Which Readmissions May Be Preventable? Lessons Learned From a Posthospitalization Care Transitions Program for High-risk Elders (original) (raw)

Background-Care transitions programs have been shown to reduce hospital readmissions. Objectives-Evaluate effects of the Mayo Clinic Care Transitions program (MCCT) on potentially preventable and non-preventable 30-day unplanned readmissions among high risk elders. Research Design-Retrospective cohort study of patients enrolled in MCCT following hospitalization and propensity score-matched controls receiving usual primary care. Subjects-Primary care patients ≥60 years, at high risk for readmission, hospitalized for any cause between January 1, 2011 and June 30, 2013. Measures-30-day hospital readmission. The 3M™ algorithm was used to identify potentially preventable readmissions. Readmissions for ambulatory care sensitive conditions (ACSCs), a subset of preventable readmissions identified by the 3M algorithm, were also assessed. Results-The study cohort included 365 pairs of MCCT enrollees and propensity score-matched controls. Patients were similar in age (mean 83 years) and other baseline demographic and clinical characteristics, including reason for index hospitalization. MCCT enrollees had a significantly lower all-cause readmission rate (12.4% [95% CI, 8.9-15.7] vs. 20.1% [15.8-24.1]; p=0.004) resulting from a decrease in potentially preventable readmissions (8.4% [95% CI, 5.5-11.3] vs.

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