Scott et al. Quality of care using Documentation of Diagnosis readmitted patients, 50 ** 201434 routinely collected assessment and (44.3%) were associated Assessment and Australia data on completed management strategies at with at least one quality management of active episodes of care transitions of care factor versus 23 (11.6%) comorbid disease during patients’ controls (P < 0.001). Patients with Management of primary hospital stay comorbidities admitted Most common factors were: clinical problem during within 30 days of failure to develop or activate admission discharge an advance care plan (18, Management of preventable 15.9% vs 2, 1.0%; P < complication of procedure or 0.001); sub-optimal therapy undertaken or management of presenting initiated during admission illness (13, 11.4% vs 0, 0%; Assessment of needs and P < 0.001); inadequate limitations assessment of functional limitations (11, 9.7% vs 0, Patient and education 0%; P < 0.001); and about clinical management of potentially preventable disease complication of therapy (8, Communication of discharge 7.1% vs 1, 0.5%, P = 0.002) information to post-hospital care providers Advance care plan Palliative care plan Organise appropriate medical follow-up Referral to chronic disease management and outreach service where indicated
Scott et al. 201434 Australia Quality of care using routinely collected data on completed episodes of care during patients’ hospital stay Documentation of assessment and management strategies at transitions of care Patients with comorbidities admitted within 30 days of discharge Diagnosis Assessment and management of active comorbid disease Management of primary clinical problem during admission Management of preventable complication of procedure or therapy undertaken or initiated during admission Assessment of needs and limitations Patient and education about clinical management of disease Communication of discharge information to post-hospital care providers Advance care plan Palliative care plan Organise appropriate medical follow-up Referral to chronic disease management and outreach service where indicated readmitted patients, 50 (44.3%) were associated with at least one quality factor versus 23 (11.6%) controls (P < 0.001). Most common factors were: failure to develop or activate an advance care plan (18, 15.9% vs 2, 1.0%; P < 0.001); sub-optimal management of presenting illness (13, 11.4% vs 0, 0%; P < 0.001); inadequate assessment of functional limitations (11, 9.7% vs 0, 0%; P < 0.001); and potentially preventable complication of therapy (8, 7.1% vs 1, 0.5%, P = 0.002) **
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