Inaccessible Outpatient Care Is Linked With Late Hospital Readmissions

Unplanned hospital readmissions, which affect more than 18% of Medicare beneficiaries each year, are generally understood to be tied to gaps in care coordination between hospitals and community healthcare providers, and new research suggests that readmission more than a week after discharge may be tied to patients’ inability to access appropriate outpatient care after discharge.

Presenting their findings in the Annals of Internal Medicine, a research team led by Kelly L. Graham, MD, MPH, Director of Ambulatory Residency Training at Beth Israel Deaconess Medical Center and an instructor in medicine at Harvard Medical School, sought to determine whether there was a difference between hospital readmissions that occur early (within 7 days of discharge) and those that occur later (8 days to 30 days after discharge).

The prospective cohort study involved 822 adult patients who were readmitted to 10 US-based academic medical centers in the Hospital Medicine Reengineering Network in 2013. The research team used a structured survey, administered by 2 site-specific physician adjudicators, to assess whether each readmission was preventable in nature. They found that, among early readmissions, 36.2% were classified as preventable, whereas 23.0% of the late readmissions were preventable (median risk difference, 13.0 percentage points; interquartile range [IQR], 5.5-26.4).

Across the various sites, hospitals, rather than outpatient clinics, were more likely to be identified by the adjudicators as an ideal location to prevent early readmissions (47.2% vs 25.5%; median risk difference, 22.8 percentage points; IQR, 17.9-31.8), and causal factors for early readmission were frequently related to physician decision making concerning diagnosis and management during the patient’s initial hospitalization.

However, among the group of patients with late readmission, outpatient clinics were more likely than hospitals to be identified as an ideal site for prevention (15.2% vs 6.6%; median risk difference, 10.0 percentage points; IQR, 4.6-12.2), as interventions that could have prevented these readmissions were more likely to take place outside the hospital. Such interventions include outpatient appointment availability within an appropriate timeframe for patient monitoring and symptom management by primary care clinicians.

The authors add that long wait times for follow-up visits and patients’ inability to keep appointments with primary care providers after discharge were more often cited as causes for late readmission than early readmission, pointing to a need for better postdischarge monitoring.

“Our findings suggest that the 30 days following hospital discharge are not the same with regard to what influences outcomes for sick patients, and that the current model oversimplifies this high-risk time,” said Graham in a statement. “One potential unintended consequence of this is that outpatient environments have not been involved in efforts to manage this high-risk timeframe, which results in poorly coordinated care and worse outcomes for our patients.”

Reference

Graham KL, Auerbach AD, Schnipper JL, et al. Preventability of early versus late hospital readmissions in a national cohort of general medicine patients. Ann Intern Med. 2018;168(11):766-774. doi: 10.7326/M17-1724.