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.


Patients with illnesses that last a long time often have a hard time taking care of themselves after they go home from the hospital. Some end up returning to the hospital to get help soon after they go home.

Having to go back to the hospital can be hard on patients and their caregivers, but there is little information about how to prevent it from happening. There are no good ways to know which patients are more likely to have problems and need to go back to the hospital.

Project Purpose

The research team wanted to find out which challenges patients with long-term health problems were having that made them decide to go back to the hospital soon after they left. By better understanding these challenges, doctors might be able to help patients manage their illness better at home.

The researchers focused on patients with heart failure, their caregivers, and their doctors. In people who have heart failure, the heart doesn’t pump blood as well as it should, leading to tiredness and shortness of breath.


The researchers studied patients with heart failure from two hospitals in the same health system. They interviewed the patients and their caregivers individually and in groups. The research team also sent a survey to patients and caregivers. The researchers also interviewed the patients’ doctors.

Researchers looked at whether patients went back to the hospital within 30 days of leaving. They also looked at health information from patient medical records and what participants said was important to patients.

The study had four parts.

Part 1: The researchers first wanted to get as many ideas as possible about why patients might return to the hospital. They interviewed

  • 57 patients who went to the hospital for heart failure
  • 27 caregivers
  • 67 doctors

Part 2: The researchers interviewed

  • 16 heart failure patients who had to go back to the hospital within 30 days of leaving
  • 15 heart failure patients who left the hospital and were still at home 30 days later

They asked more detailed questions about why they had returned to the hospital or had been able to stay at home.

Part 3: The researchers created a survey with 30 questions based on what they learned from the interviews. The researchers gave the survey to 202 patients who were in the hospital for heart failure. After these patients left the hospital, researchers tracked them for 30 days to see which people needed to go back for more care. The researchers looked at the survey answers to find out which types of challenges made it more likely that patients would go back to the hospital.

Part 4: The researchers talked with 19 patients and 11 caregivers in groups. During these group discussions, the researchers shared what they learned during the other phases of research and asked if patients and caregivers agreed with their findings.


Parts 1 and 2: Interviews with patients, caregivers, and doctors. Researchers identified a number of reasons that make living with heart failure difficult:

  • Patients talked about problems managing symptoms at home.
  • Caregivers talked about difficulties in managing daily tasks.
  • Doctors talked about patients’ problems with taking their medications as prescribed.

Part 3: Survey of patients and caregivers. Patients had different types of problems at home. The researchers didn’t find anything that would tell them whether a patient was likely to go back to the hospital.

Part 4: Group discussions with patients and caregivers. People in the group discussions agreed with what patients and caregivers had said during interviews and in survey responses. People in the group discussions also thought that in order to keep patients from going back to the hospital, help should be available for patients who

  • Feel alone and isolated at home
  • Worry about their symptoms

Finally, researchers learned that patients do not like going back to the hospital, but they think it’s the right choice if they are feeling very sick.


All of the people in this study came from two hospitals. Results might be different if the researchers studied people at many different hospitals.


There are many reasons why patients go back to the hospital. This study didn’t find links between the types of problems that patients had and whether they decided to go back to the hospital within 30 days of leaving. Because patients have different types of problems, a one-size-fits-all approach to helping patients manage their illnesses at home might not help people avoid return trips to the hospital. Patients might need solutions that match their individual needs.

Sharing the Results

The researchers presented their results at scientific meetings and have written articles for journals.

Project Information

Stephen E. Kimmel, MD, MSCE
The Trustees of the University of Pennsylvania
Patient and Provider Perspectives on Reasons for Hospital Re-admissions

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 4, 2022