Jurnal Psychiatry
Jurnal Psychiatry
Abstract
Background: Studies that identify reasons for readmissions are gaining importance in the light of the changing
demographics worldwide which has led to greater demand for hospital beds. It is essential to profile the
prevalence of avoidable readmissions and understand its drivers so as to develop possible interventions for
reducing readmissions that are preventable. The aim of this study is to identify the magnitude of avoidable
readmissions, its contributing factors and costs in Hong Kong.
Methods: This was a retrospective analysis of 332,453 inpatient admissions in the Medical specialty in public
hospital system in Hong Kong in year 2007. A stratified random sample of patients with unplanned readmission
within 30 days after discharge was selected for medical record reviews. Eight physicians reviewed patients’ medical
records and classified whether a readmission was avoidable according to an assessment checklist. The results were
correlated with hospital inpatient data.
Results: It was found that 40.8% of the 603 unplanned readmissions were judged avoidable by the reviewers.
Avoidable readmissions were due to: clinician factor (42.3%) including low threshold for admission and premature
discharge etc.; patient factor (including medical and health factor) (41.9%) such as relapse or progress of previous
complaint, and compliance problems etc., followed by system factor (14.6%) including inadequate discharge
planning, inadequate palliative care/terminal care, etc., and social factor (1.2%) such as carer system, lack of support
and community services. After adjusting for patients’ age, gender, principal diagnosis at previous discharge and
readmission hospitals, the risk factors for avoidable readmissions in the total population i.e. all acute care
admissions irrespective of whether there was a readmission or not, included patients with a longer length of stay,
and with higher number of hospitalizations and attendance in public outpatient clinics and Accident and
Emergency departments in the past 12 months. In the analysis of only unplanned readmissions, it was found that
the concordance of the principal diagnosis for admission and readmission, and shorter time period between
discharge and readmission were associated with avoidable readmissions.
Conclusions: Our study found that almost half of the readmissions could have been prevented. They had been
mainly due to clinician and patient factors, in particular, both of which were intimately related to clinical
management and patient care. These readmissions could be prevented by a system of ongoing clinical review to
examine the clinical practice/decision for discharge, and improving clinical care and enhancing patient knowledge
of the early warning signs for relapse. The importance of adequate and appropriate ambulatory care to support
the patients in the community was also a key finding to reduce avoidable readmissions. Education on patient self-
management should also be enhanced to minimize the patient factors with regard to avoidable readmission. Our
findings thus provide important insights into the development of an effective discharge planning system which
should place patients and carers as the primacy focus of care by engaging them along with the healthcare
professionals in the whole discharge planning process.
* Correspondence: [email protected]
Division of Health System, Policy and Management, School of Public Health
and Primary Care, The Chinese University of Hong Kong, Hong Kong
© 2010 Yam et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons
Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in
any medium, provided the original work is properly cited.
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Authority which is responsible for all public hospitals. records as incomplete, thus 605 cases were randomly
The Hospital Authority provides a comprehensive range sampled from the 56,102 unplanned readmissions.
of secondary and tertiary specialist care, medical and A two-stage proportional stratified sampling was used i.e.
rehabilitation services to patients through 41 public firstly stratifying all unplanned readmissions by hospitals
hospitals, 48 specialist outpatient clinics, 74 general out- and by patients’ age, and then a systematic sampling
patient clinics, and a range of community outreach ser- within each stratum.
vices that are organized into seven organisational
clusters, each serving a geographical region with a popu- Assessment of avoidability of readmissions
lation catchment of approximately 1 million people. The To assess the avoidability of a readmission, an expert
Government subsidises nearly 95% of the costs of the panel, which consisted of three clinical experts from the
public outpatient and inpatient services through general Medical specialty, was formed. A quality assessment
taxation whereas the patients only need to pay 5% checklist was developed to record the reasons for rehos-
of the cost through user fees and charges out of their pitalization and the avoidability of readmission in terms
pocket [14]. of system, clinician, patient (or so-called medical and
There were 332,453 inpatient admissions between 1st health factors) and social factors. These factors are
January 2007 and 31st December 2007 in the Medical selected according to the international published litera-
specialty of public hospitals managed by the Hong Kong ture, which includes classification scheme for assessing
Hospital Authority. In order to quantify the unplanned readmissions [1], a categorization of the causes of read-
readmissions, the first or initial hospitalization in a ser- mission [3], a checklist for assessing preventability [5]
ies of hospitalization has to be identified first. The first and correlation of the principal and associated factors for
hospitalization, so called index hospitalization, was iden- readmission [12]. A panel of eight physicians used the
tified as the first hospitalization appearing in the year of checklist to classify the readmission as avoidable or una-
2007. The second hospitalization was defined as a read- voidable. All the members of expert panel and reviewers
mission with a predetermined timeframe. Each subse- have at least 10 years of working experience in the pro-
quent hospitalization e.g. the second admission then fession and worked as grade of senior medical officer or
becomes an index admission to be compared with the above in the hospital. Each record was reviewed by two
next hospitalization. In our study, the 30-day unplanned physicians independently. No reviewers reviewed the
readmission is defined as the readmission, which was medical records from his or her cluster. They firstly
not planned or prescheduled, to the same specialty recorded the reason for rehospitalization of a patient as
through Accident & Emergency Department within relating to the following categories: (a) deterioration of
30 days to the index admission. The 30-day timeframe existing disorder; (b) new medical conditions; (c) term-
is commonly used in studies in the United States [2,5] inal care; (d) non-compliance with medication or diet; (e)
whereas a 28-day timeframe is commonly used in the unresolved medical problems; (f) complication of treat-
United Kingdom studies [1,12]. Based on statistical ment other than drugs; (g) side effects of drugs/drug-
modelling such as survival analyses as well as sensitivity drug interaction; (h) social problems; (i) psychological
and specificity analyses, two studies mathematically problems; and (j) others to give an overall impression of
demonstrated that 30-day was an optimal choice for the readmission; and then identified one principal factor
identifying readmission [3,15]. Thus, we used 30-day and any other possible factors contributing to readmis-
timeframe as one of criteria to define the unplanned sion in terms of system, clinician, patient as well as social
readmission. factors - where the factors were in more detailed classifi-
cations to assess the causes of readmissions. Then they
Study population determined the preventability of the hospitalization. The
The study population was all the unplanned readmissions preventability of the readmission was based on the
within 30 days in the Medical specialty of any acute pub- assessment of the principal factor as avoidable or not
lic hospitals in Hong Kong between 1st January 2007 and avoidable. If there was a difference between assessments
31st December 2007. There were 56,102 unplanned read- among a pair of physicians, they were required to discuss
missions in 2007 (16.9% of all the 332,453 inpatient the case together and come to an agreement. A consen-
admissions in the Medical specialty). A retrospective ana- sus of opinion among the reviewers was required for a
lysis of a stratified random sample of medical records of readmission to be classified as avoidable. If no agreement
patients with these unplanned readmissions was adopted. was reached, the case would then be submitted to the
Based on an estimated rate of avoidable readmission at expert panel for a decision. To ascertain the reliability of
15% and a desired confidence interval at 0.06 at 5% risk the judgment, a random sample of 10% of subjects’
of error, the effective sample size was 550 by a Poisson’s records were assessed independently by members of the
estimation model. We further assumed 10% of medical expert panel.
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Clinical data
Main principal diagnosis at readmission %
Symptoms, signs & ill-defined condition 16.5 13.8 15.4 0.099
Chronic obstructive pulmonary disease 12.6 11.8 12.3
Pneumonia 13.7 7.7 11.3
Heart failure 5.3 8.9 6.8
Ischaemic heart disease 5.0 4.1 4.6
Cancer 3.6 2.4 3.2
Chronic renal failure 3.4 2.4 3.0
Cerebrovascular diseases 2.2 1.6 2.0
Diabetes 0.8 2.4 1.5
Others 36.7 44.7 40.0
Same principal diagnosis in both discharge and 24.4 45.1 32.8 < 0.001
readmission episode %
Length of stay in previous discharge, in days 9.9 8.5 9.3 0.217
No. of hospitalization in the past 12 months 4.1 4.5 4.3 0.290
No. of attendance to the public general & specialist 13.1 13.1 13.1 0.960
outpatient clinics and Accident and Emergency
Departments in the past 12 months
No. of medication on discharge 7.0 7.4 7.2 0.218
Physical and cognitive function
Mobility status %
Not available 0.3 0.0 0.2 0.493
Walk independent 36.7 41.5 38.6
Walk with support 32.2 34.1 33.0
Chairbound/Bedbound 30.5 24.4 28.1
Others 0.3 0.0 0.2
Cognitive function %
Not available 1.7 2.0 1.8 0.127
Normal 66.9 76.0 70.6
Dementia 19.9 12.6 16.9
Impaired mental state 9.5 8.1 9.0
Others 2.0 1.2 1.7
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Instrumentation %
No 73.1 78.5 75.3 0.039
Foley Cath 5.3 4.9 5.1
R/T 9.0 4.9 7.3
PEG 0.0 0.4 0.2
Tracheostomy 0.3 0.4 0.3
CAPD 4.5 7.7 5.8
Others 7.8 3.3 6.0
Time interval between discharge from index 12.9 11.0 12.1 0.006
episode and readmission, in days
Note: P-value is used to show the significance of each independent variable with the outcome variable on whether the readmission was avoidable or not
avoidable.
diseases (2.0%) and diabetes (1.5%). Similar distributions was further identified to assess the principal cause of
of principal diagnosis were found in previous discharge readmissions. The major principal factor contributing to
that leads to the readmission. 32.8% of patients had the unplanned readmission (n = 603) was found to be patient
same principal diagnosis in the previous discharge and factor (74.0%), followed by clinician factor (19.4%), sys-
the readmission episode. On average, readmissions tem factor (6.1%) and social factor (0.5%) (Table 3). The
occurred 12 days (SD 8 days) after the previous index preventability of the readmission was based on an assess-
admission and 37.1% of readmissions occurred during ment of whether the principal factor could have been
the first week. avoided.
Table 2 Reasons for rehospitalisation system, lack of support and community services (0.8%),
Reasons % etc (Table 3). Only in a few cases social factor (n = 3)
Deterioration of existing disorder 52.6 was found to be the principal factor contributing to the
New medical conditions 43.9 readmission.
Unresolved medical problems 15.3 With regard to the avoidability of each factor, system
Side effects of drugs/drug-drug interaction 6.1 factor and clinician factor were highly avoidable, with
Social problem 3.2 avoidability of 97.3% and 88.9% respectively. Only 23.1%
Non-compliance with medication or diet 3.0 of patient factor was found to be avoidable.
Terminal care 2.7 The characteristics of the index admission were used
Psychological problems 2.7 to predict the risk factors for avoidable readmissions
Complication of treatment other than drugs 1.7 among readmission episodes. Multilevel logistic regres-
Note: Multiple answers are allowed.
sion for the patient population with unplanned readmis-
sions only (Table 4) found that after adjusting for
factors such as relapse or progress of previous complaint patients’ age, gender and principal diagnosis in previous
(28.9%), and compliance problems (8.1%), etc., followed discharge, the concordance of the principal diagnosis for
by system factor (14.6%) including inadequate discharge admission and readmission increased the probability of
planning (5.7%), inadequate palliative care/terminal care the readmission being avoidable (Odd Ratio: 3.41). Also,
(4.1%), etc. and social factor (1.2%) covering carer the shorter the time between discharge and readmission,
Table 4 Multilevel logistics regression on factors for avoidable readmissions on all unplanned readmissions
Factor OR 95.0% C.I.
Same principal diagnosis in both discharge and readmission episode 3.41*** (2.20 - 5.30)
No. of attendance to public outpatient clinics and A&E departments in the past 12 months 0.99 (0.96 - 1.01)
No. of hospitalization in the past 12 months 1.01 (0.96 - 1.07)
Use of sub acute & community services 1.03 (0.61 - 1.75)
Length of stay (in days) of previous linked episode that induce the readmission 0.99 (0.98 - 1.01)
Time (in days) elapsed between discharge from index episode and readmission 0.97** (0.95 - 0.99)
Fee was not paid by public assistance 1.19 (0.81 - 1.74)
Transferred to rehabilitation hospital 0.79 (0.45 - 1.39)
No. of drugs taken on previous discharge 1.03 (0.97 - 1.09)
Notes:
(i) No. of hospital = 14; No. of patients within each hospital ranged from 19-66.
(ii) Intra class correlation = 9.9% implying the correlation of patients within hospital is small.
(iii) Regression adjusted for age, gender and principal diagnosis of previous discharge.
(iv) ** p-value < 0.01, *** p-value < 0.001, OR refers to Odd Ratio, CI refers to Confidence Interval.
the higher the probability of the readmission being With a unit cost of US$423 per average acute inpatient
avoidable (Odd Ratio: 0.97). Other characteristics of day, the maximum estimated cost for avoidable readmis-
index hospitalization such as length of stay, whether the sion in Hong Kong in 2007 was US$67 millions.
patients was transferred to rehabilitation hospital, and
whether received sub acute care services after discharge Discussion
were not predictive of the readmission being avoidable. In the present study, we have quantified the magnitude
Patients’ previous inpatient or outpatient healthcare of avoidable readmissions in an entire hospital system
services utilization and whether the patients received for a full calendar year and elucidated the factors contri-
public assistance were not associated with avoidable buting to the avoidable readmission. A high proportion
readmission. of avoidable readmission (40.8%) was recorded in the
With regard to the risk factors for avoidable readmis- present study compared to the two local previous stu-
sions in the total population i.e. all acute care admis- dies conducted among geriatric populations in Hong
sions irrespective of whether there was a readmission or Kong, probably due to the different population of
not, after controlling the same factors above, the multi- patients studied, various definition or criteria used, and
level Poisson regression (Table 5) showed that patients different methodologies [8,9]. Internationally, the pro-
with a longer length of stay (IRR = 1.01), with higher portion of all readmissions assessed to be preventable
number of hospitalizations (IRR = 1.08) and attendance also varies greatly from 9-59% [1-6]. This implied a
in public outpatient clinics and Accident and Emergency need for a consistent tool and methodology to measure
departments (IRR = 1.02) in the past 12 months were the avoidable readmissions. Our study has designed a
more likely to have avoidable readmission. tool with reference to international papers which is tai-
The overall avoidable hospital readmission rate for lored to the context of Hong Kong’s health system. The
female and male were 6.5% and 7.2% respectively. The tool was validated by the expert panels and reviewers to
avoidable readmission episode comprised 8.3% of the measure the rate of avoidable readmission. It serves as a
total bed-days (158 897 bed-days) in 2007. Of which, 57 baseline for future comparison and for monitoring pur-
183 bed-days (mean stay of 6 days) were for female and poses and to provide alerts for action for hospitals in
101 714 bed-days (mean stay of 8 days) were for male. Hong Kong. It can also serve as reference for other
Table 5 Multilevel Poisson regression on factors for avoidable readmissions on the total population at risk (all acute
care hospitalizations which included: avoidable readmissions, unavoidable readmissions and no readmissions)
Factor IRR 95.0% C.I.
No. of attendance to public outpatient clinics and A&E departments in the past 12 months 1.02* (1.01 - 1.03)
No. of hospitalization in the past 12 months 1.08*** (1.05 - 1.10)
Length of stay (in days) of previous linked episode that induce the readmission 1.01* (1.00 - 1.02)
Fee was not paid by public assistance 1.14 (0.87 - 1.49)
Notes:
(i) Regression adjusted for age, gender and principal diagnosis of previous discharge.
(ii) * p-value < 0.05, ** p-value < 0.01, *** p-value < 0.001, IRR refers to incidence rate ratio, CI refers to Confidence Interval.
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countries in using medical record review to assess the Avoidable readmission occurred earlier if it was
preventability of readmissions in the context of how the related to system and clinician factors. The median
own health system is organised and functions. avoidable readmission intervals between the index
Our study showed that readmission could have been admission and readmission for system and clinician fac-
prevented in almost half of the cases and had been tors are 7 days and 8 days respectively compared with
mainly due to the clinician factor (42.3%) and patient 10 days for all avoidable cases. The cumulative readmis-
factor (including medical and health factor) (41.9%), sions due to system and clinician factors also paralleled
both of which were intimately related to clinical man- each other so closely that these factors must be consid-
agement and patient care. Our result is also consistent ered to be interrelated (Figure 1). This affirmed the
with studies of the nature of readmissions where relapse importance of enhancement in the system of care in
of medical problems predominate [4,12]. The findings order to reduce avoidable readmission.
supported that better clinical care and better communi- Our results showed that socio-economic status of the
cation between physicians and patients are required. patients was not correlated with avoidable readmission.
The readmissions could have also been averted by We also found that if the diagnosis in the index admis-
enhancing patient knowledge of early warning signs for sion and readmission was the same, the chance of the
relapse and patient education to improve patient adher- subsequent readmission to be avoidable was increased.
ence to prescribed treatment and management regi- In the analyse of the avoidability of hospitalization by
mens. Many patients’ relapse was assessed to be disease category in previous discharge, it was found that
avoidable since patients could have been treated in the there was a wide range of avoidability among the dis-
community instead of going to the hospital. Adequate eases, ranging from an avoidability rate of 28.0% for
and easily accessible ambulatory care should be provided pneumonia to 49.2% for chronic obstructive pulmonary
to keep the patients in the community. Education on disease. The result provides insights for identifying
patient self-management should also be enhanced to which patient groups should be targeted for any inter-
minimize the patient factors with regard to avoidable vention to reduce readmission. Priority for intervention
readmission. There is also a need for a system of should be targeted at these disease categories. It is also
ongoing clinical review to examine the clinical practice/ important to note that there were some hospitals with a
decision for discharge. A clinical audit system should be high proportion of avoidable readmissions, while others
considered. Thus, the use of educational programmes had a relatively lower proportion (ranging from 15.8% -
tailored to patients’ needs and appropriate clinical 64.4%). However, the number of cases sampled per hos-
guidelines are important components in reducing avoid- pital was quite small for some of the hospitals (from 19
able readmission [8]. patients to 66 patients per hospital) and it was not pos-
With regard to the preventability of each factor, sys- sible to draw conclusions on the geographic difference
tem and clinician factors were found to be highly avoid- in avoidable readmissions in Hong Kong.
able. This is consistent with another study in UK on In the analysis of the total population at risk i.e. all
preventable readmission that a high proportion of read- acute care admissions, we found that patients with a
missions for diagnostic testing, social problems, or pro- longer stay in a previous discharge, higher number of
blems in the delivery of medical care were deemed
avoidable [5]. In our study, a low threshold for admis-
sion, premature discharge and inadequate discharge
planning accounted for 25.6% of avoidable readmissions.
These types of readmissions could be prevented by
improving clinical pathways and better gate-keeping at
the Accident and Emergency Departments. In addition,
reducing preventable readmissions would very likely
require better discharge planning and a coordinated
approach that links the medical and social components
of services that meet patients’ needs. The discharge pro-
cess should be patient-oriented. Apart from this, dis-
charge planning also requires a standardized and
validated tool to assess patients’ medical, physical, func-
tional, social, psychological and financial needs of
patients which could be used to assess the appropriate
sub acute care services system/mechanism to support Figure 1 Cumulative proportion of avoidable readmissions by
principal factor (n = 246).
the patients and carers in the community.
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hospitalizations and attendance in public outpatient the prevalence of avoidable readmissions, but also
clinic and Accident and Emergency departments in the ensure quality of patient care by improving patient out-
past 12 months had a higher risk of avoidable readmis- comes and enhancing their satisfaction.
sions. The findings were consistent with those reported
in other studies [3,16]. The findings of these risk factors
Acknowledgements
for avoidable readmissions permit the identification of We would like to thank the Hong Kong Hospital Authority which helped us
groups of patients who are frequent users of health ser- on the logistics and arrangement for the conduct of medical record review,
vices for whom preventive measures could be imple- and provided us the data for analysis. We would also sincerely thank for
expert panel members’ advice on our study as well as the reviewers’ help in
mented to reduce avoidable readmissions. conducting the medical record review. This study is funded by the Hong
There are some important limitations in our study. We Kong Hospital Authority.
conducted a review of patients’ medical records to exam-
Authors’ contributions
ine the factors contributing to the avoidable readmissions. All authors carried out and designed the study. CHKY wrote the first draft of
However, the hospital notes might not provide compre- the manuscript and all authors made important contributions to the
hensive information about the causes of readmission. A subsequent draft. All authors have seen and approved the final version.
more detailed assessment involving patients and their rela- Competing interests
tives is required to provide a full picture on the reasons The authors declare that they have no competing interests.
for avoidable readmissions. In addition, our results only
Received: 17 May 2010 Accepted: 17 November 2010
represent patients from the Medical specialty. Patients Published: 17 November 2010
from other specialties such as Surgery might have different
contributing reasons for readmissions. Nevertheless, References
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Pre-publication history
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Cite this article as: Yam et al.: Avoidable readmission in Hong Kong -
system, clinician, patient or social factor? BMC Health Services Research
2010 10:311.