Patient related factors in frequent readmissions: the influence of condition, access to services and patient choice.
ABSTRACT People use emergency department services for a wide variety of health complaints, many of which could be handled outside hospitals. Many frequent readmissions are due to problems with chronic disease and are preventable. We postulated that patient related factors such as the type of condition, demographic factors, access to alternative services outside hospitals and patient preference for hospital or non-hospital services would influence readmissions for chronic disease. This study aimed to explore the link between frequent readmissions in chronic disease and these patient related factors.
A retrospective analysis was performed on emergency department data collected from a regional hospital in NSW Australia in 2008. Frequently readmitted patients were defined as those with three or more admissions in a year. Clinical, service usage and demographic patient characteristics were examined for their influence on readmissions using multivariate analysis.
The emergency department received about 20,000 presentations a year involving some 16,000 patients. Most patients (80%) presented only once. In 2008 one hundred and forty four patients were readmitted three or more times in a year. About 20% of all presentations resulted in an admission. Frequently readmitted patients were more likely to be older, have an urgent Triage classification, present with an unplanned returned visit and have a diagnosis of neurosis, chronic obstructive pulmonary disease, dyspnoea or chronic heart failure. The chronic ambulatory care sensitive conditions were strongly associated with frequent readmissions. Frequent readmissions were unrelated to gender, time, day or season of presentation or country of birth.
Multivariate analysis of routinely collected hospital data identified that the factors associated with frequent readmission include the type of condition, urgency, unplanned return visit and age. Interventions to improve patient uptake of chronic disease management services and improving the availability of alternative non-hospital services should reduce the readmission rate in chronic disease patients.
[show abstract] [hide abstract]
ABSTRACT: Unplanned hospital readmissions increase healthcare costs and patient morbidity. We sought to identify risk factors associated with early readmission in surgical patients. All admissions from a mixed surgical unit during 2009 were retrospectively reviewed and unplanned readmissions within 30 d of discharge were identified. Demographic data, length of stay, pre-existing diagnoses, and complications during the index admission were evaluated. T-tests and Fisher exact tests were used to examine the relationship of independent variables with readmission. Univariate and multivariate regression analysis were performed. A total of 1808 index admissions occurred during the study period. In all, 51 (3%) patients were readmitted within 30 d of discharge. The majority of readmissions (53%) were for infectious reasons. On univariate analyses, DVT (P = 0.004) and acute renal failure (P = 0.002) were associated with increased risk of readmission. Readmitted patients were also more likely to have public insurance (63% versus 37%, P = 0.03) and have a longer stay in the hospital (8 d, range 4-14 d versus 3 d, range 2-7 d, P = 0.001). Initial admission after trauma evaluation was associated with a decreased risk of readmission (OR 0.374, P = 0.004). Other demographic variables and pre-existing conditions were not associated with increased readmission. On multivariate logistic regression only DVT (P = 0.039) and LOS (P = 0.014) remained significant. Increased LOS and the development of a DVT are risk factors for early unplanned hospital readmission. Admission following trauma is associated with a decreased risk of readmission, possibly due to proactive multidisciplinary discharge planning and geographically-based nurse practitioner involvement.Journal of Surgical Research 05/2011; 170(2):297-301. · 2.25 Impact Factor
Article: Community based service providers' perspectives on frequent and/or avoidable admission of older people with chronic disease in rural NSW: a qualitative study.[show abstract] [hide abstract]
ABSTRACT: Frequent and potentially avoidable hospital admission amongst older patients with ambulatory care sensitive (ACS) chronic conditions is a major topic for research internationally, driven by the imperative to understand and therefore reduce hospital admissions. Research to date has mostly focused on analysis of routine data using ACS as a proxy for 'potentially avoidable'. There has been less research on the antecedents of frequent and/or avoidable admission from the perspectives of patients or those offering community based care and support for these patients. This study aimed to explore community based service providers' perspectives on the factors contributing to admission among older patients with chronic disease and a history of frequent and potentially avoidable admission. 15 semi-structured interviews with community based providers of health care and other services, and an emergency department physician were conducted. Summary documents were produced and thematic analysis undertaken. A range of complex barriers which limit or inhibit access to services were reported. We classified these as external and internal barriers. Important external barriers included: complexity of provision of services, patients' limited awareness of different services and their inexperience in accessing services, patients needing a higher level or longer length of service than they currently have access to, or an actual lack of available services, patient poverty, rurality, and transport. Important internal barriers included: fear (of change for example), a 'stoic' attitude to life, and for some, the difficulty of accepting their changed health status. The factors underlying frequent and/or potentially avoidable admission are numerous and complex. Identifying strategies to improve services or interventions for this group requires understanding patient, carer and service providers' perspectives. Improving accessibility of services is also complex, and includes consideration of patients' social, emotional and psychological ability and willingness to use services as well as those services being available and easily accessed.BMC Health Services Research 01/2011; 11:265. · 1.66 Impact Factor
RESEARCH ARTICLE Open Access
Patient related factors in frequent readmissions:
the influence of condition, access to services
and patient choice
Sue E Kirby*, Sarah M Dennis, Upali W Jayasinghe, Mark F Harris
Background: People use emergency department services for a wide variety of health complaints, many of which
could be handled outside hospitals. Many frequent readmissions are due to problems with chronic disease and are
preventable. We postulated that patient related factors such as the type of condition, demographic factors, access
to alternative services outside hospitals and patient preference for hospital or non-hospital services would influence
readmissions for chronic disease. This study aimed to explore the link between frequent readmissions in chronic
disease and these patient related factors.
Methods: A retrospective analysis was performed on emergency department data collected from a regional
hospital in NSW Australia in 2008. Frequently readmitted patients were defined as those with three or more
admissions in a year. Clinical, service usage and demographic patient characteristics were examined for their
influence on readmissions using multivariate analysis.
Results: The emergency department received about 20,000 presentations a year involving some 16,000 patients.
Most patients (80%) presented only once. In 2008 one hundred and forty four patients were readmitted three or
more times in a year. About 20% of all presentations resulted in an admission. Frequently readmitted patients were
more likely to be older, have an urgent Triage classification, present with an unplanned returned visit and have a
diagnosis of neurosis, chronic obstructive pulmonary disease, dyspnoea or chronic heart failure. The chronic
ambulatory care sensitive conditions were strongly associated with frequent readmissions. Frequent readmissions
were unrelated to gender, time, day or season of presentation or country of birth.
Conclusions: Multivariate analysis of routinely collected hospital data identified that the factors associated with
frequent readmission include the type of condition, urgency, unplanned return visit and age. Interventions to
improve patient uptake of chronic disease management services and improving the availability of alternative non-
hospital services should reduce the readmission rate in chronic disease patients.
Emergency departments aim to provide treatment for
more urgent and serious conditions. In Australia, the
role of emergency departments has been specified as
“prevention, diagnosis and management of acute and
urgent aspects of illness and injury affecting patients of
all age groups with a full spectrum of undifferentiated
physical and behavioural disorders”. However, many
people who access emergency departments have
complex social needs as well as a clinical condition
requiring treatment [2-4]. Emergency departments
across the world are reporting serious overcrowding
resulting in lengthy waits which impair the quality of
care and patient outcomes [5-7]. Investigation of patient
profiles and the reasons behind the choice of emergency
department services by frequent attenders and fre-
quently readmitted patients is vital to guide the develop-
ment of policy and design of interventions to address
more appropriate patient management strategies and to
prevent overcrowding .
Overcrowding of emergency departments has spawned
a plethora of research on frequent emergency
* Correspondence: firstname.lastname@example.org
Centre for Primary Health Care & Equity, School of Public Health &
Community Medicine, University of New South Wales, UNSW, Sydney 2052,
Kirby et al. BMC Health Services Research 2010, 10:216
© 2010 Kirby 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.
department users. Byrne et al  reported that frequent
emergency department users were more likely to be
males from low socioeconomic backgrounds with severe
psychosocial problems who have a high morbidity and
mortality. There have been similar findings from
researchers in the UK [9-12], Canada [12,13], Sweden
[14-16], USA [17-25], Italy , Taiwan [27,28] and
Frequently readmissions, however, have received less
research attention. The Patients At Risk of Readmission
(PARR) tool, used extensively in the UK for identifica-
tion of patients for case management to prevent read-
missions, [31,32] indicates that age, sex, ethnicity,
number of previous admissions, and clinical condition
are associated with readmissions. Howell et al  in a
2009 study in Australia identified age, co-morbidities,
economic disadvantage, number of previous admissions
as risk factors for frequent readmissions through a sta-
tistical algorithm derived from inpatient data. The Aus-
tralian model was only moderately successful because of
the relatively high number of false negatives.
Andersen’s model of health service utilisation [34-36]
provides a theoretical framework for thinking about why
patients are frequently readmitted. This model postu-
lates that health service utilisation is dependent on a
range of factors such as the environment, population
characteristics and health behaviours resulting in out-
comes such as perceived health status, evaluated health
status and consumer satisfaction. The environment
includes available services and access issues. Population
characteristics include demographic details, age, gender,
cultural background, needs and resources. Health beha-
viours are influenced by personal attitudes and beliefs.
Identifying the clinical, service utilisation details and
demographic patient characteristics available from hos-
pital data can identify risk factors for frequent readmis-
sions and thereby help to develop strategies to divert
these patients away from hospitals where clinically pos-
sible. The direct application of this model to emergency
department utilisation summarised by Padgett et al
[37,38], who suggests that only about 15% of emergency
visits in the USA are for life threatening reasons and
that poor mental health, anxiety about health combined
with symptoms and injury influence people to decide to
use the emergency department.
How important is access to primary care in readmis-
sions? Hospitalisations for ambulatory care sensitive
(ACS) conditions is used an outcome indicator for
access to primary care . It is acknowledged that
treatment of ACS conditions outside hospitals, including
chronic disease, reduces hospitalisations . It would
be expected that ACS conditions would contribute to
frequent readmissions in areas with limited access to
primary care services.
The problem that a small number of emergency
department users account for a disproportionate use of
scarce resources has been reported since the 1980s
[41,42] and continues to plague the health system .
An Australian survey of emergency departments indi-
cated that patients awaiting admission are a major con-
tributing factor in emergency department overcrowding
. Two Australian States, NSW and Victoria, report
diversion of chronic disease patients to chronic disease
management services, including those provided by
primary care, can reduce readmission rates [25,45].
We know little about the reasons behind the choice of
emergency department services over other alternative
medical services in the community. However, studies in
NSW Australia have reported that patients came to the
emergency department because they thought their con-
dition warranted urgent services, with access to a doctor
and tests or x-rays done in the same place but there was
a mismatch between the views of clinicians and patients
[46,47]. In a qualitative study performed in the USA
, patients reported that they were unable to obtain
an appointment with a primary care provider; were
referred by the staff to be evaluated in the emergency
department; and it took less of their time to be seen in
the emergency department than it did to contact their
primary care provider, only to then be told to go to the
Fulde and Duffy argued that patients who present
frequently to emergency departments are a vulnerable
and marginalised group perceived as not looking after
themselves. Padgett et al  suggest that the emer-
gency department is the “least appropriate setting for
treating multiple co-morbidities”. These authors also
reported that people who feel powerless and isolated
tend to be high emergency department users.
Hong et al  suggest that we need a radical para-
digm shift to legitimise the role of emergency depart-
ments to include primary care services for those people
on the lower end of the socioeconomic scale who tend
not to have a primary care provider in the community.
The counter opinion would be to restrict the role of
emergency departments and to increase the availability
of alternative primary care services and to thereby
reduce emergency department overcrowding.
This research analysed emergency department data
routinely collected by hospitals in the state of NSW,
Australia, to identify patient related factors associated
with three or more admissions a year and with admis-
sion for ACS conditions. The analysis was designed to
answer questions about the impact on frequent readmis-
sions of three sets of variables: demographic, clinical
and arrival times and dates. The answers provide a basis
for exploring the reasons underlying frequent readmis-
sions. The research sets the scene for further
Kirby et al. BMC Health Services Research 2010, 10:216
Page 2 of 8
examination of the reasons why people with chronic
conditions are repeatedly admitted to hospital rather
than seeking chronic disease management services.
Study design and site
In this study, we analysed 2008 data from the Emer-
gency Department Information System collected at a
regional hospital. The University of Wollongong/South
Eastern Sydney Illawarra Health Service Medical
Human Research Ethics Committee approved the
research study (approval HE07/271). All patient data
were de-identified. The study was carried out in a one
hundred and fifty bed regional hospital in south eastern
Australia which is part of a network with a major teach-
ing and referral hospital. The hospital, funded by the
State and Commonwealth Government, is located in a
coastal regional urban area with a feeder population of
All statistical analyses were performed using SPSS statis-
tical software (Version18; SPSS, Chicago, Illinois, USA).
Two-sided P values of less than 0.05 were considered
The original variables were: patient identifier number,
age, gender, date and time of arrival, country of birth,
ICD 9 diagnosis, level of urgency based on the Austra-
lian Triage Classification , type of visit and mode of
separation (treated in emergency or admitted). Type of
visit is a local code referring to the type of emergency
presentation: normal, planned return and unplanned
return within 28 days of the original presentation. Each
patient presentation was accorded one primary ICD 9
diagnosis based on the major reason for the presenta-
tion. Date and time of arrival variables were converted
into hour, day and season of arrival.
The data was analysed either from the perspective of
presentations in row-for-each-presentation format or
from the perspective of patients in a row-for-each-
patient format with nested data for each patient. The
primary research question to uncover the patient char-
acteristics associated with frequent readmissions
required the row-for-each-patient format. However, pre-
liminary univariate analysis was performed on the row-
for-each-presentation format on the variables for which
there were different or potentially different, values for
each presentation: hour, day and season of arrival;
urgency; unplanned return visit and diagnosis. Univari-
ate analysis was also performed with the variables which
were constant for each presentation (age, gender and
country of birth).
Primary outcome variable
The primary outcome variable was a binary variable of
the number of admissions set with a cut off point at
three or more admissions denoting frequent readmis-
sions. Presenting patients judged to have conditions
warranting admissions may be either admitted to the
study hospital or to another hospital in the network if
the bed supply is inadequate. All admissions, including
those for which patients were placed in a bed in another
hospital, were included in the sample. The number of
admissions variable was obtained by separating the pre-
sentations for patients admitted, converting to the row-
for-each-patient format and merging the admissions
variable in to the main file.
Regression models and manipulation of predictor
Two logistic regression models for multivariate analysis
were constructed with the binary dependent variable.
The independent variables were transformed by count-
ing the number of occurrences in the nested variables
for each patient and dividing by the total number of
presentations for that patient resulting in a variable of
the proportion of occurrences and used in the multivari-
ate analysis. As the values in the proportion variables
ranged from zero to one, they were treated as continu-
ous covariates. The independent diagnosis variables
included the proportion of the most common ICD 9
diagnosis codes for presentations resulting in frequent
readmissions: neurosis, chronic heart failure, chronic
obstructive pulmonary disease (COPD), dyspnoeas and
In the second logistic regression model was created to
determine the impact of diagnoses which are deemed
suitable for non-hospital services. Ambulatory care sen-
sitive conditions are defined as those which hospitalisa-
tion is considered potentially avoidable through
preventive care and early disease management, usually
delivered in an ambulatory setting, such as primary
health care (for example by general practitioners or
community health centres). For the second logistic
regression model, the independent continuous propor-
tion-of-diagnoses variables based on the ACS groupings:
rapid onset conditions and chronic conditions . were
substituted for the continuous ICD 9 diagnoses propor-
tion variables in the first model.
Logistic regression was considered the best option for
analysis of the possible predictor variables because the
dependent variable demonstrated Poisson distribution,
with the variance higher than the mean, rendering linear
regression models inappropriate [51,52]. However, there
has been debate in the literature about the impact of
intra-patient variability in emergency department pre-
sentations on the choice of statistical analysis. This has
Kirby et al. BMC Health Services Research 2010, 10:216
Page 3 of 8
led to questioning of the appropriateness of logistic
regression and the proposition that negative binomial
regression should be used [53,54]. The results of the
logistic regression were therefore checked against those
of negative binomial regression. A backward elimination
approach was adopted in the interest of achieving a par-
simonious model [55,56]. The categorical variables, male
gender and born in Australia both met the criterion of a
minimum of ten cases in each category.
There were 21,956 presentations in 2008, of which 20%
were admitted. Results of the univariate analysis on
patient data in Table 1 indicate that there were signifi-
cant differences between the general patient population
and the frequent readmissions group in age, country of
birth and gender. Table 2, presentation data, comparing
the frequencies of the independent proportion variables
in the general presenting population and presentations
resulting in frequently readmissions, shows there were
significant differences in all of the five most common
diagnosis codes amongst frequently readmitted presenta-
tions and the “other” diagnoses, in urgent presentations,
unplanned return visits and the chronic and “other”
ambulatory care sensitive variables.
Of the seasonal variables, only in summer was there a
significant difference between the two groups. There
were no differences observed in time or day of arrival.
Direct logistic regression uncovered the impact of the
independent variables on frequent readmissions. Both
models were initially set up with the independent vari-
ables gender, age, country of birth, and the proportion
variables unplanned return visit, urgency, season, week-
end, after hours and the diagnosis. Subsequently, step-
wise backward elimination of the variable with the
highest p value was performed to establish the most
parsimonious model for the independent variables. The
first model including the “proportion” variables for the
five most common ICD 9 diagnoses was statistically sig-
nificant with a c2value of 278.3 (7 degrees of freedom,
N = 15806, p < 0.01) indicating the model was able to
distinguish between frequently readmitted and patients
not frequently readmitted based on the definition of fre-
quent admissions as three or more. As a whole, the ICD
9 diagnoses model explained up to 17.1% (R2Nagelkerk
value) of the variance [57,58] in the dependent variable.
As Table 3 reveals, seven of the independent variables,
age, proportion of unplanned return visits, urgent, diag-
noses of neurosis, chronic heart failure, COPD and dys-
pnoeas, made a statistically significant (p < 0.05) positive
contribution to the model.
In the second model, a similar logistic regression ana-
lysis was performed substituting three variables of the
proportion of preventable, rapid onset and chronic ACS
conditions for the diagnosis variables in the first model.
The other independent variables were similar to those
used for model one. Overall, the ACS model was statis-
tically significant with a c2value of 192.8 (4 degrees of
freedom, N = 15806, p < 0.01) indicating that the model
could distinguish between frequently readmitted patients
and non-frequently readmitted patients. As a whole, the
ACS model explained up to 12.3% (Nagelkerk R2value
) of the variance of the dependent variable. In model
two, four of the independent variables age, proportion of
unplanned return visits, urgency and proportion of ACS
chronic conditions made a statistically significant (p <
0.05) positive contribution to the model (see Table 4
The results of negative binomial regression models con-
firmed the logistic regression models.
The majority of presentations to the emergency depart-
ment were by patients who had a single presentation in
the year. The patients under investigation in this study
were the one hundred and forty four frequently read-
mitted patients who had three or more admissions in a
year. The univariate analysis showed significant differ-
ences in all the independent variables except the seasons
of autumn, winter and spring and time and day of arri-
val. However, the multivariate analysis identified age,
chronic conditions of neurosis, COPD, dyspnoeas and
chronic heart failure, ACS chronic conditions, urgency
and unplanned return visit as being associated with fre-
quent readmissions. The study highlights the advantage
of the multivariate analysis using the patient rather than
presentation perspective to separate factors important in
Using the framework of Andersen’s model of health
service utilisation, the results can be considered in
terms of patient demographics, clinical significance,
Table 1 Univariate analysis of patient characteristics comparing the general patient population with frequently
readmitted patients 2008
All patients (n = 15,806)Patients admitted = >3 times (n = 144) 1% of all patients
48% p < 0.051
66 (21, 2-96) p < 0.05
27% p < 0.051
Mean age (SD, range)
Born outside Australia
39 (26, 1-106)
1Chi square results
Kirby et al. BMC Health Services Research 2010, 10:216
Page 4 of 8
access to services and individual patient preferences.
The finding that age significantly influenced frequent
readmissions is in line with other studies [31-33] These
studies also reported that other demographic factors,
sex and ethnicity, are associated with readmissions.
However, there was no discernible sex difference, nor
was there a difference between Australian born and
those born outside Australia, in our study.
The type of condition is important in readmissions.
Our model looked specifically at the most common con-
ditions in presentations by patients admitted to a
hospital bed. The diagnoses of neurosis, COPD, dys-
pnoeas and chronic heart failure, all serious conditions,
were associated with frequent readmissions. Chest pain
in our model was not associated with frequent readmis-
sions. Although the regression models did not include a
variable for severity of illness per se, other variables
point to severity. The triage level specifically indicates
urgency and more urgent conditions are generally more
Unplanned return visits within 28 days of the previous
visit for the same condition are reported by all public
Table 2 Univariate analysis independent variables in the general presenting population compared to presentations
resulting in frequent readmissions 2008
Variable groupVariable General presenting
population N = 21956
ICD9 diagnostic code2
Dyspnoeas (ICD 78609)
Neurotic disorder (ICD 3079)
Chest pain (ICD 78650)
Chronic obstructive pulmonary
disease (ICD 496)
Congestive heart failure (ICD
All other ICD codes
Triage categoryUrgent (Triage 1 & 2)
Visit typeUnplanned return visit
Season of arrival Autumn
Day of arrival Weekend
Time of arrivalAfter hours
Ambulatory Care Sensitive
Presentations resulting in frequently
readmissions N = 227
15.9% p < 0.013
10.6% p < 0.01
9.7% p < 0.01
7% p < 0.01 0.7%
0.3% 2.6% p < 0.01
54.2% p < 0.01
15.4% p < 0.01
8.8% p < 0.01
12.3% p < 0.01
ACS rapid onset
7.5% P < 0.01
87.7% P < 0.01
2There were 1004 other ICD 9 codes with at least one presentation.
3Chi square results.
4ACS preventable was excluded because there was only one presentation in the general presenting population and none in the presentations resulting in
frequent readmissions group.
Table 3 Odds ratio and confidence limits for the variables having a significant impact on frequent readmissions in
model one five most common ICD 9 diagnoses, results from logistic regression backwards elimination
Variable P value Odds ratio95% Confidence Interval for odds ratio
Proportion of urgent (Triage categories 1 and 2)
Proportion of neuroses (ICD 9 code 3079)
Proportion of congestive heart failure (ICD 9 code 4280)
Proportion of chronic obstructive pulmonary disease (ICD 9 code 496)
Proportion of dyspnoeas (ICD 9 code 78609)
Proportion of unplanned return visits within 28 days of previous visit
Kirby et al. BMC Health Services Research 2010, 10:216
Page 5 of 8
hospitals on a monthly basis to the NSW Department of
Health. This indicator is considered to be important in
assessing the quality of hospital care  on the basis
that the underlying reason for the return visit may be
related to premature discharge. Although the incidence
of unplanned return visits is low, this is a predictor of
frequent readmission and therefore worthy of further
detailed investigation. An early warning system to flag
unplanned return visits would assist in addressing their
needs in a more timely way and reducing the burden on
emergency services. Our findings in relation to
unplanned return visits are in line with those reported
for a US study on the Triage Risk Screening Tool .
The finding that frequent readmissions are associated
with diagnoses of COPD, dyspnoeas and chronic heart
failure is consistent with the notion that patients experi-
encing the symptoms associated with these conditions
are more likely to believe their condition is serious
enough for them to choose hospital care rather than pri-
mary care outside the hospital setting.
Seasonal variations in arrivals might have been
expected because of the differences in temperature influ-
encing the incidence of respiratory exacerbations. The
fact that there were no seasonal variations is difficult to
Patients with ACS chronic conditions were signifi-
cantly more likely to be frequent readmissions. This
finding could mean that access to primary care services
for preventable conditions (immunisation and nutri-
tional interventions) and rapid onset ACS conditions is
adequate and access to chronic disease management ser-
vices is not. Alternatively, the findings could indicate
that patients are choosing hospital services over primary
care services for chronic disease management.
Frequent readmissions for neurosis might be asso-
ciated with reduced access to community based mental
health services in the area. Another interpretation of
this finding is that patients are voting with their feet
expressing a preference for hospital services over com-
Does poor access to other services contribute to fre-
quent readmissions? Time and day of arrival had no sig-
nificant impact on frequent readmissions. It might be
expected that the more frequent emergency department
users would opt for after hours or weekend visits when
other community based services are less available. Our
findings tend to negate any notion that access to after-
hours and weekend services is an issue. However, the
finding that ACS chronic conditions were associated
with frequent readmissions suggests there are access
issues at play. Although alternative general or specialist
medical and chronic disease management services exists,
there may be access difficulties other than the time of
availability of services. Access factors such as, availabil-
ity, accessibility, accommodation, affordability and
acceptability, need to be further explored before we
have a definitive answer on the impact on frequent
readmissions. In particular, transport, location of com-
munity-based services and waiting times would act as
barriers to access.
In our analysis, age and type of illness influenced
readmissions. The impact of access issues on frequent
readmissions is less clear. The other factors which
could influence readmissions are related to patient pre-
ferences for the type of services, for example, general
and specialist medical and chronic disease manage-
ment services. If the uptake of these alternative ser-
vices were to be increased, readmissions rates would
be reduced. Further research to explore patient choice
of services would be of benefit to the problem of fre-
On the basis of the findings presented in this study,
the question of whether readmissions are preventable
was not directly answered, but the evidence from other
studies shows that hospitalisation of chronic disease
patients can be reduced by a range of targeted interven-
tions to improve chronic disease management .
Logistic regression models were developed to identify
the characteristics associated with frequent readmis-
sions. The reliability of the predicting factors identified
is determined by the robustness of the models. Although
the overall fit of the model was significant, the Nagelk-
erk R2values of less than 20% were relatively low. How-
ever, other studies of patient utilisation and clinical data
have quoted similarly low Nagelkerk R2values in logistic
regression models [61,62].
Table 4 Odds ratio and confidence limits for the variables having a significant impact on frequent readmissions in
model two ambulatory care sensitive conditions, results from logistic regression backwards elimination
Variable P valueOdds ratio95% Confidence Interval for odds ratio
Proportion urgent (Triage 1 & 2)
Proportion unplanned return visits within 28 days of previous visit
Proportion ACS Chronic conditions
Kirby et al. BMC Health Services Research 2010, 10:216
Page 6 of 8
This study is limited by the fact that it involves data per-
taining to one hospital only. Although the results may not
be generalisable to all hospitals, they are relevant to similar
sized hospitals in non-metropolitan urban areas. Compari-
son with other hospitals with a similar role would lend
weight to these findings. Another limitation is the purpose
of the data collection. The data forms part of the Emer-
gency Department Information System collected by all
NSW hospitals. The accuracy of the recording of primary
diagnosis in the data base is complicated by the fact that
many of the older patients have multiple comorbidities
and the reason for their presentation may not be apparent
until test results are available. It was not possible to make
any estimation of socioeconomic status from the data
available. However, the area which the hospital services,
although it contains some affluent pockets, is generally a
low socioeconomic area . As this study examines
emergency department data only there is an inbuilt selec-
tion bias. We did not examine the use of other primary
care services by people who did not access emergency
department services. An expanded study to include the
patterns of emergency department and community based
primary care, particularly general practitioner services, is
needed to develop population-based solutions to emer-
gency department overcrowding. Another possible limita-
tion is the failure of logistic regression analysis to take into
account the intra-patient variability [51-54]. To address
this issue we have compared the results of logistic and
negative binomial regression models and found similar
results. The relatively wide confidence intervals for some
of the variables reduce the precision of the estimates. The
study is also limited by the lack of a specific measurement
of severity of illness.
This study of routinely collected hospital data identified
the factors associated with frequent readmissions with
the aim of exploring the reasons behind readmissions.
Strategies to identify and improve access to alternative
non-emergency department services for neuroses,
COPD, dyspnoea and chronic heart failure patients,
including chronic disease self management and case
coordination services, would reduce readmissions. An
early warning system for the unplanned return visit
patients would allow for special strategies to be put in
place to address the needs of these patients. Possible
community-based services access barriers such as trans-
port, location of community-based services and waiting
times should be explored and reduced. This study has
opened up the possibility that a patient’s preference for
hospital over non-hospital services might influence read-
missions and warrants further investigation.
There are no acknowledgements.
SEK, SMD, UWJ and MFH planned the research study. SMD and MFH
supervised the PhD work. SEK carried out the initial analysis. All authors
reviewed and approved the final manuscript.
The authors declare that they have no competing interests.
Received: 19 November 2009 Accepted: 21 July 2010
Published: 21 July 2010
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Cite this article as: Kirby et al.: Patient related factors in frequent
readmissions: the influence of condition, access to services and patient
choice. BMC Health Services Research 2010 10:216.
Kirby et al. BMC Health Services Research 2010, 10:216
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