Elizabeth McCullough, 3M Health Information Systems 6 April 2010

Potentially Preventable Readmissions: Overview of

Definitions and Clinical Logic

HSCRCApril 6, 2010

Elizabeth McCullough, 3M Health Information Systems 6 April 2010

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PPR-Potentially Preventable Readmissions

PPR Definition: A Potentially Preventable Readmission (PPR) is a readmission that

is clinically-related to the initial hospital admission that may have resulted from a deficiency in the process of care and treatment or lack of post discharge follow-up rather than

• unrelated events that occur post discharge (broken leg due to trauma), or

• readmissions that were planned at the time of the discharge from the initial admission.

Clinically-related: Clinically-related is defined as a requirement that the underlying

reason for following a prior hospital readmission be plausibly related to the care rendered during or immediately following a prior hospital admission.

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Why PPRs

What might cause a PPR to happen?

A readmission is considered to be clinically related to a prior admission and potentially preventable if there was a reasonable expectation that it could have been prevented by one or more of the following:– The provision of quality care in the initial hospitalization– Adequate discharge planning– Adequate post-discharge follow up– Improved coordination between inpatient and outpatient Health

Care Teams

• **Identifying Potential Preventable Readmission Article, Health Care Financing Review Fall 2008

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The Identification of Potentially Preventable Readmissions (PPRs)

Three Phases

Phase I: Identify Excluded Admissions and Non Events

Phase II: Determine Preliminary Classification of Remaining Admissions

Phase III: Identify PPRs and Determine Final Classification of Admissions

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Phase I :Identify Excluded Admissions and Non-events

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Exclusions from the readmission methodology

• No possible clinical relation to the index admission (cholecsytectomy two weeks after total hip replacement);

• Not clearly related to improvement opportunities in either hospital or outpatient care (e.g. readmissions for malignancy care or a motor vehicle accident)

• If any of the following conditions apply to the initial admission, a subsequent readmission is globally excluded from consideration as a PPR

– Admissions for which follow-up care is intrinsically extensive and complex• Major or metastatic malignancies treated medically• Multiple trauma, burns

– Discharge status indicates limited hospital & provider control• Left against medical advice• Transferred to another acute care hospital

– Neonates– Other exclusions

• Specific eye procedures and infections• Cystic fibrosis with pulmonary diagnoses

– Died – not included as candidate initial admissions (denominator)

• PPR Definition Manual Appendix E for List of Globally Excluded APR DRGs• PPR Definition Manual Appendix G for List of Major and Metastatic Malignant

Diagnoses

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Non Event Admissions•Admissions for certain non-acute care services during the interval between a prior admission and subsequent admission do not affect the classification of the subsequent admission•List of Non Event APR DRGs

•860 Rehabilitiation, •862 Other Aftercare & Convalescense, •863 Neonatal Aftercare

•List of Non Event Discharge Status Codes

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Phase II: Determine Preliminary Classification of Remaining Admissions

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Example Readmission

Patient 2AAdmission 1

(discharge home)Days

BetweenAdmission 2


BetweenAdmission 3

(discharge home)

Phase I APR DRG 133 3 APR DRG 133 14 APR DRG 140Phase II Initial Admission Readmission Readmission

Patient 2DAdmission 1


BetweenAdmission 2


BetweenAdmission 3

(discharge home)

Phase I APR DRG 133 3 APR DRG 133 20 APR DRG 140Phase II Initial Admission Readmission Only Admission

Patient 2CAdmission 1


BetweenAdmission 2

(discharge home)

Phase I APR DRG 133 4 APR DRG 133Phase II Initial Admission Readmission

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Examples of a Non EventsAdmissions that get “ignored”

Patient 2BAdmission 1


BetweenAdmission 2


BetweenAdmission 3

(discharge home)

Phase I APR DRG 133 3 APR DRG 860 14 APR DRG 140Phase II Initial Admission Non Event Readmission

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Transfer ExampleTransfer To Another facility:

Transferred from To Another facility:

Patient 2EAdmission 1


BetweenAdmission 2(transferred)

Days Between

Admission 3(discharge home)

Phase I APR DRG 174 3 APR DRG 198 0 APR DRG 198Phase II Initial Admission Readmission Only Admission

Patient 2FAdmission 1(transferred)

Days Between


Phase I APR DRG 174 0 APR DRG 194Phase II Transfer Only Admission

Patient 2JAdmission 1(transferred)

Days Between


Days Between


Phase I APR DRG 174 0 APR DRG 140 14 APR DRG 139Phase II Transfer Initial Admission Readmission

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Excluded and Only Admissions Example

Patient 2GAdmission 1


BetweenAdmission 2

(discharge home)

Phase I APR DRG 20 3 APR DRG 194Phase II Excluded Only Admission

Patient 2LAdmission 1

(discharge home)

Phase I APR DRG 174Phase II Only Admission

Patient 2MAdmission 1


BetweenAdmission 2

(discharge home)

Phase I APR DRG 174 32 APR DRG 174Phase II Only Admission Only Admission

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Phase III: Identify PPRs and Determine Final Classification of Admissions

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Clinically Related Medical Readmissions• Medical readmission for a continuation or recurrence of

the reason for the initial admission, or for a closely related condition.

• Medical readmission for an acute decompensation of a chronic problem that was not the principal reason for the initial admission, but may be related to care either during or after the initial admission.

• Medical readmission for an acute medical condition or complication that may be related to or may have resulted from care during the initial admission or in the post-discharge period after the initial admission.

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Clinically Related Surgical Readmissions

• Readmission for a surgical procedure to address a continuation or a recurrence of the problem causing the initial admission.

• Readmission for surgical procedure to address a complication that may be related to or may have resulted from care during the initial admission.

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Methodology for Selecting Potentially Preventable Readmissions (PPRs)

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MS MS MS MS MS MS XTB MS MS MS MS MS M XMA M M M M M M M M M

MDCPPRType IA APR Desc

RA APR→IA APR↓

1 2 3 4 5 6 20 21 22 23 24 26 40 41 42 43 44 45 46 47 48 49 50

00 MS Liver trans &/or intest trans 1 4 X X 5 3 X G X X X X X X G X X X X X X X X X00 MS Heart &/or lung transplant 2 X 4 X 5 1 X G X X X X X X G X X X X X X X X X00 MS Bone marrow transplant 3 X X 4 5 3 X G X X X X X X G X X X X X X X X X00 MS ECMO or trach w MV w extn proc 4 X X X X X X G X X X X X X G X X X X X X X X X00 MS Trach w MV wo exten proc 5 X X X 4 4 X G 4 4 4 4 4 3 G 2B 2B 3 3 3 3 2B 3 300 MS Pancreas transplant 6 X X X 5 3 4 G X X X X X X G X X X X X X X X X01 XTB Craniotomy for trauma 20 G G G G G G G G G G G G G G G G G G G G G G G01 MS Craniotomy exc for trauma 21 X X X 5 3 X G 4 4 X X 4 X G 2B X 3 3 3 3 2B 3 301 MS Ventricular shunt proc 22 X X X 5 3 X G 4 4 X X 4 X G 2B X 3 3 3 3 3 3 301 MS Spinal procedures 23 X X X 5 3 X G X X 4 X 4 1 G 2B X X X X X 2B 3 301 MS Extracranial vascular proc 24 X X X 5 3 X G 4 X X 4 4 X G 2B X X 3 3 3 2B X X01 MS Oth nervous syst & relat proc 26 X X X 5 3 X G X 4 X 5 4 3 G 2B X X X X 2B 2B 3 301 M Spinal disorders & injuries 40 X X X X X X G X X X X X X G 2B X X X X X 3 X X01 XMA Nervous system malignancy 41 G G G G G G G G G G G G G G G G G G G G G G G01 M Degeneratv nerv sys dis exc MS 42 X X X X X X G X X X X X X G 1 X X X X X 2B X X01 M Mult sclerosis/oth demyelin dx 43 X X X X X X G X X X X X X G 1 1 X X X X 2B X X01 M Intracranial hemorrhage 44 X X X X X X G X X X X X X G 2B X 1 1 1 1 2B X X01 M CVA w infarct 45 X X X X X X G X X X X X X G 2B X 1 1 1 1 2B X X01 M Nonspec CVA & precereb occl 46 X X X X X X G X X X X X X G 2B X 1 1 1 1 2B X X01 M Transient ischemia 47 X X X X X X G X X X X X X G 2B X 1 1 1 1 2B X X01 M Periph, cranial, auton nerv dx 48 X X X X X X G X X X X X X G 2B X X X X X 1 X X01 M Bact & tuberculous nerv infect 49 X X X X X X G X X X X X X G 2B X X X X X 2B 1 X01 M Non-bact nerv infect exc VM 50 X X X X X X G X X X X X X G 2B X X X X X 2B X 1

M - MedicalMS - Major SurgicalOS - Other SurgicalEM - Elective MedicalES - Elective Major SurgicalEO - Elective Other SurgicalXMA - Malignancy ExclusionXTB - Trauma ExclusionXNN - Neonatal ExclusionXOB - Obstectrical ExclusionXOG - Other Exclusion

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PPR Matrix v27

• 98,596 cells in 314 Initial Admission (IA) APR DRG x 314 Readmission (RA) APR DRG Matrix

• 22% clinically related IA by RA APR DRG combination• 37% globally excluded IA by RA APR DRG combination• 41% DRG specific clinical exclusion IA by RA APR DRG

combination

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Phase III- Identify PPRs and Determine Final Classification of Admission

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Determine if a Readmission Chain is TerminatedReasons for terminating a readmission chain

– Admissions with a discharge status of “died”• Still classified as PPR, but PPR terminates the readmission chain

– Excluded admissions• Any subsequent admission may be classified as an initial admission and start a

new chain

– Transfers to another acute care facility• Considered a PPR• Transfer readmission will terminate the readmission chain and no subsequent

admission will be part of the readmission chain


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Re-classify Readmission when not Clinically Related to Initial Admission


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Re-classify Initial Admission when Readmission not Clinically Related


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Reasons for Readmission Florida, All Patients, 2004-2005

Reason Reason Description Count Percent

1 Medical – continuation of initial problem 57,515 24.7

2AMedical – decompensation of chronic problem

(ambulatory care sensitive condition) 39,736 17.1

2B Medical – other decompensation 18,164 7.8

3 Medical – complication of previous admission 76,361 32.8

4 Surgical – continuation of initial problem 8,217 3.5

5 Surgical – complication of initial admission 6,532 2.8

6A Mental health, non-MH initial admission 6,325 2.7

6B Substance abuse, non SA initial admission 1,496 0.6

6C Mental health or substance abuse readmission, initial admission for MH or SA 18,704 8.0

Total 233,050 100.0

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Top 15 represents 35% of all initial admissions followed by PPRs

APR DRG

Initial Admissions Followed by

PPRs

Percent of Initial

AdmissionsPPR Rate

Initial Admissions Followed by

PPRs

Percent of Initial

AdmissionsPPR Rate

194 HEART FAILURE 1,838 5.77% 12.03% 2,567 5.78% 18.80%140 CHRONIC OBSTRUCTIVE PULMONARY DISEASE 1,178 3.70% 10.02% 1,693 3.81% 15.67%720 SEPTICEMIA & DISSEMINATED INFECTIONS 1,024 3.21% 10.14% 1,321 2.97% 14.31%139 OTHER PNEUMONIA 765 2.40% 6.55% 1,078 2.43% 9.61%175 PERCUTANEOUS CARDIOVASCULAR PROCEDURES W/O AMI 737 2.31% 8.02% 1,063 2.39% 11.81%753 BIPOLAR DISORDERS 634 1.99% 7.53% 918 2.07% 11.56%460 RENAL FAILURE 683 2.14% 9.85% 896 2.02% 14.01%463 KIDNEY & URINARY TRACT INFECTIONS 606 1.90% 7.60% 836 1.88% 11.11%201 CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS 604 1.90% 6.93% 830 1.87% 9.95%173 OTHER VASCULAR PROCEDURES 489 1.53% 10.38% 752 1.69% 16.61%198 ANGINA PECTORIS & CORONARY ATHEROSCLEROSIS 542 1.70% 5.93% 752 1.69% 8.68%751 MAJOR DEPRESSIVE DISORDERS & OTHER/UNSPECIFIED PSYCHOSES 512 1.61% 6.87% 732 1.65% 10.29%383 CELLULITIS & OTHER BACTERIAL SKIN INFECTIONS 505 1.58% 4.73% 724 1.63% 7.01%221 MAJOR SMALL & LARGE BOWEL PROCEDURES 529 1.66% 10.36% 718 1.62% 14.14%750 SCHIZOPHRENIA 506 1.59% 9.16% 709 1.60% 13.85%

30 Day Window15 Day Window

Top 15 Initial Admissions followed by one or more PPR - 2007

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Top 15 PPRs represents 42% of charges on PPRs for a 30 day readmission time window

Top 15 Reasons for PPRs - 2007

APR DRG

Number of Admissions

Identified as a PPR

Total Charges for

PPRs

Number of Admissions Identified as

a PPR

Total Charges for

PPRs

720 SEPTICEMIA & DISSEMINATED INFECTIONS 1,945 $36,578,709 3,041 $57,464,024194 HEART FAILURE 2,929 $28,621,634 4,712 $45,489,197140 CHRONIC OBSTRUCTIVE PULMONARY DISEASE 1,338 $11,695,437 2,317 $19,740,461130 RESPIRATORY SYSTEM DIAG W VENTILATOR SUPPORT 96+ HOURS 247 $13,131,776 352 $19,531,963460 RENAL FAILURE 993 $10,852,746 1,568 $17,288,207133 PULMONARY EDEMA & RESPIRATORY FAILURE 755 $11,477,824 1,145 $17,236,788721 POST-OPERATIVE, POST-TRAUMATIC, OTHER DEVICE INFECTIONS 904 $9,858,735 1,241 $13,552,588139 OTHER PNEUMONIA 878 $8,208,719 1,376 $12,538,408711 POST-OP, POST-TRAUMA, OTHER DEVICE INFECTIONS W O.R. PROC 298 $8,652,870 441 $11,882,757137 MAJOR RESPIRATORY INFECTIONS & INFLAMMATIONS 599 $7,545,054 855 $11,476,928753 BIPOLAR DISORDERS 883 $7,083,904 1,365 $10,923,940750 SCHIZOPHRENIA 678 $6,867,837 1,085 $10,247,78145 CVA & PRECEREBRAL OCCLUSION W INFARCT 550 $6,946,806 796 $9,976,474

248 MAJOR GASTROINTESTINAL & PERITONEAL INFECTIONS 562 $5,873,658 890 $9,544,644890 HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS 231 $6,893,043 335 $9,451,503

15 Day Window 30 Day Window

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Top Five PPR Reasons for an Initial Admission of Heart Failure - 2007

APR DRG

Number of Admissions

Identified as a PPR

Total Charges for

PPRs

Number of Admissions Identified as

a PPR

Total Charges for

PPRs

194 HEART FAILURE 962 $9,109,280 1,557 $14,239,684

460 RENAL FAILURE 104 $1,335,969 150 $1,969,758

720 SEPTICEMIA & DISSEMINATED INFECTIONS 97 $1,627,948 135 $2,535,465

140 RESPIRATORY SYSTEM DIAG W VENTILATOR SUPPORT 96+ HOURS 84 $691,335 134 $1,164,383

133 PULMONARY EDEMA & RESPIRATORY FAILURE 80 $1,044,021 113 $1,523,105

All Other PPRs 1,602 $14,813,081 2,623 $24,056,802

Total PPRs for Initial Admission of Heart Failure 2,929 $28,621,634 4,712 $45,489,197

15 Day Window 30 Day Window

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Summary of PPRs• Determines if there is a probable clinical

relationship between an initial hospitalization and a readmission

• Identify admissions that are potentially preventable• Identify admissions that are “at risk” for being

followed by a potentially preventable readmission• Identify chains of readmissions that are all related to

the same prior admission• Determine numerator and denominator for

computing readmission rates (dependent variable)

Elizabeth McCullough, 3M Health Information Systems 6 April 2010

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