When Mohana Karlekar, M.D., talks with patient families, she almost always asks what they know about palliative care, and the answer is almost always the same — “Not much.”

As more and better treatments are developed for heart disease, it is becoming more difficult to safely manage care as patients return home from the hospital. A new study led by Vanderbilt researchers highlights growing concern that the period after hospital discharge is a risky time, especially for cardiac patients.

Each year millions of Americans return to the hospital within 30 days of their previous discharge. Although many readmissions could be preventable, most statistical models for predicting them "perform poorly," according to researchers at Vanderbilt and the Oregon Health and Science University and their affiliated VA medical centers.