APRDRGs Potentially Preventable Readmissions Module

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APR-DRGs Potentially Preventable Readmissions
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 Potentially Preventable
  Readmissions Module
• Suggestion for enhancing public reporting of
  readmissions data

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IMPORTANT CAVEATS

• Not all readmissions are preventable!
• 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 Readmission Module

• Hypothesis Readmissions e.g. within 15 days
  are useful for two purposes identify
  opportunities for quality improvement in the
  initial/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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Research Results

• AHRQ has published a summary synthesis/ new
  analysis providing support for looking at
  readmissions.
• 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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General Definition of Readmission

• 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 and Define Parameters

•     the site (e.g. nursing home, rehabilitation,
  hospital) or level of care 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. Our norms will be
  developed for 15 days.

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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 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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Types of Readmissions

• 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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For each admission typed as a readmission,
store the APR-DRG and SOI of the initial
admission that the readmission resulted from.
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Chain Rules defined for creating a
readmission chain (that is an
initial/index admission followed by a number of
related readmissions)
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Types of Chain Logic

• I.- Exclusion Logic stops a chain, wont be part
  of a chain and wont reinitiate a new chain.
  This logic applies to all global exclusions and
  left against medical advice.
• II.- Transfer Logic stops a chain but only after
  being considered as a possible valid readmission.
  No subsequent readmission is allowed. The
  subsequent admission can be considered an initial
  admission if followed by a valid readmission
  within the 15 days. This logic applies only to
  Transfers (TA).

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Types of Chain Logic

• III.- Other Trauma PDX Logic stops any existing
  chain and wont be part of that chain, but can
  initiate a new chain if followed by a valid
  readmission within 15 days. This logic applies
  to hospitalizations that have any PDX of trauma
  except those already globally excluded because of
  multiple significant trauma or burn (Multiple
  TR).
• Note the global exclusions (MA, TR, etc.) and
  left against medical advice (LA) terminate any
  existing chain, so by definition, they cannot
  have a subsequent readmission (RA) even if the
  days to the next hospitalization is within 15
  days

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Non-Event Readmissions do NOT count as a
readmission but do NOT break a chain

• Identify rehabilitation and aftercare cases with
  APR-DRGs 860, 862, 863 and mark them as a
  non-event (NE).

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Patients who died during the hospitalization

• Identify cases that are not part of a chain and
  have a discharge status of 20-Died, and mark them
  as only admissions-died (OD).
• They do not count in the denominator of the
  readmissions rate formulas

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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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Patients with a significant chronic mental health
problem

• Have a higher risk of readmission
• Are included in the readmission rate but added
  weight is given to this type of patient

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Number of readmissions in a chain
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There will be an outlier policy built into
the norms that we will publish with the data.
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Sample Cases with DRGS Selected for Defining
Readmission Rates
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(No Transcript)
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Readmission Rate- Major Surgical Procedures 15
days
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Readmission Rate- Major Surgical Procedures 30
days
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Coronary Bypass with Cardiac Cath-30 days
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COPD 30 Day Readmissions
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Summary

• The APR-DRG Readmission Module is a clinically
  meaningful classification system which provides
  useful information to consumers and hospitals on
  hospital centric readmission rates.
• Recommendation Consider Implementation of
  APR-DRG Readmission module as a refinement to
  reporting single readmission rate
• (Future Steps Consider moving from a
  hospital-centric to a patient-centric view of
  readmissions by tracking patients as the axis for
  analysis)