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Table 4 Measures collected from patients undergoing colorectal, thoracic and vascular operations in four VA medical centers

From: A study to reduce readmissions after surgery in the Veterans Health Administration: design and methodology

RUG-ADL Assessment The Resource Utilization Group – Activities of Daily Living Assessment measures functional status at discharge, readmission and at 30-day follow-up. This four-item validated questionnaire assesses a patient’s independence with mobility, toileting, transfer and eating [39].
Pain The National Institutes of Health Numeric Rating Pain Scale assesses pain intensity at the time of discharge, readmission and 30-day follow-up [40].
Pain Meds Total dose of pain medication administered 24 h (7 am-7 am) before discharge
Perceived Stress Scale Cohen’s Perceived Stress Scale (PSS) is a 10-item scale that quantifies patient’s stress. The PSS has been shown to correlate with health behavior and health services utilization [41].
CES-D4 The Center for Epidemiologic Studies Depression Screen, 4-item version, assesses psychological distress at the time of discharge. The CES-D4 has been shown to be have a positive predictive value of 85% for depression in an older adult population [31].
MoCA The Montreal Cognitive Assessment is a validated tool to assess a patient’s cognitive function. This tool has a positive predictive value of 89% for mild cognitive impairment (90% sensitivity; 87% specificity) when compared to clinical criteria supported by psychometric measures [42].
Caregiver Accessibility These questions were guided by the literature around the immediacy and availability of the designated caregiver (i.e., does caregiver live with patient) [43, 44].
Transportation Patient access to transportation and burden of transportation (number of post-operative visits and travel distance).
CTM-15, adapted The Care Transition Measure is a 15-item scale that addresses the hospital’s efforts at care coordination at discharge. The survey also assesses patient self-efficacy in implementing the discharge plan. The tool was designed as a post-discharge, recall assessment [45]. We will adapt the tool: a) to assess these items on the day of discharge; b) to assess patient self-efficacy with wound, indwelling device, new ostomy or durable medical equipment, as applicable; and c) to assess patient understanding of whom and when to contact regarding warning signs or symptoms that may arise.
Institute for Healthcare Improvement Readmission Tool This tool was developed by IHI as part of a conceptual roadmap to reduce avoidable re-hospitalizations by intervening at the system level. The tool will be adapted for surveying patients at readmission [46].
Brief Survey of Post-operative Care Queries patient on unplanned emergency visit or readmission at an outside hospital; keeping post-operative appointments; difficulty getting medications filled (costs) and refilled (especially pain medication); receipt of home health or durable medical equipment.