PPR Clinical Vetting Session: November 1st 2010

Identification of clinically unrelated readmissions designated as preventable It will always be possible to identify individual cases for which the readmission was a) probably planned or b) probably not preventable Identifying exceptions to the PPR logic misses the point of a system that is based on rates, and seeks to identify deviation from expected performance based on peer-hospital rates It is precisely because of the impossibility of specifying all possible rules, exceptions, and details for what constitutes a preventable readmission that the PPR system is built upon the comparison of rates.

Identification of clinically unrelated readmissions designated as preventable - 2 The guiding principle in identifying combinations of initial admissions and readmissions that might be potentially preventable was the following: If a hospital has a rate of a particular kind of readmission that is substantially higher than its peer hospitals, then reasonable clinicians would be concerned that a problem with the quality of patient care existed. Unless the APR DRG pair that constitutes a potentially preventable readmission can be demonstrated to be typically planned or unpreventable, then the existing logic, which was the product of an intensive iterative process of clinical hypothesis generation and testing, should stand.

How responsible is the discharging hospital for readmissions for the deterioration of a chronic condition?

Time Interval for Preventable Readmissions

Risk Adjustment – APR DRG Severity of Illness Levels

Top 10 Medical APR DRGs for Frequency of PPRs, by SOI (Florida 2005-2006)   All Pts SOI 1 SOI 2 SOI 3 SOI 4 194 Heart Failure Chains 15,053 1,304 8,151 4,675 923 Rate 12.5 8.9 11.7 15.0 19.4 140 Chronic Obstructive Lung Disease 8,271 1,737 3,745 2,416 373 9.7 7.3 9.3 12.7 17.3 750 Schizophrenia 7,592 3,382 3,931 251 28 17.7 17.1 18.1 20.8 16.8 139 Other Pneumonia 7,579 393 3,295 3,394 497 7.7 2.7 6.5 11.4 16.4 751 Major Depressive Disorder 5,608 1,814 3,391 339 64 10.9 8.3 12.6 16.5 10.8 198 Angina Pectoris & Coronary Atherosclerosis 5,151 1,414 2,685 982 70 5.6 3.7 6.2 9.9 753 Bipolar Disorders 4,830 2,366 2,260 179 25 14.0 15.3 18.8 11.6 720 Septicemia & Disseminated Infection 4,370 46 881 1,808 1,635 3.6 19.3 460 Renal Failure 4,288 92 471 3,250 475 12.8 11.0 10.6 21.1 201 Card Arrhythmia & Conduction Disturbance 4,066 898 1,950 1,070 148 6.3 4.0 6.4 10.2 16.0 All Other Medical APR DRGs 41,412 8,036 15,942 13,011 4,423 2.9 1.7 2.5 5.0 9.4 Total Medical APR-DRG 108,220 21,482 46,702 31,375 8,661 3.2 4.7 7.4 These numbers are 1) the total number of PPR chains (Number of initial admissions with at least 1 PPR) and 2) the rate – no. of PPR chains/ no. of candidate admissions

Top 10 Surgical APR DRGs for Frequency of PPRs, by SOI (Florida 2005-2006)   Surgical APR DRG All Pts SOI 1 SOI 2 SOI 3 SOI 4 175 Percutaneous Cardiovascular Procs w/o AMI Chains 7,260 3,222 2,850 1,043 145 Rate 7.9 6.4 9.0 12.7 14.8 221 Major Small & Large Bowel Procedures 3,426 606 1,201 913 706 9.4 6.0 8.3 11.1 19.5 173 Other Vascular Procedures 3,186 627 1,140 1,075 344 11.3 6.9 10.2 16.9 23.7 174 Percutaneous Cardiovascular Procedures with AMI 3,115 791 1,288 648 388 9.8 10.0 14.4 18.5 165 Coronary Bypass with Cath or PCI 2,638 101 909 1,073 555 12.3 7.2 9.3 13.9 21.5 301 Hip Joint Replacement 2,870 1,123 1,106 445 196 6.2 5.1 8.9 21.4 308 Hip/femur Procedure x Joint Replacement d/t Trauma 2,395 234 1,115 835 211 8.0 4.9 10.6 302 Knee Joint Replacement 2,373 780 1,323 233 37 4.0 2.9 4.5 7.4 13.1 161 Cardiac Defibrillator & Heart Assist Implant 2,048 113 614 1,132 189 171 Perm Card Pacemaker w/o AMI, CHF, or Shock 2,044 523 1,068 382 71 8.1 5.5 8.7 19.6 All Other Surgical 36,608 8,940 13,142 10,196 4,330 6.1 3.2 12.4 18.6 Total Surgical APR-DRG 67,963 17,060 25,756 17,975 7,172 6.8 19.0

Percutaneous cardiovascular procedures w/o AMI Predicted v. Actual Number of PPRs for Reporting Year 2007 Florida, Selected APR DRGs (Based on Calendar Year 2005 Rate) Admission Volume APR Description SOI CY 05 PPR Rate RY07 Volume Predicted Actual 540   Cesarean delivery 1 0.03% 56,689 15 16 2 0.06% 17,269 11 9 3 0.09% 4,820 4 0.98% 295 Sub Total 0.04% 79,073 33 28 139 Other pneumonia 3.14% 6,828 215 246 7.38% 21,987 1,622 1,677 12.71% 12,314 1,565 1,654 17.77% 1,387 222 8.58% 42,516 3,648 3,799 175 Percutaneous cardiovascular procedures w/o AMI 7.90% 20,312 1,604 1,474 11.15% 14,902 1,662 1,596 15.84% 4,906 777 761 18.04% 639 115 164 10.20% 40,759 4,158 3,995

Predicted v. Actual Number of PPRs for Reporting Year 2007 Florida, Selected APR DRGs (Based on Calendar Year 2005 Rate) APR Description SOI PPR Rate 2007 Volume Predicted Actual 194   Heart failure 1 11.04% 4,852 535 591 2 14.61% 24,769 3,618 3,767 3 18.53% 14,833 2,748 2,820 4 18.38% 1,870 344 373 Sub Total 15.64% 46,324 7,245 7,551 750 Schizophrenia 21.26% 4,610 980 941 22.42% 10,138 2,273 2,407 25.44% 791 201 191 20.51% 45 9 12 22.23% 15,584 3,464 3,551 460 Renal failure 13.76% 387 53 47 13.29% 2,283 303 286 14.21% 16,040 2,279 2,258 18.17% 1,331 242 295 14.36% 20,041 2,878 2,886

PPR Performance Florida data, FY 2005 vs RY 2006 Pearson Correlation Coefficient = 0.9976 (Calendar year ’05, Reporting year ’07) Hospital level R-square = 0.45

“Elective” Admissions as a proxy for planned readmissions

Readmissions with one of these procedures following an Initial Admission for DRG 301 (Total Hip Replacement) WILL be considered preventable: 0070 Revision of hip replacement, both acetabular and femoral components 0071 Revision of hip replacement, acetabular component 0072 Revision of hip replacement, femoral component 0073 Revision of hip replacement, acetabular liner and/or femoral head only 8153 Revision of hip replacement, not otherwise specified

Readmissions with one of these procedures following an Initial Admission for DRG 301 (Total Hip Replacement) will be considered PLANNED, and not preventable: 0085 Resurfacing hip, total, acetabulum and femoral head 0086 Resurfacing hip, partial, femoral head 0087 Resurfacing hip, partial, acetabulum 8151 Total Hip Replacement 8152 Partial Hip Replacement

Re DRG 173 (Other Vascular Procedures) Readmissions for endovascular grafts following peripheral vascular procedures (procedure 3971) will be classified as planned. Re the suggestion that “Some patients cannot physiologically tolerate enough contrast and require 2 different vascular bypass procedures in order to perform multiple grafting.” This is not only an unusually rare group of patients but should be randomly distributed between hospitals. Thus this consideration does not merit excluding the entire group of readmissions, many of which are potentially preventable and should be adequately addressed in a rate-based system.

Re APR DRG 304 (Dorsal and Lumbar Fusion) Regarding the suggestion that “These fusion procedures may be done in a staged process requiring 2 separate planned admissions”: Based on consultation with orthopedists about this situation, staging is rarely done for dorsal and/or lumbar fusions.