Characterizing Potentially Preventable Admissions: A Mixed Methods Study of Rates, Associated Factors, Outcomes, and Physician Decision-Making

Lisa M. Daniels, Atsushi Sorita, Deanne T. Kashiwagi, Masashi Okubo, Evan Small, Eric C. Polley, Adam P. Sawatsky

Potentially preventable admissions are a target for healthcare cost containment. To identify rates of, characterize associations with, and explore physician decision-making around potentially preventable admissions. A comparative cohort study was used to determine rates of potentially preventable admissions and to identify associated factors and patient outcomes. A qualitative case study was used to explore physicians' clinical decision-making. Patients admitted from the emergency department (ED) to the general medicine (GM) service over a total of 4 weeks were included as cases (N = 401). Physicians from both emergency medicine (EM) and GM that were involved in the cases were included (N = 82). Physicians categorized admissions as potentially preventable. We examined differences in patient characteristics, admission characteristics, and patient outcomes between potentially preventable and control admissions. Interviews with participating physicians were conducted and transcribed. Transcriptions were systematically analyzed for key concepts regarding potentially preventable admissions. EM and GM physicians categorized 22.2% (90/401) of admissions as potentially preventable. There were no significant differences between potentially preventable and control admissions in patient or admission characteristics. Potentially preventable admissions had shorter length of stay (2.1 vs. 3.6 days, p < 0.001). There was no difference in other patient outcomes. Physicians discussed several provider, system, and patient factors that affected clinical decision-making around potentially preventable admissions, particularly in the "gray zone," including risk of deterioration at home, the risk of hospitalization, the cost to the patient, and the presence of outpatient resources. Differences in provider training, risk assessment, and provider understanding of outpatient access accounted for differences in decisions between EM and GM physicians. Collaboration between EM and GM physicians around patients in the gray zone, focusing on patient risk, cost, and outpatient resources, may provide an avenues for reducing potentially preventable admissions and lowering healthcare spending.