Journal of General Internal Medicine

, Volume 29, Issue 2, pp 349–355 | Cite as

Patient Activation and 30-Day Post-Discharge Hospital Utilization

  • Suzanne E. MitchellEmail author
  • Paula M. Gardiner
  • Ekaterina Sadikova
  • Jessica M. Martin
  • Brian W. Jack
  • Judith H. Hibbard
  • Michael K. Paasche-Orlow
Original Research



Patient activation is linked to better health outcomes and lower rates of health service utilization. The role of patient activation in the rate of hospital readmission within 30 days of hospital discharge has not been examined.


A secondary analysis using data from the Project RED-LIT randomized controlled trial conducted at an urban safety net hospital. Data from 695 English-speaking general medical inpatient subjects were analyzed. We used an adapted, eight-item version of the validated Patient Activation Measure (PAM). Total scores were categorized, according to standardized methods, as one of four PAM levels of activation: Level 1 (lowest activation) through Level 4 (highest activation). The primary outcome measure was total 30-day post-discharge hospital utilization, defined as total emergency department (ED) visits plus hospital readmissions including observation stays. Poisson regression was used to control for confounding.


Of the 695 subjects, 67 (9.6 %) were PAM Level 1, 123 (17.7 %) were Level 2, 193 (27.8 %) were Level 3, and 312 (44.9 %) were Level 4. Compared with highly activated patients (PAM Level 4), a higher rate of 30-day post-discharge hospital utilization was observed for patients at lower levels of activation (PAM Level 1, incident rate ratio [IRR] 1.75, 95 % CI,1.18 to 2.60) and (PAM Level 2, IRR 1.50, 95 % CI 1.06 to 2.13). The rate of returning to the hospital among patients at PAM Level 3 was not statistically different than patients with PAM Level 4 (IRR 1.30, 95 % CI, 0.94 to 1.80). The rate ratio for PAM Level 1 was also higher compared with Level 4 for ED use alone (1.68(1.07 to 2.63)) and for hospital readmissions alone (1.93 [1.22 to 3.06]).


Hospitalized adult medical patients in an urban academic safety net hospital with lower levels of Patient Activation had a higher rate of post-discharge 30-day hospital utilization.


patient activation readmission 



Dr. Mitchell is supported by a mentored clinical scientist award from the Agency for Healthcare Research and Quality (1K08HS019771-01). The REDLIT trial was funded by the National Heart Lung and Blood Institute (NHLBI 1 R01 HL081307-01).

Conflict of Interest

No authors have any conflict of interest to report. Dr. Mitchell is a non-product speaker on health behavior counseling for MERCK & Co.


  1. 1.
    Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009;360(14):1418–28.PubMedCrossRefGoogle Scholar
  2. 2.
    Steiner C, Barrett M, Hunter K. Hospital Readmissions and Multiple Emergency Department Visits, in Selected States, 2006–2007: Statistical Brief #90. Healthcare Cost and Utilization Project (HCUP) Statistical Briefs [Internet]. Rockville: Agency for Health Care Policy and Research (US); 2010.Google Scholar
  3. 3.
    Rising KL, White LF, Fernandez WG, Boutwell AE. Emergency department visits after hospital discharge: a missing part of the equation. Ann Emerg Med. 2013.Google Scholar
  4. 4.
    Jack BW, Chetty VK, Anthony D, Greenwald JL, Sanchez GM, Johnson AE, et al. A reengineered hospital discharge program to decrease rehospitalization: a randomized trial. Ann Intern Med. 2009;150(3):178–87.PubMedCentralPubMedCrossRefGoogle Scholar
  5. 5.
    Mitchell SE, Paasche-Orlow MK, Forsythe SR, Chetty VK, O’Donnell JK, Greenwald JL, et al. Post-discharge hospital utilization among adult medical inpatients with depressive symptoms. J Hosp Med. 2010;5(7):378–84.PubMedCrossRefGoogle Scholar
  6. 6.
    Mitchell SE, Sadikova E, Jack BW, Paasche-Orlow MK. Health literacy and 30-day post-discharge hospital utilization. J Health Commun. 2012;17(Suppl 3):325–38.PubMedCrossRefGoogle Scholar
  7. 7.
    Marcantonio ER, McKean S, Goldfinger M, Kleefield S, Yurkofsky M, Brennan TA. Factors associated with unplanned hospital readmission among patients 65 years of age and older in a Medicare managed care plan. Am J Med. 1999;107(1):13–7.PubMedCrossRefGoogle Scholar
  8. 8.
    Woz S, Mitchell S, Hesko C, Paasche-Orlow M, Greenwald J, Chetty VK, et al. Gender as risk factor for 30 days post-discharge hospital utilisation: a secondary data analysis. BMJ Open. 2012;2(2):e000428.PubMedCentralPubMedCrossRefGoogle Scholar
  9. 9.
    Wei NJ, Wexler D, Nathan DM, Grant RW. Intensification of diabetes medication and risk for 30-day readmission. Diabet Med. 2012.Google Scholar
  10. 10.
    Hibbard JH, Stockard J, Mahoney ER, Tusler M. Development of the Patient Activation Measure (PAM): conceptualizing and measuring activation in patients and consumers. Health Serv Res. 2004;39(4 Pt 1):1005–26.PubMedCrossRefGoogle Scholar
  11. 11.
    Hibbard JH, Tusler M. Assessing activation stage and employing a “next steps” approach to supporting patient self-management. J Ambul Care Manage. 2007;30(1):2–8.PubMedCrossRefGoogle Scholar
  12. 12.
    Parchman ML, Zeber JE, Palmer RF. Participatory decision making, patient activation, medication adherence, and intermediate clinical outcomes in type 2 diabetes: a STARNet study. Ann Fam Med. 2010;8(5):410–7.PubMedCentralPubMedCrossRefGoogle Scholar
  13. 13.
    Begum N, Donald M, Ozolins IZ, Dower J. Hospital admissions, emergency department utilization and patient activation for self-management among people with diabetes. Diabetes Res Clin Pract. 2011;93(2):260–7.PubMedCrossRefGoogle Scholar
  14. 14.
    Greene J, Hibbard JH. Why does patient activation matter? An examination of the relationships between patient activation and health-related outcomes. J Gen Intern Med. 2012;27(5):520–6.PubMedCentralPubMedCrossRefGoogle Scholar
  15. 15.
    Remmers C, Hibbard J, Mosen DM, Wagenfield M, Hoye RE, Jones C. Is patient activation associated with future health outcomes and healthcare utilization among patients with diabetes? J Ambul Care Manage. 2009;32(4):320–7.PubMedCrossRefGoogle Scholar
  16. 16.
    Kirby SE. An Exploration of the Reasons for Frequent Readmission in Patients with Chronic Disease: Activation from Frequent Flyers to Self-Management. University of New South Whales; 2012.Google Scholar
  17. 17.
    Stepleman L, Rutter MC, Hibbard J, Johns L, Wright D, Hughes M. Validation of the patient activation measure in a multiple sclerosis clinic sample and implications for care. Disabil Rehabil. 2010;32(19):1558–67.PubMedCrossRefGoogle Scholar
  18. 18.
    Fowles JB, Terry P, Xi M, Hibbard J, Bloom CT, Harvey L. Measuring self-management of patients’ and employees’ health: further validation of the Patient Activation Measure (PAM) based on its relation to employee characteristics. Patient Educ Couns. 2009;77(1):116–22.PubMedCrossRefGoogle Scholar
  19. 19.
    Glasgow RE, Wagner EH, Schaefer J, Mahoney LD, Reid RJ, Greene SM. Development and validation of the Patient Assessment of Chronic Illness Care (PACIC). Med Care. 2005;43(5):436–44.PubMedCrossRefGoogle Scholar
  20. 20.
    SAS Institute I. SAS 9.1.3 Help and Documentation. 2000–2004.Google Scholar
  21. 21.
    Deen D, Lu WH, Rothstein D, Santana L, Gold MR. Asking questions: the effect of a brief intervention in community health centers on patient activation. Patient Educ Couns. 2011;84(2):257–60.PubMedCrossRefGoogle Scholar

Copyright information

© Society of General Internal Medicine 2013

Authors and Affiliations

  • Suzanne E. Mitchell
    • 1
    • 4
    Email author
  • Paula M. Gardiner
    • 1
  • Ekaterina Sadikova
    • 1
  • Jessica M. Martin
    • 1
  • Brian W. Jack
    • 1
  • Judith H. Hibbard
    • 2
  • Michael K. Paasche-Orlow
    • 3
  1. 1.Department of Family MedicineBoston University School of MedicineBostonUSA
  2. 2.Institute for Policy Research and InnovationUniversity of OregonEugeneUSA
  3. 3.Department of Medicine, Section of General Internal MedicineBoston University School of MedicineBostonUSA
  4. 4.Department of Family MedicineDowling 5 South Boston Medical CenterBostonUSA

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