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.


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).


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.


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.


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. 

Project Information

Brian W. Jack, MD
Boston University School of Medicine/ Boston Medical Center
Developing an Analytic Tool to Assess Patient Responses

Key Dates

June 2012
June 2015

Study Registration Information


Has Results
Award Type
Funding Type
State State The state where the project originates, or where the primary institution or organization is located. View Glossary
Last updated: March 14, 2024