APRDRGs Hospital CentricReadmission Module

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APR-DRGs (Hospital Centric)Readmission Module

• 3M HIS
• Clinical Research Department

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This Session Will Provide

• A summary of research findings on hospital
  readmissions
• Summary of the APR-DRG Readmission Module
• Suggestions for future collaboration

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IMPORTANT CAVEATS

• Not all readmissions are preventable! In theory
  all Ambulatory Care Sensitive Conditions are
  preventable(but of course not really)
• It is the rates that we are interested in!
• Even if we are primarily interested in the rates,
  readmission rate must have clinical meaning and
  thus must be carefully defined.

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Current APR-DRG Research (Hospital Centric)
Readmission Module

• Hypothesis Readmissions e.g. within 15 or 30
  days are useful for two purposes identify
  opportunities for quality improvement in the
  index hospitalization and/or identify good
  candidates for care management after hospital
  discharge

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It is fairly clear from the extensive literature
that the hospital can assist in avoiding
readmissions by a combination of

• providing excellent care during the first
  hospitalization and 
• putting into place the best possible coordination
  plans with the outpatient setting including
  both the outpatient health professional team and
  the patient/family/caregiver.

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Researchers have long posited a relationship
between severity of illness at hospital discharge
for any hospitalized individual and likelihood of
readmission.
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Most recently, Hannen et al (JAMA August
13,2003) published an article entitled
Predictors of Readmission for Complications for
Coronary Artery Bypass Graft Surgery. In this
study, 15.3 of approximately 16,000 patients
were readmitted within 30 days after discharge
following CABG surgery. Of these readmissions,
85 were readmitted for purposes that were
identified as complications directly related to
the CABG. Approximately 60 of the 2,111
readmitted patients died during their
readmission.
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Research Approach for the Development of the
APR-DRG Readmission Module

• Provide Readmission Definition
• Develop logic.
• Specify classification system identifying which
  APR subclasses we hypothesize as likely resulting
  in a readmission
• Test the classification methodology with
  appropriate data bases

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With this as background, the following general
definition of readmission is provided

• A readmission to the hospital within 15 days is
  considered applicable for the APR-DRG readmission
  methodology if reasonable clinicians would agree
  that the readmission was likely related to the
  index hospital stay. The APR-DRG readmission
  methodology contains detailed logic excluding
  readmissions unlikely to be related to the index
  hospitalization and excluding readmissions
  unlikely to represent a quality improvement
  opportunity for either the hospital stay and/or
  the coordination process between the hospital
  discharge team and the receiving outpatient
  health care team.

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Develop Logic. Define Parameters

•     the site (e.g. nursing home, rehabilitation,
  hospital) of care to which the return occurs
• time period within which the return occurs
•  
•         the clinical definition of the return
  and
•  
•         the type of admission of the return.

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Level of care of return

• Probably the most fundamental element of a
  hospital readmission is the level of care to
  which the return occurs. By definition, the
  APR-DRG readmission module involves the return of
  a patient to inpatient acute care. It is beyond
  the scope of this effort to examine admissions
  after hospital discharge to other intermediate
  levels of care such as nursing homes or
  rehabilitation hospitals.

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Time period of return

•  Experience suggests that a flexible approach to
  defining time periods for hospital readmissions
  may be best. This type of definition can
  initially focus on 15 days, then extend to longer
  intervals such as 30 days as more experience with
  the use of this indicator is developed and
  hospitals increasingly coordinate services with
  the outpatient sector.

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Clinical definition of return

• While some pay for performance arrangements
  identify an index condition/procedure (e.g. CABG)
  and consider all hospital admissions occurring
  within 15 or 30 days as readmissions, it is
  important to have a clearly specified methodology
  that excludes admissions that are likely not to
  be related to the index admission.

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The following types of readmissions are excluded
from the APR-DRG readmission methodology

• -readmissions for which there is no possible
  clinical relation to the index admission (hip
  replacement two weeks after a finger operation)
• -readmissions that are not clearly related to
  improvement opportunities in either hospital or
  outpatient care (e.g. readmissions for malignancy
  care or motor vehicle accidents) and

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Chain Rules were defined for creating a
readmission chain (that is an initial index
admission followed by a number of related
readmissions)
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Thus, for example

• Any elective surgical admission that occurs after
  a medical admission is not considered to be
  related and thus terminates a chain.

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Sample Cases with DRGS Selected for Defining
Readmission Rates
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(No Transcript)
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Coronary Bypass with Cardiac Cath
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COPD 30 Day Readmissions
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Summary of Module

• The APR-DRG Readmission Module is a clinically
  meaningful classification system which provides
  useful information to consumers and hospitals on
  hospital centric readmission rates.
• Year 1 Recommendation Consider Implementation
  of APR-DRG Readmission module
• Year 2 Recommendation Consider working with
  employers/managed care organizations to help
  specify year long readmission rates a
  complementary measure to hospital centric
  readmission module.