQI tool in identifying preventable admissions. </p> </div><div class="section"> <a class="named-anchor" id="d586127e204">  </a> <h5 class="section-title" id="d586127e205">Design</h5> <p id="d586127e207">Cross-sectional survey.</p> </div><div class="section"> <a class="named-anchor" id="d586127e209">  </a> <h5 class="section-title" id="d586127e210">Setting</h5> <p id="d586127e212">General medicine service at an academic medical center.</p> </div><div class="section"> <a class="named-anchor" id="d586127e214">  </a> <h5 class="section-title" id="d586127e215">Participants</h5> <p id="d586127e217">Consecutive inpatient admissions from December 1–15, 2013.</p> </div><div class="section"> <a class="named-anchor" id="d586127e219">  </a> <h5 class="section-title" id="d586127e220">Main Measures</h5> <p id="d586127e222">Survey of inpatient attending physicians regarding the preventability of the admissions, primary contributing factors and feasibility of prevention. For the same patients, the PQI tool was applied to determine the claims-derived preventable admission rate. </p> </div><div class="section"> <a class="named-anchor" id="d586127e224">  </a> <h5 class="section-title" id="d586127e225">Key Results</h5> <p id="d586127e227">Physicians rated all 322 admissions and classified 122 (38 %) as preventable, of which 31 (25 %) were readmissions. Readmissions were more likely to be rated preventable than other admissions (49 % vs. 35 %, <i>p</i> = 0.04). Application of the AHRQ PQI methodology identified 75 (23 %) preventable admissions. Thirty-one admissions (10 %) were classified as preventable by both methods, and the majority of admissions considered preventable by the AHRQ PQI method (44/78) were not considered preventable by physician assessment ( <i>K</i> = 0.04). Of the preventable admissions, physicians assigned patient factors in 54 (44 %), clinician factors in 36 (30 %) and system factors in 32 (26 %). </p> </div><div class="section"> <a class="named-anchor" id="d586127e235">  </a> <h5 class="section-title" id="d586127e236">Conclusions</h5> <p id="d586127e238">A large proportion of admissions to a general medicine service appeared preventable, but AHRQ’s PQI tool was unable to identify these admissions. Before initiation of the PQI rate for use in pay-for-performance programs, further study is warranted. </p> </div><div class="section"> <a class="named-anchor" id="d586127e240">  </a> <h5 class="section-title" id="d586127e241">Electronic supplementary material</h5> <p id="d586127e243">The online version of this article (doi:10.1007/s11606-016-3615-4) contains supplementary material, which is available to authorized users. </p> </div>

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Most cited references 8

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The rate and cost of hospital readmissions for preventable conditions.

Bernard Friedman, J Basu (2004)

The study estimates the rate and cost of preventable readmissions within 6 months after a first preventable admission, by age-group, and by payer and race within age-group. The descriptive results are contrasted with several hypotheses. The hospital discharge data are for residents of New York, Pennsylvania, Tennessee, and Wisconsin in 1999, from files of the Healthcare Cost and Utilization Project of the Agency for Healthcare Research and Quality. About 19 percent of persons with an initial preventable admission had at least one preventable readmission rate within 6 months. Hospital cost for preventable readmissions during 6 months was about 730 million US dollars. There were substantial differences in readmission rates by payer group and by race. Some evidence suggests that preventable readmissions may partly reflect complexity of underlying problems. Interventions to reduce cost might focus on identifying high-risk patients before discharge and devising new approaches to follow-up.

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Preventable Hospitalizations and Access to Health Care

Andrew B. Bindman (1995)

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Association between quality improvement for care transitions in communities and rehospitalizations among Medicare beneficiaries.

Alicia Goroski, Kimberly Irby, T Archibald … (2013)

Medicare beneficiaries experience errors during transitions among care settings, yielding harms that include unnecessary rehospitalizations. To evaluate whether implementation of improved care transitions for patients with Medicare fee-for-service (FFS) insurance is associated with reduced rehospitalizations and hospitalizations in geographic communities. Quality improvement initiative for care transitions by health care and social services personnel and Medicare Quality Improvement Organization staff in defined geographic areas, with monitoring by community-specific and aggregate control charts and evaluation with pre-post comparison of performance differences for 14 intervention communities and 50 comparison communities from before (2006-2008) and during (2009-2010) implementation. Intervention communities had between 22,070 and 90,843 Medicare FFS beneficiaries. Quality Improvement Organizations facilitated community-wide quality improvement activities to implement evidence-based improvements in care transitions by community organizing, technical assistance, and monitoring of participation, implementation, effectiveness, and adverse effects. The primary outcome measure was all-cause 30-day rehospitalizations per 1000 Medicare FFS beneficiaries; secondary outcome measures were all-cause hospitalizations per 1000 Medicare FFS beneficiaries and all-cause 30-day rehospitalizations as a percentage of hospital discharges. The mean rate of 30-day all-cause rehospitalizations per 1000 beneficiaries per quarter was 15.21 in 2006-2008 and 14.34 in 2009-2010 in the 14 intervention communities and was 15.03 in 2006-2008 and 14.72 in 2009-2010 in the 50 comparison communities, with the pre-post between-group difference showing larger reductions in rehospitalizations in intervention communities (by 0.56/1000 per quarter; 95% CI, 0.05-1.07; P = .03). The mean rate of hospitalizations per 1000 beneficiaries per quarter was 82.27 in 2006-2008 and 77.54 in 2009-2010 in intervention communities and was 82.09 in 2006-2008 and 79.48 in 2009-2010 in comparison communities, with the pre-post between-group difference showing larger reductions in hospitalizations in intervention communities (by 2.12/1000 per quarter; 95% CI, 0.47-3.77; P = .01). Mean community-wide rates of rehospitalizations as a percentage of hospital discharges in the intervention communities were 18.97% in 2006-2008 and 18.91% in 2009-2010 and were 18.76% in 2006-2008 and 18.91% in 2009-2010 in the comparison communities, with no significant difference in the pre-post between-group differences (0.22%; 95% CI, -0.08% to 0.51%; P = .14). Process control charts signaled onset of improvement coincident with initiating intervention. Among Medicare beneficiaries in intervention communities, compared with those in uninvolved communities, all-cause 30-day rehospitalization and all-cause hospitalization declined. However, there was no change in the rate of all-cause 30-day rehospitalizations as a percentage of hospital discharges.