Pathways to Potentially Preventable Hospitalizations for Diabetes and Heart Failure: Patient Perspectives

Research Objective: Hospitalizations for heart failure (HF) and diabetes (DM) cost the United States over $14 billion annually, yet these hospitalizations are considered avoidable with good outpatient management. Patients can provide key insight into their reasons for these “potentially preventable hospitalizations” (PPH).

Study Design: English-speaking individuals with a PPH for HF or DM (n=90) at the largest hospital in Hawai‘i completed an in-person interview that included open-ended questions on patents’ perspectives of the precipitating factors to their PPH. Using the framework approach, two independent coders identified pathways to preventable hospitalizations, including the patients’ identified reason for the acute problem and significant precipitating background factors.

Results: Seventy-two percent of respondents were under 65 years and 30% were female; 90% had health insurance. More than half (66%) had previously been hospitalized for the same problem. Patients identified seven types of reasons for the acute issue leading to hospitalizations: medication issues (e.g., did not refill medication—57% of respondents); lifestyle and self-care challenges (e.g., drank too much water—47%); issues in the clinical encounter (e.g., logistical problems getting to the clinic—44%); priorities/attitude (e.g., other concerns are more urgent than managing chronic illness—19%); readmission specific challenges (e.g., they believed they were discharged too early—24%) and did not know had illness(5%). Patients’ stories of the precipitating background factors were critical to understanding why patients had these problems that lead to their hospitalizations and included six themes: extreme social vulnerability (homeless, poverty, limited social support—54%); health care system interaction issues (e.g., poor coordination with providers—44%); lack of knowledge (42%); behavioral health issues (e.g., substance abuse, mental health problems—36%); denial of illness (27%); and practical problems(e.g., just forgot, too busy—6%).

Conclusions: In a young, predominately insured population, factors well outside the traditional purview of the hospital or even clinical medicine were critical precipitating factors for many PPH. This information is unlikely to show up in administrative data and may not be discussed in the clinical encounter, but is critical in determining which “potentially preventable hospitalizations” are truly preventable and by what part of our health and social system (i.e., where PPH-targeted interventions should most fruitfully focus). Patient perspectives were vital to understanding this issue.  Innovative partnerships or policies should be developed to address these issues, including linkages to social services and behavioral health.