Multifaceted Approach Required to Improve Self-Care, Reduce Hospital Readmissions

Aaron L. Leppin, MD Knowledge and Evaluation Research Unit Mayo Clinic, Rochester, Interview with:
Aaron L. Leppin, MD
Knowledge and Evaluation Research Unit
Mayo Clinic, Rochester, Minnesota What are the main findings of the study?

Dr. Leppin: We conducted a systematic review and meta-analysis of randomized trials assessing the effectiveness of hospital discharge interventions on reducing 30-day readmission rates. We identified 47 trials, 42 of which contributed to the primary meta-analysis.

Overall, the interventions that have been tested to reduce early hospital readmissions reduce them by about 20%.

The ones that are most effective, though, reduce them by almost 40% and use a consistent but complex approach. These interventions make a robust effort to fully understand the patient’s post-discharge context, often by visiting the patient’s home. They focus on identifying all the things the patient needs to do to be well—whether that’s organizing medications, getting a ride to the clinic, or paying the electric bill—and they determine whether the patient has the necessary resources and capacity to pull it all off. When limitations are found, these interventions have a strategy in place to support the patient through the post-discharge period. Were any of the findings unexpected?

Dr. Leppin: We were somewhat surprised that the interventions that have been tested most recently have been less effective. There seems to be a shift toward trying simpler, more “high-tech” interventions and this may be the cause for this finding.

We had also hypothesized that giving patients too much “work” to do after discharge (i.e. enacting self-care, scheduling and attending appointments, organizing medication regimens, coordinating care) would overwhelm them and lead to readmission. In reality, patients do not all become overwhelmed in the same way or to the same degree. Instead, it seems the amount of work that health care assigns to patients is not nearly as important as whether the patient and/or caregiver have the ability to carry out this work and/or whether support from the health care system is supplied when needed. What should clinicians and patients take away from your report?

Dr. Leppin: Clinicians should focus limited resources on arriving at a more complete understanding of the patient’s post-discharge context and they should consider whether the patient and/or caregiver have the resources they need to do everything asked of them. Patients should feel empowered to inform their clinicians when they are feeling overwhelmed or when they lack the resources they need to be well. What recommendations do you have for future research as a result of this study?

Dr. Leppin: This report is the strongest evidence we have on what seems to work best in reducing early hospital readmissions. A comprehensive strategy that focuses on identifying and addressing limitations in patient capacity for self-care worked in 1995 and it continues to work today. Researchers should assess the barriers to uptake and implementation of this effective strategy in diverse health care settings. Finally, although these studies often reported cost savings, this may need to be confirmed in future studies across diverse settings.


Leppin AL, Gionfriddo MR, Kessler M, et al. Preventing 30-Day Hospital Readmissions: A Systematic Review and Meta-analysis of Randomized Trials. JAMA Intern Med. Published online May 12, 2014. doi:10.1001/jamainternmed.2014.1608.