CLASSIFYING GENERAL MEDICINE READMISSIONS - ARE THEY PREVENTABLE

OBJECTIVES: To describe a new quality assessment method used to classi fy the preventability of hospitalization in terms of patient, clinicia n, or system factors. DESIGN:The instrument was developed in two phase s. Phase I was a prospective comparison of admitting residents' and th eir attending physicians' classifications of the perceived preventabil ity of consecutive admissions to one Veterans Affairs Medical Center ( VAMC) excluding admissions to the intensive care unit (ICU). In phase 2, a panel of 10 physicians rated 811 abstracted records of readmissio ns from nine VAMCs. SETTING: Nine VAMCs across the United States with varying degrees of university hospital affiliation. PATIENTS: Phase 1, 156 patients admitted to the general medicine service at the Durham V AMC. Phase 2, 514 patients accounting for 811 readmissions within 6 mo nths of a general medicine service discharge at nine VAMCs. MEASUREMEN TS AND MAIN RESULTS: Physicians used a checklist to record the reason for hospitalization, the preventability of the hospitalization, and, i f preventable, a reason defining preventability, which was classified in terms of system, clinician, and patient factors. In phase 2, two ph ysician panelists assessed preventability for each chart. When two pan elists disagreed on the preventability of hospitalization, a third pan elist, blind to the original assessments, rated the chart. In phase 1, residents and attending physicians rated 33% and 34% of admissions as preventable (kappa = 0.41), respectively. In phase 2, 277 (34%) of 81 1 readmissions were deemed preventable. Intraobserver accuracy for the assessment of preventability was 96% (kappa = 0.89). Interobserver ac curacy was 73% (kappa = 0.43). Hospital system factors accounted for 3 7% of preventable readmissions, clinician factors for 38%, and patient factors for 21%. The nine hospitals differed markedly in their profil e of reasons for preventable readmissions (p = .005). CONCLUSIONS: Usi ng a new method of determining the preventability of hospitalizations, we identified several factors that might avert hospitalizations. Focu sing efforts to identify preventable hospitalizations may yield better methods for managing patients' total health care needs: however, the content of those efforts will vary by institution.