Results Summary
PCORI funded the Pilot Projects to explore how to conduct and use patient-centered outcomes research in ways that can better serve patients and the healthcare community. Learn more.
Background
Making sure patients can recover at home after being in the hospital is an important goal in health care, but it is often hard to predict which patients will be able to do that successfully. Also, if patients have to go back into the hospital soon after treatment, some kinds of insurance pay the hospitals less for care. As a result, hospitals want to find ways to figure out which patients might come back to the hospital because they do not have the support they need at home to help them get better. Going back to the hospital soon after an earlier stay is called a readmission.
Project Purpose
The goal of this study was to develop a survey healthcare providers could use before patients leave the hospital to identify patients’ needs at home and help prevent unnecessary return trips. The researchers called this survey the Patient Readmission Evaluation Tool (PRET).
Methods
The researchers’ first step was to do 36 interviews to find out what types of problems might make patients more likely to be readmitted. The people interviewed in this study were getting care or working at Boston Medical Center. The research team talked to
- Patients who had been readmitted to the hospital
- Families of readmitted patients
- Doctors and nurses who work with patients who are getting ready to leave the hospital
- Researchers who study the best ways to help patients recover safely at home after being in the hospital
The research team also looked at patients’ medical records.
The research team summarized the ideas that came out of the interviews. The team then wrote survey questions based on the ideas the surveyed people had about why patients return to the hospital. They used these questions to prepare the first version of the PRET. Next, the researchers asked 157 people to look at the survey. The researchers wanted to see whether people thought the questions meant what the researchers had intended.
Findings
The researchers found four main types of reasons why patients return to the hospital after being treated:
- Life structure: Some patients did not have a place to live, enough money to live on, or health insurance.
- Health care: Some patients had problems using the health system. These problems included not having a primary doctor, not being able to get medicine, and not having transportation to the doctor.
- Support: Some patients did not have the kind of help or emotional support that they needed at home.
- Taking care of oneself: Some patients did not feel that they could take care of themselves at home.
Limitations
Everyone who took part in this study got care or worked at one large hospital in Boston. The results might be different at other hospitals.
Importance of Findings
This study found four types of reasons that might make patients more likely to return to the hospital after treatment. The research team used these findings to create a survey to help providers identify these problems before patients go home. If these problems can be solved before patients go home, then the patients might not have to return to the hospital.
Future Research
After additional testing of PRET, the next step would be to make a computer version that is easier to use.
Professional Abstract
PCORI funded the Pilot Projects to explore how to conduct and use patient-centered outcomes research in ways that can better serve patients and the healthcare community. Learn more.
Background
The need to address gaps in transitional care has received significant attention since the Centers for Medicare and Medicaid Services (CMS) began imposing financial penalties on hospitals for excess readmissions in 2012. Several evidence-based interventions and risk prediction models have been implemented to streamline patient discharge and improve patient care transitions. However, most of these interventions and models have performed poorly, in part due to their failure to address patients’ needs outside of medical care. In this study, researchers used qualitative methods to identify patient-centered domains for inclusion in readmission risk prediction models to more efficiently and accurately anticipate patients’ needs during care transitions.
Project Purpose
The goal of this study was to develop the Patient Readmission Evaluation Tool (PRET), a patient-centered analytical tool designed to help medical professionals better understand the events that lead to hospital readmission. It was anticipated that the PRET could be used by providers to efficiently identify and address patients’ medical and social needs to aid in care transitions and help prevent avoidable hospital readmissions.
Study Design
Qualitative interviews were conducted with key stakeholders and experts in care transition. The interviews identified medical errors and adverse events that occurred during and following hospitalization from the perspective of patients, families, and healthcare providers. Researchers conducted failure modes effect analysis, root cause analysis, and comparative narrative analyses. Informed by the qualitative data, researchers used a modified Delphi panel to design the PRET, which was then refined after cognitive testing.
Participants, Interventions, Settings, and Outcomes
The study included a total of 193 participants. Researchers conducted 36 qualitative interviews with stakeholders (readmitted patients, family caregivers, MDs, nurses) and 157 cognitive interviews.
The setting was inpatient general medicine and family medicine department at Boston Medical Center, a private, not-for-profit, 496-bed academic medical center.
Data Sources
Qualitative interviews with stakeholders and electronic medical records.
Data Analysis
Qualitative interviews were analyzed using comparative narrative analysis and root cause analysis. In addition, researchers used process maps of post-discharge tasks, chart review, and failure mode effects analysis to explore patient-identified antecedents to readmission. Finally, the research team periodically convened a modified Delphi panel comprised of inpatient and outpatient providers, the Medical Legal Partnership-Boston, case management, and other care providers with knowledge about hospital readmissions. Emerging themes from the qualitative interviews and feedback from the Delphi panel were incorporated into the evolving conceptual model. From these themes, researchers developed a bank of questions that they used to develop and later refine the PRET.
Findings
Key themes included patient-identified antecedents for hospital readmission, which the researchers aggregated into four domains:
- Societal Influences: Patients viewed certain factors that contributed to their re-hospitalization as structural and therefore out of their control. These societal influences included housing environment, access to health insurance, and socioeconomic status.
- Patients’ Experience of Care: Patients’ experiences of care were identified as reliable antecedents for hospital readmission, especially for those patients who had unsatisfactory interactions with healthcare systems. Events during and immediately following hospital discharge, a patient’s relationship or lack thereof with primary care, and access to health care (including access to transportation, medical devices, medicine, and providers) are all factors that heavily impact a patient’s experience.
- Psychosocial Well-Being: Some participants identified caregivers, social support (or a lack thereof), isolation, and loneliness as being linked to their rehospitalizations.
- Self-Care Management: This broad class included intrinsic patient attributes such as behaviors, attitudes, and perceptions that ultimately influence self-care.
Limitations
There were some limitations to this exploratory study. First, this study was limited in scope. The sample size was small, and all interview participants were associated with Boston Medical Center, which is unique in its geography and in the community it serves. Findings may not be generalizable outside this setting.
Conclusions
This study identified four patient-centered domains that may be antecedents to hospital readmissions. Researchers used these domains to inform the development of the PRET, which can be used to identify social factors affecting individual patients. If the PRET is successful in effectively identifying patients at highest risk for readmission, it may be a useful tool for improving transitional care.