Table 2

Factors contributing to potentially preventable readmissions according to physician and nurse opinion

P value
Preventable readmission or undecided81(29.3)93(33.7)174(31.5)0.14
 Care during index stay*45(16.3)69(25.0)114(20.6)0.01
 Discharge process†17(6.2)12(4.3)29(5.2)0.45
 Follow-up care‡40(14.5)14(5.1)54(9.8)<0.001
  • *Care during index stay included: (a) inattention to advance care planning, (b) suboptimal management of chronic condition (c) unrecognised worsening condition, (d) suboptimal coordination of care, (e) patient unstable at discharge or discharged too soon, (e) medication error, (f) missed or inaccurate diagnosis and (g) surgical/procedural complication.

  • †Discharge process included: (a) transition care plan absent or inadequate, (b) unaddressed psychological and social needs, (c) inadequate assessment of patient or caregiver understanding or ability, (d) delayed/inaccurate information from hospital to outpatient providers and (e) inadequate arrangements for supplies.

  • ‡Follow-up care included: (a) inadequate attention to psychological or social needs, (b) suboptimal management of index satay condition, (c) suboptimal management of chronic condition, (d) medication error, (e) inadequate patient instructions, (f) poor coordination between inpatient and outpatient providers, (g) surgical/procedural complication, (h) missed or inaccurate diagnosis and (i) lack of follow-up on referrals made after discharge.