What helps and hinders doctors in engaging in continuous professional development? An explanatory sequential design.

BACKGROUND: Licensure and registration are the traditional approaches to ensure minimally acceptable standards of care for practice. However, due to advances in medical technology and changes in clinical practice, the knowledge and skills obtained from basic education and training may rapidly become out of date. There is no mandated, structured and ongoing mechanism to assess all doctors' competence in Hong Kong. This paper assessed doctors' perceived needs for continuous professional development, and to identify facilitators and barriers that are likely to influence the implementation of compulsory continuous professional development for maintaining professional competence and ensuring patient safety. METHODS: An explanatory sequential mixed method design with two distinct interactive phases was adopted comprising a postal self-administered questionnaire survey among a random sample of 2,459 of doctors (Phase 1), followed by individual interviews of a stratified sample of 30 questionnaire respondents for the subsequent qualitative analysis (Phase 2). RESULTS: The majority of doctors (over 90%) agreed the importance of continuous professional development to update knowledge and skills. However, just 30.7% of non-specialists compared with 65.4% of specialists agreed it would be desirable for continuous professional development to be a requirement for renewal of licenses. A relatively higher percentage of non-specialists compared with specialists reported barriers to participation such as accessibility, availability and relevance of the content of the programmes. Facilitators for uptake included more convenient schedule and location, relevant content, and incentives for participation such as making this a pre-condition for enrolling in government-funded services. CONCLUSIONS: To address the needs of individual doctors, the spheres of practice, personal preferences and learning styles should be considered in deciding the content and processes of continuous professional development. Flexibility is also an important principle. A learning model, incentives for participation and a compliance strategy (instead of deterrence) could be effective strategy for continuous professional development.

An evaluation of universal vouchers as a demand-side subsidy to change primary care utilization: A retrospective analysis of longitudinal services utilisation and voucher claims data from a survey cohort in Hong Kong.

To incentivize private primary care utilization and reduce reliance on public healthcare services, Elderly Healthcare Voucher Scheme has been implemented to provide a voucher entitlement to entire older resident population for subsidising their purchase of unspecified primary healthcare services in the private sector. Our study assessed whether voucher usage is associated with reduced utilization of public healthcare services. We retrieved the public healthcare services utilization and voucher transaction data of a survey cohort of 551 participants, who were age eligible for the scheme since 2009, over the period 2009-2015. Our results showed that voucher usage was not associated with reduced utilization of public healthcare services and has encouraged dual utilization of public and private healthcare. It may be due to a generated supply-induced demand and price inflation. The finding suggests the voucher is specifically designed to address the health systems issues to achieve the effective policy objectives. Defining the specific services to be provided and the prices at which they should be offered based on the needs of specified populations is a fundamental design parameter which needs to be incorporated. The alternatives of whether primary care services should be expanded and provided in the public sector or purchased using supply/demand side instruments should be considered taking the context and goals of the health system into account.

What is the long term impact of voucher scheme on primary care? Findings from a repeated cross sectional study using propensity score matching.

BACKGROUND: Vouchers are increasingly used as a demand-side subsidy to reduce financial hardship and improve quality of services. Elderly Healthcare Voucher Scheme has been introduced by the Hong Kong Government since 2009 to provide subsidy to elderly aged 65 and above to visit ten different types of private primary care providers for curative, preventive and chronic disease management. Several enhancements have been made over the past few years. This paper (as part of an evaluation study of this unique healthcare voucher scheme) aims to assess the long term impact of the voucher scheme in encouraging the use of primary care services. METHODS: Two rounds of cross-sectional survey among elderly in Hong Kong were conducted in 2010 and 2016. Propensity score matching and analysis were used to compare changes in perception and usage of vouchers over time. RESULTS: 61.5% of respondents in 2016 agreed "the scheme encourages me to use more private primary care services", a significant increase from 36.2% in 2010. Among those who agreed in 2016, the majority thought the voucher scheme would encourage them to use acute services (90.3%) in the private sector, rather than preventive care (40.3%) and chronic disease management (12.2%). Respondents also reported that their current usual choice of care was visiting "both public and private doctors" (61.9%), representing a significant increase (up from 48.4%) prior to their use of voucher. CONCLUSIONS: The voucher scheme has encouraged the use of more private care services, particularly acute services rather than disease prevention or management of chronic disease. However, there needs to be caution that the untargeted and open-ended nature of voucher scheme could result in supply-induced demand which would affect long term financial sustainability. The dual utilization of health services in both the public and private sector may also compromise continuity and quality of care. The design of the voucher needs to be more specific, targeting prevention and chronic disease management rather than unspecified care which is mainly acute and episodic in order to maximize service delivery capacity as a whole for equitable access in universal health coverage and to contribute to a sustainable financing system.

How shall we examine and learn about public-private partnerships (PPPs) in the health sector? Realist evaluation of PPPs in Hong Kong.

The World Health Organization advocates the goal of universal coverage of health systems to ensure that everyone can avail the services they need and are protected from the associated financial risks. Governments are increasingly engaging and interacting with the private sector in initiatives collectively referred to as public-private partnerships (PPPs) to enhance the capacity of health systems to meet this objective. Understanding the values that motivate partners and demonstrating commitment for building relationships were found to be key lessons in building effective PPPs; however there, remain many research gaps. This study focusses on the practice of PPPs at the inter-organisational (meso) level and interpersonal (micro) level in Hong Kong Special Administrative Region (HKSAR). The influence of the structural components of different PPPs on stakeholder interpretation and actions, as well as the eventual outcomes of the PPPs, is examined, in terms of a realist evaluation, which applies a context-mechanism-outcome configuration as the research methodology. Seven key factors initiating commitment in a partnership, critical for sustainable PPPs, were identified as follows: (1) building of trust; (2) clearly defined objectives and roles; (3) time commitment; (4) transparency and candid information, particularly in relation to risk and benefit; (5) contract flexibility; (6) technical assistance or financial incentive behind procedural arrangements; and (7) the awareness and acceptability of structural changes related to responsibility and decisions (power and authority).

Patient experience and satisfaction with inpatient service: development of short form survey instrument measuring the core aspect of inpatient experience.

Patient experience reflects quality of care from the patients' perspective; therefore, patients' experiences are important data in the evaluation of the quality of health services. The development of an abbreviated, reliable and valid instrument for measuring inpatients' experience would reflect the key aspect of inpatient care from patients' perspective as well as facilitate quality improvement by cultivating patient engagement and allow the trends in patient satisfaction and experience to be measured regularly. The study developed a short-form inpatient instrument and tested its ability to capture a core set of inpatients' experiences. The Hong Kong Inpatient Experience Questionnaire (HKIEQ) was established in 2010; it is an adaptation of the General Inpatient Questionnaire of the Care Quality Commission created by the Picker Institute in United Kingdom. This study used a consensus conference and a cross-sectional validation survey to create and validate a short-form of the Hong Kong Inpatient Experience Questionnaire (SF-HKIEQ). The short-form, the SF-HKIEQ, consisted of 18 items derived from the HKIEQ. The 18 items mainly covered relational aspects of care under four dimensions of the patient's journey: hospital staff, patient care and treatment, information on leaving the hospital, and overall impression. The SF-HKIEQ had a high degree of face validity, construct validity and internal reliability. The validated SF-HKIEQ reflects the relevant core aspects of inpatients' experience in a hospital setting. It provides a quick reference tool for quality improvement purposes and a platform that allows both healthcare staff and patients to monitor the quality of hospital care over time.

Item generation in the development of an inpatient experience questionnaire: a qualitative study.

BACKGROUND: Patient experience is a key feature of quality improvement in modern health-care delivery. Measuring patient experience is one of several tools used to assess and monitor the quality of health services. This study aims to develop a tool for assessing patient experience with inpatient care in public hospitals in Hong Kong. METHODS: Based on the General Inpatient Questionnaire (GIQ) framework of the Care Quality Commission as a discussion guide, a qualitative study involving focus group discussions and in-depth individual interviews with patients was employed to develop a tool for measuring inpatient experience in Hong Kong. RESULTS: All participants agreed that a patient satisfaction survey is an important platform for collecting patients' views on improving the quality of health-care services. Findings of the focus group discussions and in-depth individual interviews identified nine key themes as important hospital quality indicators: prompt access, information provision, care and involvement in decision making, physical and emotional needs, coordination of care, respect and privacy, environment and facilities, handling of patient feedback, and overall care from health-care professionals and quality of care. Privacy, complaint mechanisms, patient involvement, and information provision were further highlighted as particularly important areas for item revision by the in-depth individual interviews. Thus, the initial version of the Hong Kong Inpatient Experience Questionnaire (HKIEQ), comprising 58 core items under nine themes, was developed. CONCLUSIONS: A set of dimensions and core items of the HKIEQ was developed and the instrument will undergo validity and reliability tests through a validation survey. A valid and reliable tool is important in accurately assessing patient experience with care delivery in hospitals to improve the quality of health-care services.

Validation of inpatient experience questionnaire.

OBJECTIVE: A validation survey was carried out in this study to assess the acceptability, validity and reliability of the Hong Kong Inpatient Experience Questionnaire (HKIEQ), which was newly developed to measure patient experiences of hospital care in Hong Kong (HK). DESIGN: Cross-sectional validation survey. MAIN OUTCOME MEASURES: Principal component exploratory factor analysis assessed the construct validity of the questionnaire. Cronbach's alpha coefficients and Spearman's rank correlation coefficient estimated the reliability of the instrument. Acceptability of the questionnaire regarding the percentage of missing value of individual items was also assessed. RESULTS: A total of 511 patients discharged from public hospitals in HK were interviewed. Low percentage of missing value (0.2 to 21.3%) showed high acceptability. Nine dimensions of hospital care explaining 75.4% of the variance were derived from factor analysis and content validity. These items showed satisfactory internal reliability consistency (0.49 to 0.97). Test-retest reliability ranged from 0.36 to 0.96. CONCLUSIONS: The HKIEQ performed well on several psychometric indicators and is a promising measure of patient experience with public hospital inpatient care in HK. The findings provided important insight on developing tools to measure patient experience in hospitals to improve the quality of care and to lay the foundation for further research on patient expectations and needs regarding hospitalization.

Willingness to pay for private primary care services in Hong Kong: are elderly ready to move from the public sector?

How to provide better primary care and achieve the right level of public-private balance in doing so is at the centre of many healthcare reforms around the world. In a healthcare system like Hong Kong, where inpatient services are largely funded through general taxation and ambulatory services out of pocket, the family doctor model of primary care is underdeveloped. Since 2008, the Government has taken forward various initiatives to promote primary care and encourage more use of private services. However, little is known in Hong Kong or elsewhere about consumers' willingness to pay (WTP) for private services when care is available in the public sector. This study assessed willingness of the Hong Kong elderly to pay for specific primary care and preventive services in the private sector, through a cross-sectional in-person questionnaire survey and focus group discussions among respondents. The survey revealed that the WTP for private services in general was low among the elderly; particularly, reported WTP for chronic conditions and preventive care both fell below the current market prices. Sub-group analysis showed higher WTP among healthier and more affluent elderly. Among other things, concerns over affordability and uncertainty (of price and quality) in the private sector were associated with this low level of WTP. These results suggest that most elderly, who are heavy users of public health services but with limited income, may not use more private services without seeing significant reduction in price. Financial incentives for consumers alone may not be enough to promote primary care or public-private partnership. Public education on the value of prevention and primary care, as well as supply-side interventions should both be considered. Hong Kong's policy-making process of the initiative studied here may also provide lessons for other countries with ongoing healthcare reforms.

Framework and components for effective discharge planning system: a Delphi methodology.

BACKGROUND: To reduce avoidable hospital readmissions, effective discharge planning and appropriate post discharge support care are key requirements. This study is a 3-staged process to develop, pretest and pilot a framework for an effective discharge planning system in Hong Kong. This paper reports on the methodology of Delphi approach and findings of the second stage on pre-testing the framework developed so as to validate and attest to its applicability and practicability in which consensus was sought on the key components of discharge planning. METHODS: Delphi methodology was adopted to engage a group of experienced healthcare professionals to rate and discuss the framework and components of an effective discharge planning. The framework was consisted 36 statements under 5 major themes: initial screening, discharge planning process, coordination of discharge, implementation of discharge, and post discharge follow-up. Each statement was rated independently based on 3 aspects including clarity, validity and applicability on a 5-point Likert-scale. Statement with 75% or above of participants scoring 4-5 on all 3 aspects would be included in the discharge planning framework. For those statements not reaching 75% of consensus in any one of the aspect, it would be revised or discarded following the group discussion, and be re-rated in another round. RESULTS: A total of 24 participants participated in the consensus-building process. In round one rating, consensus was achieved in 25 out of 36 statements. Among those 11 statements not reaching consensus, the major concern was related to the "applicability" of the statements. The participants expressed a lack of manpower, skills and time in particular during weekends and long holidays in carrying out assessment and care plans within 24 h after admission. There were also timeliness and availability issue in providing transportation and necessary equipment to the patients. To make the statements more applicable, the wordings of some of the statements were revised to provide greater flexibility. Due to the lack of a statement in clarifying the role of the members of the healthcare professional team, one additional statement on the role and responsibility of the multidisciplinary team members was added. The first theme on "initial screening" was further revised to "initial screening and assessment" to better reflect the first stage of discharge planning process. After two rounds of rating process, all the 36 statements and the newly added statement reached consensus CONCLUSIONS: A structured, systematic and coordinated system of hospital discharge system is required to facilitate the discharge process to ensure a smooth patient transition from the hospital to the community and improve patient health outcome in both clinical and social aspect. The findings of this paper provide a reference framework helping policymakers and hospital managers to facilitate the development of a coherent and systematized discharge planning process. Adopting a Delphi approach also demonstrates the values of the method as a pre-test (before the clinical run) of the components and requirements of a discharge planning system taking into account of the local context and system constraints, which would lead to improvements to its applicability and practicability. To confirm the applicability and practicability of this consensus framework for discharge planning system, the third stage of process of development of the discharge planning framework is to apply and pilot the framework in a hospital setting to evaluate its feasibility, applicability and impact in hospital including satisfaction from both the perspectives of staff and patients.

Patient experiences with public hospital care: first benchmark survey in Hong Kong.

OBJECTIVE. To measure patient satisfaction in relation to in-patient experience in public hospitals. DESIGN. Cross-sectional study. SETTING. Twenty-five selected Hospital Authority acute and convalescence hospitals in Hong Kong. PARTICIPANTS. Eligible patients discharged between 15 June and 27 September 2010 from the selected Hospital Authority public hospitals. MAIN OUTCOME MEASURES. A total of 54 items were used to measure patient experience on aspects of hospital care. They included the process of admission to hospital, staying in the hospital and ward (environment, food and facilities; hospital staff; patient care and treatment), the process of leaving hospital, and the overall impression of hospital care. Free-text comments from respondents were also recorded. RESULTS. A total of 5030 patients were successfully interviewed, amounting to a response rate of 52%. The findings showed that 80% (confidence interval, 79-81%) of patients rated the care they received in hospital as good or better. However, there were a few areas where performance was relatively low, including waiting time for a ward bed for accident and emergency cases, food quality, infection control, information provided about their condition/treatment, seeking patient input about their opinions and quality of care, and patient engagement in the decisions about their treatment and care, as well as the discharge process. CONCLUSIONS. This patient experience survey used a validated instrument (Hong Kong Inpatient Experience Questionnaire) to provide important insights to executives and health care professionals on their care to patients and to identify areas for improvement in public hospitals. Further surveys should be carried out to monitor changes in patient experience and satisfaction on a regular basis. Such surveys could facilitate improvements through analysis of results on patient satisfaction.

Can vouchers make a difference to the use of private primary care services by older people? Experience from the healthcare reform programme in Hong Kong.

BACKGROUND: As part of its ongoing healthcare reform, the Hong Kong Government introduced a voucher scheme, intended for encouraging older patients to use primary healthcare services in the private sector, thereby, reducing burden on the overwhelmed public sector. The voucher program is also considered one of the strategies to further develop the public private partnership in healthcare, a policy direction of high political priority as indicated in the Chief Executive Policy Address in 2008-09. This study assessed whether the voucher scheme, as implemented so far, has reached its intended goals, and how it might be further improved in the context of public-private partnership. METHODS: This was a cross-sectional study using structured questionnaires by face-to-face interviews with older people aged 70 or above in Hong Kong, the target group of the demand-side voucher program. RESULTS: 71.2% of 1,026 older people were aware of the new voucher scheme but only 35.0% had ever used it. The majority of the older people used the vouchers for acute curative services in the private sector (82.4%) and spent less on preventive services. Despite the provision of vouchers valued US$30 per year as an incentive to encourage the use of private primary care services, after 12-months of implementation, 66.2% of all respondents agreed with the statement that "the voucher scheme does not change their health seeking behaviours on seeing public or private healthcare professionals". The most common reasons for no change in their behaviours included "I am used to seeing doctors in the public system" and "The amount of the subsidy is too low". Those who usually used a mix of public and private doctors and those with better self-reported health condition compared to last year were more likely to perceive a change in their own health seeking behaviours. CONCLUSIONS: Our study showed that despite a reasonably high awareness of the voucher scheme, its usage was low. The voucher alone was not enough to realize the government's policy of greater use of the private primary care services. Greater publicity and more variety of media promotion would increase awareness but the effectiveness of vouchers in changing older people's behaviour needs to be revisited. Designating vouchers for use of preventive services with evidence-based practice could be considered. In addition to the demand-side subsidies, improving transparency and comparability of private services against the public sector might be necessary.

Risk factors of hospitalization and readmission of patients with COPD in Hong Kong population: analysis of hospital admission records.

BACKGROUND: Chronic Obstructive Pulmonary Disease (COPD) accounts for around 4% of all public hospital annual admissions in Hong Kong. By year 2020, COPD will be ranked fifth among the conditions with the highest burden to the society. This study identifies admission and unplanned readmission of COPD patients, factors affecting unplanned readmission, and estimates its cost burden on the public healthcare system in Hong Kong. METHODS: This is a retrospective study analyzing COPD admissions to all public hospitals in Hong Kong. All admission episodes to acute medical wards with the principal diagnosis of COPD (ICD-9:490-492, 494-496) from January 2006 to December 2007 were captured. Unplanned readmission was defined as an admission which followed a previous admission within 30 days. RESULTS: In 2006 and 2007, 65497 (8.0%) of episodes from medical wards were identified as COPD admissions, and among these, 15882 (24.2%) were unplanned readmissions. The mean age of COPD patients was 76.81 ± 9.59 years and 77% were male. Unplanned readmission was significantly associated with male gender, receiving public assistance and living in nursing homes while no association was found with the Charlson comorbidity index. Patients who were readmitted unplanned had a significant longer acute length of stay (ß = 0.3894, P < 0.001) after adjustment for other covariates. CONCLUSIONS: Unplanned readmission of COPD patients has a huge impact on the public healthcare system. A systematic approach in programme provision and a good discharge planning process targeting on COPD patients who are at high risk of unplanned readmission are essential.

A population-based survey using PPE-15: relationship of care aspects to patient satisfaction in Hong Kong.

OBJECTIVE: Satisfaction with hospitalization may lead to both better health outcomes for patients and create better working environment and relationship between staff and patients. The objective of this study is to explore the relationship between the experiences of inpatients with specific aspects of care and satisfaction with the hospitalization experience. DESIGN: A secondary data analysis based on the Thematic Household Survey which was regularly conducted by the Census and Statistic Department. SETTING: This survey covered the land-based non-institutional population of the Hong Kong Special Administrative Region (HKSAR), China, and representing 99% of the total population of HKSAR of 6.8 million. PARTICIPANTS: Totally 1264 respondents aged ≥15 who had ever been admitted to local hospital in 12 months prior enumeration were recruited. MAIN OUTCOME MEASURES: The Picker Patient Experience Questionnaire-15 (PPE-15) was adopted for measuring patient-perceived quality of hospitalization; and one global rating of the overall quality of hospital service was included. RESULTS: The mean global satisfaction scores for public and private hospital care were 7.3/10 and 7.8/10, respectively. By adjusting patient demographics, the regression models show that 'want to be more involved in decision made about the care and treatment', 'respect for patient's dignity', 'patients' family have enough opportunity to talk to doctor' and 'tell about danger signals regarding illness/treatment after went home' are major determinants of the global satisfaction scores. CONCLUSION: Communication, respect and patient engagement in provider-patient relationship are important in determining patient's satisfaction. Training and healthcare education curriculum could take this into account for ensuring the quality of patient-centered care.

Unplanned readmission rates, length of hospital stay, mortality, and medical costs of ten common medical conditions: a retrospective analysis of Hong Kong hospital data.

BACKGROUND: Studies on readmissions attributed to particular medical conditions, especially heart failure, have generally not addressed the factors associated with readmissions and the implications for health outcomes and costs. This study aimed to investigate the factors associated with 30-day unplanned readmission for 10 common conditions and to determine the cost implications. METHODS: This population-based retrospective cohort study included patients admitted to all public hospitals in Hong Kong in 2007. The sample consisted of 337,694 hospitalizations in Internal Medicine. The disease-specific risk-adjusted odd ratio (OR), length of stay (LOS), mortality and attributable medical costs for the year were examined for unplanned readmissions for 10 medical conditions, namely malignant neoplasms, heart diseases, cerebrovascular diseases, pneumonia, injury and poisoning, nephritis and nephrosis, diabetes mellitus, chronic liver disease and cirrhosis, septicaemia, and aortic aneurysm. RESULTS: The overall unplanned readmission rate was 16.7%. Chronic liver disease and cirrhosis had the highest OR (1.62, 95% confidence interval (CI) 1.39-1.87). Patients with cerebrovascular disease had the longest LOS, with mean acute and rehabilitation stays of 6.9 and 3.0 days, respectively. Malignant neoplasms had the highest mortality rate (30.8%) followed by aortic aneurysm and pneumonia. The attributed medical cost of readmission was highest for heart disease (US$3 199 418, 95% CI US$2 579 443-803 393). CONCLUSIONS: Our findings showed variations in readmission rates and mortality for different medical conditions which may suggest differences in the quality of care provided for various medical conditions. In-hospital care, comprehensive discharge planning, and post-discharge community support for patients need to be reviewed to improve the quality of care and patient health outcomes.

Perspective from health professionals on delivery of sub-acute care in Hong Kong: a qualitative study in a health system.

OBJECTIVES: The perception and understanding of health professionals of the role of sub-acute care in the health system will have an impact on the potential effectiveness in preventing unnecessary hospitalization. This study aims to explore the perceived role and quality of sub-acute care services in the context of Hong Kong from the perspective of health service providers and to identify barriers to effectiveness. METHODS: Seven focus groups were conducted and the discussion was led by a guide covering three main areas: definition/component/role of sub-acute, difficulties in the sub-acute care services provision, and suggestion for further improvement in the provision of sub-acute care. RESULTS: The participants highlighted the positive role of sub-acute to promote patient's health and quality of life so as to reduce unnecessary hospitalization. The potential barriers in the sub-acute care identified were interrelated and focused mainly on systemic issues including lack of service coordination, specialist input and resources. The participants also suggested a number of practical ways to improve the quality of sub-acute care services. CONCLUSIONS: The findings showed a need for further improvement in the process of sub-acute care by developing operation guideline and re-evaluating the allocation of resources to support the sub-acute care provision.

Avoidable readmission in Hong Kong--system, clinician, patient or social factor?

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.

Measuring and preventing potentially avoidable hospital readmissions: a review of the literature.

OBJECTIVE: To review literature identifying key components for measuring avoidable readmissions, their prevalence, risk factors, and interventions that can reduce potentially avoidable readmissions. DATA SOURCES AND EXTRACTION: Literature search using Medline, PubMed and the Cochrane Library up to June 2010, using the terms "avoidable", "preventable", "unplanned", "unnecessary", "readmission", and "rehospitalization". STUDY SELECTION: A total of 48 original papers and review articles were selected for inclusion in this review. DATA SYNTHESIS: Although hospital readmission seemed to be a term commonly used as an outcome indicator in many studies, it is difficult to make valid comparison of results from different studies. This is because the definitions of terms, methods of data collection, and approaches to data analysis differ greatly. The following criteria for studying hospital readmissions have been recommended: (a) identify hospital admissions and define relevant terms, (b) establish a clinical diagnosis for a readmission; (c) establish the purpose for a readmission, (d) set a discharge-to-readmission timeframe, and (e) identify the sources of information for assessing readmissions. Studies to identify avoidable readmissions usually involve medical records and chart reviews by clinicians using the classification scheme developed by the authors. The proportion of all readmissions assessed as preventable varies from 9 to 59% depending on the population of patients studied, duration of follow-up, type and methodology of the study and case-mix-related factors. A number of studies classified risk factors for readmission into four categories: patient, social, clinical, and system factors. Home-based interventions, intensive education/counselling, multidisciplinary care approaches, and telephone follow-up were the main types of interventions to address potentially avoidable readmissions. CONCLUSIONS: A standard instrument to identify avoidable readmission is important in enabling valid comparisons within the system and at different timelines, so as to permit robust evaluation of interventions. The assessment of preventable risk factors for readmissions also provides a basis for designing and implementing intervention programmes.

Seasonality in suicide: a study of farming suicides in England and Wales.

Seasonality in suicide rates has long been reported. Spring peaks in suicide deaths have been positively correlated with the proportion of the workforce engaged in agriculture. Some studies have indicated that suicides using violent methods are more likely to show seasonality. Recent research has suggested that seasonal patterns have diminished. This study examined deaths in male farmers, an occupational group which might be expected to be more vulnerable to seasonal influences because of the nature of their work and the relatively high proportion of farmers using violent methods for suicide. Data on suicides between 1982 and 1999 by males in England and Wales aged 15 years and over were provided by the Office for National Statistics. Seasonal patterns of suicide in farmers and nonfarmers were examined by nonparametric tests and harmonic analysis. No significant seasonal variation was found for farmers. For nonfarmers, although a chi-square test showed significant variation in monthly distribution, this was not found when a harmonic analysis was applied. There was no significant difference in the variation of violent suicides throughout the year. This study reinforces recent findings that seasonal variation in suicide appears to be diminishing, even in an occupational group where this might be expected.