Project BOOST

Effectiveness of a Multihospital Effort to Reduce Rehospitalization

Luke O. Hansen MD; Jeffrey L. Greenwald MD; Tina Budnitz MPH; Eric Howell MD; Lakshmi Halasyamani MD; Greg Maynard MD; Arpana Vidyarthi MD; Eric A. Coleman MD; Mark V. Williams MD


Journal of Hospital Medicine. 2013;8(8):421-427. 

In This Article

Abstract and Introduction


Background Rehospitalization is a prominent target for healthcare quality improvement and performance-based reimbursement. The generalizability of existing evidence on best practices is unknown.

Objective To determine the effect of Project BOOST (Better Outcomes for Older adults through Safe Transitions) on rehospitalization rates and length of stay.

Design Semicontrolled pre–post study.

Setting/Participants Volunteer sample of 11 hospitals varying in geography, size, and academic affiliation.

Intervention Hospitals implemented Project BOOST-recommended tools supported by an external quality improvement physician mentor.

Methods Pre–post changes in readmission rates and length of stay within BOOST units, and between BOOST units and site-designated control units.

Results The average rate of 30-day rehospitalization in BOOST units was 14.7% prior to implementation and 12.7% 12 months later (P = 0.010), reflecting an absolute reduction of 2% and a relative reduction of 13.6%. Rehospitalization rates for matched control units were 14.0% in the preintervention period and 14.1% in the postintervention period (P = 0.831). The mean absolute reduction in readmission rates in BOOST units compared to control units was 2.0% (P = 0.054 for signed rank test comparing differences in readmission rate reduction in BOOST units compared to site-matched control units).

Conclusions Participation in Project BOOST appeared to be associated with a decrease in readmission rates. Journal of Hospital Medicine 2013;8:421–427. © 2013 Society of Hospital Medicine


Enactment of federal legislation imposing hospital reimbursement penalties for excess rates of rehospitalizations among Medicare fee for service beneficiaries markedly increased interest in hospital quality improvement (QI) efforts to reduce the observed 30-day rehospitalization of 19.6% in this elderly population.[1,2] The Congressional Budget Office estimated that reimbursement penalties to hospitals for high readmission rates are expected to save the Medicare program approximately $7 billion between 2010 and 2019.[3] These penalties are complemented by resources from the Center for Medicare and Medicaid Innovation aiming to reduce hospital readmissions by 20% by the end of 2013 through the Partnership for Patients campaign.[4] Although potential financial penalties and provision of resources for QI intensified efforts to enhance the quality of the hospital discharge transition, patient safety risks associated with hospital discharge are well documented.[5,6] Approximately 20% of patients discharged from the hospital may suffer adverse events,[7,8] of which up to three-quarters (72%) are medication related,[9] and over one-third of required follow-up testing after discharge is not completed.[10] Such findings indicate opportunities for improvement in the discharge process.[11]

Numerous publications describe studies aiming to improve the hospital discharge process and mitigate these hazards, though a systematic review of interventions to reduce 30-day rehospitalization indicated that the existing evidence base for the effectiveness of transition interventions demonstrates irregular effectiveness and limitations to generalizability.[12] Most studies showing effectiveness are confined to single academic medical centers. Existing evidence supports multifaceted interventions implemented in both the pre- and postdischarge periods and focused on risk assessment and tailored, patient-centered application of interventions to mitigate risk. For example Project RED (Re-Engineered Discharge) applied a bundled intervention consisting of intensified patient education and discharge planning, improved medication reconciliation and discharge instructions, and longitudinal patient contact with follow-up phone calls and a dedicated discharge advocate.[13] However, the mean age of patients participating in the study was 50 years, and it excluded patients admitted from or discharged to skilled nursing facilities, making generalizability to the geriatric population uncertain.

An integral aspect of QI projects is the contribution of local context to translation of best practices to disparate settings.[14,15,16] Most available reports of successful interventions to reduce rehospitalization have not fully described the specifics of either the intervention context or design. Moreover, the available evidence base for common interventions to reduce rehospitalization was developed in the academic setting. Validation of single academic center studies in a broader healthcare context is necessary.

Project BOOST (Better Outcomes for Older adults through Safe Transitions) recruited a diverse national cohort of both academic and nonacademic hospitals to participate in a QI effort to implement best practices for hospital discharge care transitions using a national collaborative approach facilitated by external expert mentorship. This study aimed to determine the effectiveness of BOOST in lowering hospital readmission rates and impact on length of stay.