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Medical and Surgical Readmissions in the Veterans Health Administration: What Proportion are Related to the Index Hospitalization?

Rosen, Amy K. PhD*,†; Chen, Qi MD, PhD*; Shin, Marlena H. JD, MPH*; O’Brien, William MS*; Shwartz, Michael PhD, MBA*,‡; Mull, Hillary J. PhD, MPP*,†; Cevasco, Marisa MD, MPH§; Borzecki, Ann M. MD, MPH*,∥,¶,#

doi: 10.1097/MLR.0000000000000081
Brief Report

Background: Readmissions are an attractive quality measure because they offer a broad view of quality beyond the index hospitalization. However, the extent to which medical or surgical readmissions reflect quality of care is largely unknown, because of the complexity of factors related to readmission. Identifying those readmissions that are clinically related to the index hospitalization is an important first step in closing this knowledge gap.

Objectives: The aims of this study were to examine unplanned readmissions in the Veterans Health Administration, identify clinically related versus unrelated unplanned readmissions, and compare the leading reasons for unplanned readmission between medical and surgical discharges.

Methods: We classified 2,069,804 Veterans Health Administration hospital discharges (Fiscal Years 2003–2007) into medical/surgical index discharges with/without readmissions per their diagnosis-related groups. Our outcome variable was “all-cause” 30-day unplanned readmission. We compared medical and surgical unplanned readmissions (n=217,767) on demographics, clinical characteristics, and readmission reasons using descriptive statistics.

Results: Among all unplanned readmissions, 41.5% were identified as clinically related. Not surprisingly, heart failure (10.2%) and chronic obstructive pulmonary disease (6.5%) were the top 2 reasons for clinically related readmissions among medical discharges; postoperative complications (ie, complications of surgical procedures and medical care or complications of devices) accounted for 70.5% of clinically related readmissions among surgical discharges.

Conclusions: Although almost 42% of unplanned readmissions were identified as clinically related, the majority of unplanned readmissions were unrelated to the index hospitalization. Quality improvement interventions targeted at processes of care associated with the index hospitalization are likely to be most effective in reducing clinically related readmissions. It is less clear how to reduce nonclinically related readmissions; these may involve broader factors than inpatient care.

Supplemental Digital Content is available in the text.

*Center for Healthcare Organization and Implementation Research (CHOIR)

Department of Surgery, Boston University School of Medicine

Department of Operations and Technology Management, Boston University School of Management

§Department of Surgery, Brigham and Women’s Hospital, Boston

Center for Healthcare Organization and Implementation Research (CHOIR), Bedford

Section of General Internal Medicine, Boston University School of Medicine

#Department of Health Policy and Management, Boston University School of Public Health, Boston, MA

Supplemental Digital Content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website,

Supported by the Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development, SDR #07-002.

The authors declare no conflict of interest.

Reprints: Amy K. Rosen, PhD, Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, 150 S. Huntington Avenue (152 M), Boston, MA 02130. E-mail:

© 2014 by Lippincott Williams & Wilkins.