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BMC Health Services Research
Published in: BMC Health Services Research 1/2018

Open Access 01-12-2018 | Research article

Exploring physicians’ decision-making in hospital readmission processes - a comparative case study

Authors: Malin Knutsen Glette, Tone Kringeland, Olav Røise, Siri Wiig

Published in: BMC Health Services Research | Issue 1/2018

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Abstract

Background

Hospital readmissions is an increasingly serious international problem, associated with higher risks of adverse events, especially in elderly patients. There can be many causes and influential factors leading to hospital readmissions, but they are often closely related, making hospital readmissions an overall complex area. In addition, a comprehensive coordination reform was introduced into the Norwegian healthcare system in 2012. The reform changed the premises for readmissions with economic incentives enhancing early transfer from secondary to primary care, making research on readmissions in the municipalities more urgent than ever. General practitioners (GPs) and nursing home physicians, have traditionally held a gatekeepers function in hospital readmissions from the municipal healthcare service, as they are the main decision-makers in questions of hospital readmissions. Still, the GPs’ gatekeeper function is an under-investigated area in hospital readmission research. The aim of the study was to increase knowledge about factors that lead to hospital readmissions among elderly in municipal healthcare, with special attention to GPs’ and nursing home physicians’ decision making.

Method

The study was conducted as a comparative case study. Two municipalities affiliated with the same hospital, but with different readmission rates were recruited. Twenty GPs and nursing home physicians from each municipality were recruited and interviewed. Forty hours of observation were conducted during the huddles in one long-term and one short-term nursing home in each municipality.

Results

Seven themes describing how different factors influence physicians’ decision-making in the hospital readmission process in two municipalities were identified. Poor communication, continuity and information flow account for hospital readmissions in both municipalities. Several factors, including nurse staffing and competence, patients and their families, time constraints and experience affected physicians’ decision-making.

Conclusion

Communication, continuity and information flow contributed to hospital readmissions in both municipalities. The cross-case analysis revealed slight differences between municipalities. More research focusing on GPs’ and nursing home physicians’ decision-making, nursing home nurses and home care nurses’ experience of hospital readmissions and discharges is needed.
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Literature
1.
Blunt I, Bardsley M, Grove A, Clarke A. Classifying emergency 30-day readmissions in England using routine hospital data 2004–2010: what is the scope for reduction? Emerg Med J. 2014;32(1):44-50.CrossRef
2.
Fluitman KS, van Galen LS, Merten H, Rombach SM, Brabrand M, Cooksley T, Nickel CH, Subbe CP, Kramer MHH, Nanayakkara PWB. Exploring the preventable causes of unplanned readmissions using root cause analysis: coordination of care is the weakest link. Eur J Intern Med. 2016;30:18–24.CrossRef
3.
Van Galen LS, Brabrand M, Cooksley T, van de Ven PM, Merten H, So RK, van Hooff L, Haak HR, Kidney RM, Nickel CH, et al. Patients’ and providers’ perceptions of the preventability of hospital readmission: a prospective, observational study in four European countries. BMJ Qual Saf. 2017;26(12):958–69.CrossRef
4.
Gusmano M, Rodwin V, Weisz D, Cottenet J, Quantin C. Comparison of rehospitalization rates in France and the United States. J Health Serv Res Policy. 2015;20(1):18–25.CrossRef
5.
Heim N, van Fenema EM, Weverling-Rijnsburger AWE, Tuijl JP, Jue P, Oleksik AM, Verschuur MJ, Haverkamp JS, Blauw GJ, van der Mast RC, et al. Optimal screening for increased risk for adverse outcomes in hospitalised older adults. Age & Ageing. 2015;44(2):239–44.CrossRef
6.
Hauck K, Zhao X. How dangerous is a day in hospital? A model of adverse events and length of stay for medical inpatients. Med Care. 2011;49(12):1068–75.CrossRef
7.
Donzé J, Lipsitz S, Bates DW, Schnipper JL. Causes and patterns of readmissions in patients with common comorbidities: retrospective cohort study. BMJ. 2013;347.CrossRef
8.
Graham KL, Wilker EH, Howell MD, Davis RB, Marcantonio ER. Differences between early and late readmissions among medical patients, a cohort study. Ann Intern Med. 2015;162(11):741–9.CrossRef
9.
Schou L, Anja HS, Kristoffersen DT, Tomic O, Helgeland J. 30-dagers reinnleggelse av eldre 2011–2013 – resultater for sykehus og kommuner (English title: 30-day readmission of elderly patients 2011–2013 - results for hospitals and municipalities). Norwegian Knowledge Centre for the Health Services: Oslo; 2015.
10.
Shaffer M. Automating data gathering to assist home health clinicians with planning care to reduce re-hospitalization. Nursing Informatics Today. 2013;28(4):4–6.
11.
Linertová R, García-Pérez L, Vázquez-Díaz JR, Lorenzo-Riera A, Sarría-Santamera A. Interventions to reduce hospital readmissions in the elderly: in-hospital or home care. A systematic review. J Eval Clin Pract. 2011;17(6):1167–75.CrossRef
12.
Huseby BM, Tønnesen CN, Snøfugl G, Ødegaard H, Gjøen-Øien IJ, Kjelvik J, Mehus KH, Rønningen L, Sitter M, Røtnes S, et al. Samhandlingsstatistikk 2014–2015. Norwegian Directorate of Health: Oslo; 2015.
13.
Rossdale M, Kemple T, Payne S, Calnan M, Greenwood R. An observational study of variation in GPs’ out-of-hours emergency referrals. Br J Gen Pract. 2007;57(535):152–4.PubMedPubMedCentral
14.
Dempsey OP, Bekker HL. ‘Heads you win, tails I lose’: a critical incident study of GPs’ decisions about emergency admission referrals. Fam Pract. 2002;19(6):611–6.CrossRef
15.
Grant JA, Dowell J. A qualitative study of why general practitioners admit to community hospitals. Br J Gen Pract. 2002;52(481):628–35.PubMedPubMedCentral
16.
Giannini A, Consonni D. Physicians’ perceptions and attitudes regarding inappropriate admissions and resource allocation in the intensive care setting. Br J Anaesth. 2006;96(1):57–62.CrossRef
17.
Chapman GB, Sonnenberg FA, editors. Decision making in health care theory, psychology, and applications. Cambridge: Cambrigde University Press; 2000.
18.
Deschodt M, Flamaing J, Haentjens P, Boonen S, Milisen K. Impact of geriatric consultation teams on clinical outcome in acute hospitals: a systematic review and meta-analysis. BMC Med 2013;11(1):1–13.
19.
Feltner C, Jones CD, Cené CW, Zheng Z-J, Sueta CA, Coker-Schwimmer EJL, Arvanitis M, Lohr KN, Middleton JC, Jonas DE. Transitional care interventions to prevent readmissions for persons with heart failure: a systematic review and meta-analysis. Ann Intern Med. 2014;160(11):774–84.CrossRef
20.
Gilboa I, Schmeidler D. Cased-based decision theory. Q J Econ. 1995;110(3):605–39.CrossRef
21.
Yin RK. Applications of case study research. 3rd ed. Los Angeles: SAGE; 2012.
22.
Yin RK. Case study research : design and methods. 5th ed. Los Angeles: SAGE; 2014.
23.
Aase K, Schibevaag L, Waring J. Researching quality in care transitions international perspectives. Cham: Springer Nature; 2017.CrossRef
24.
25.
Helse og omsorgsdepartementet. Samhandlingsreformen. 2012.
26.
Abelsen B, Gaski M, Nødland SI, Stephansen A. Samhandlingsreformens konsekvenser for det kommunale pleie-og omsorgstilbudet. In: International Research Institute of Stavanger (IRIS); 2014.
27.
Skinner MS. Døgnåpne kommunale akuttenheter: En helsetjeneste-modell med rom for lokale organisasjonstilpasninger - municipal emergency bed units: a national health service model with scope for local adaptation. Tidsskrift for omsorgsforskning. 2015;1(02):131–44.
28.
The Norwegian Medical Association: Medisinskfaglig veileder for kommunale akutte døgnplasser (KAD) (English title: medical guide for municipal emergency bed units). In. Edited by Association TNM; 2014.
29.
Carayon P, Hundt AS, Karsh BT, Gurses AP, Alvarado CJ, Smith M, Brennan PF. Work system design for patient safety: the SEIPS model. Quality & Safety in Health Care. 2006;15(Suppl 1):50–8.CrossRef
30.
Fangen K. Deltagende observasjon, 2. utg. Bergen: Fagbokforl; 2010.
31.
Graneheim UH, Lundman B. Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Educ Today. 2004;24(2):105–12.CrossRef
32.
Gautun H, Syse A. Samhandlingsreformen Hvordan tar de kommunale helse- og omsorgstjenestene i mot det økte antallet pasienter som skrives ut fra sykehusene? (English title: The coordination, reform How do the municipal health and care services take on the increased numbers of patients discharged from the hospitals?). In: Norsk institutt for forskning om oppvekst, velferd og aldring (NOVA); 2013.
33.
Lie S. Status for samhandlingsreformen, Forvaltningsmessig følge med-rapport fra Helsedirektoratet juni 2015 (English title: status for the coordination reform, follow-up report from the Directorate of Health June 2015). In: Directorate of Health; 2015.
34.
Kristoffersen DT, Moen HT, Schou L, Anja, Tomic O, Helgeland J. Kvalitetsindikatoren 30-dagers reinnleggelse etter sykehusopphold 2014 – resultater for sykehus og kommuner 2014 (English title: quality indicator 30-day readmission after hospital stay 2014 - results for hospitals and municipalities). In: Institute of public health; 2016.
35.
The research council of Norway: Evaluering av samhandlingsreformen Sluttrapport fra styringsgruppen for forskningsbasert følgeevaluering av samhandlingsreformen (EVASAM) (English title: Evaluation of the cordination reform Final report from the Steering Group for Research-Based Follow-up Evaluation of the Coordination reform). In. Oslo: The research council of Norway; 2016.
36.
The Norwegian Medical Association: Overbelegg i Norske sykehus - en trussel mot pasientsikkerheten (English: overlay in Norwegian hospitals - a treath against patient safety); 2015.
37.
Glette MK. General practitioners decision-making in questions of hospital admissions—a review of the literature. In: Cepin M, Bris R, editors. ESREL 2017, conference proceedings. Portoroz: Slovenia CRC press Taylor & Francis group; 2017. p. 2468–72.
38.
The office of the Auditor General of Norway: Riksrevisjonens kontroll med forvaltningen av statlige selskaper for 2016 (English title: The Auditor General's control of the management of state companies for 2016). In.: The office of the Auditor General of Norway; 2017.
39.
Dispatch of epicrisis in somatic healthcare service. In. Norwegian patient register: Directorate of Health; 2017.
40.
Garåsen H, Johnsen R. The quality of communication about older patients between hospital physicians and general practitioners: a panel study assessment. BMC Health Serv Res. 2007;7(1):133.CrossRef
41.
Storm M, Siemsen IMD, Laugaland K, Dyrstad DN, Aase K. Quality in transitional care of the elderly: key challenges and relevant improvement measures. Int J Integr Care. 2014;14.
42.
Ofoma UR, Dong Y, Gajic O, Pickering BW. A qualitative exploration of the discharge process and factors predisposing to readmissions to the intensive care unit. BMC Health Serv Res. 2018;18(1):6.CrossRef
43.
Holen-Rabbersvik E, Eikebrokk TR, Fensli RW, Thygesen E, Slettebø Å. Important challenges for coordination and inter-municipal cooperation in health care services: a Delphi study. BMC Health Serv Res. 2013;13:451.CrossRef
44.
Kristoffersen DT, Hansen TM, Tomic O, Helgeland J. Kvalitetsindikatoren 30 dagers reinnleggelse etter sykehusopphold. Resultater for helseforetak og kommuner 2016. (English title: the quality indicator 30 day readmission after hospitalization results for Norwegian health trusts and municipalities 2016) in. Senter for omsorgsforskning: Oslo; 2016.
45.
Laugaland K, Aase K. Resilient health care, volume 2: the resilience of everyday clinical work, vol. 2. United Kingdom: Ashgate publishing; 2015.
46.
Aase K, Waring J, Schibevaag, L. Ed. Can an elephant crack a nut with a slegdehammer? How physicians cross boundaries. In Researching quality in care transitions: international perspectives, 223-239. Cham: Springer Nature; 2017.
47.
Østergaard D, Madsen MD, Petersen LF, Siemsen IM: Researching quality in care transitions: international perspectives Switzerland: springer nature; 2017.
48.
Pothier D, Monteiro P, Mooktiar M, Shaw A. Pilot study to show the loss of important data in nursing handover. Br J Nurs. 2005;14(20):1090–3.CrossRef
49.
50.
Ringberg U, Fleten N, Forde OH. Examining the variation in GPs’ referral practice: a cross-sectional study of GPs’ reasons for referral. Br J Gen Pract. 2014;64(624):426–33.CrossRef
51.
McDermott C, Coppin R, Little P, Leydon G. Hospital admissions from nursing homes: a qualitative study of GP decision making. Br J Gen Pract. 2012;62(601):538–45.CrossRef
52.
Calnan M, Payne S, Kemple T, Rossdale M, Ingram J. A qualitative study exploring variations in GPs’ out-of-hours referrals to hospital. Br J Gen Pract. 2007;57(542):706–13.PubMedPubMedCentral
53.
Escher M, Perneger TV, Chevrolet J-C. National questionnaire survey on what influences doctors’ decisions about admission to intensive care. BMJ. 2004;329(7463):425.CrossRef
54.
Bing-Jonsson PC, Hofoss D, Kirkevold M, Bjørk IT, Foss C. Sufficient competence in community elderly care? Results from a competence measurement of nursing staff. BMC Nurs. 2016;15:1–11.CrossRef
55.
Skinner MS. Skeptiske leger og tomme senger? Bruken av de kommunale akutte døgnplassene. In: Senter for omsorgsforskning; 2015.
56.
Bruvik F, Drageset J, Abrahamsen JF. Fra sykehus til sykehjem – hva samhandlingsreformen har ført til (English title: from hospitals to nursing homes - what the coordination reform has led to). Sykepleien Forskning. 2017;422(2017.60613):10.
57.
Office of The Auditor General of Norway. Riksrevisjonens undersøkelse av ressursutnyttelse og kvalitet i helsetjenesten etter innføringen av samhandlingsreformen. Oslo: Office of The Auditor General of Norway; 2016.
58.
Carayon P, Schoofs Hundt A, Karsh BT, Gurses AP, Alvarado CJ, Smith M, Flatley Brennan P. Work system design for patient safety: the SEIPS model. Qual Saf Health Care. 2006;15(Suppl 1):i50–8.CrossRef
Metadata
Title
Exploring physicians’ decision-making in hospital readmission processes - a comparative case study
Authors
Malin Knutsen Glette
Tone Kringeland
Olav Røise
Siri Wiig
Publication date
01-12-2018
Publisher
BioMed Central
Published in
BMC Health Services Research / Issue 1/2018
Electronic ISSN: 1472-6963
DOI
https://doi.org/10.1186/s12913-018-3538-3

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