1. 23 september 2010 Dr. H. Pincé – UZ Leuven Validity of PPR grouper for a university hospital

2. Objectives Exploration and validation of the software: does PPR classification system correctly identify PPR’s ? Utility of PPR CS based on MHD in Belgium ?

3. Methodology Input MHD 2008 UZL Output PPR CS: 2 datasets –For readmission interval 15 and 30 days –APR-DRG 27.0 –Each admission gets a record type –Identification of “chains” of clinically related admissions of the same patient –Validation of these chains by record review

4. Methodology

5. Results Software does not take into account whether a readmission is planned or unplanned Top PPR adjusted APR chain level = APR-DRG 480: Major Male Pelvic Procedures –Radical prostatectomy where patient leaves hospital with transurethral catheter in situ –and gets systematically a planned readmission within a week for cystography, removal of the transurethral catheter, and education pelvic muscles

6. Top PPR adjusted APR chain level = APR- DRG 480: Major Male Pelvic Procedures Malignancies excluded ?  Procedures for malignancies are NOT excluded as IA Hospitalisation necessary ?  Operational items, lack of capacity in ambulatory care setting  Academic research : prospective study physiotherapists  Decreasing numbers: more conservative attitude

7. Results =>Selection of only these chains with at least one unplanned readmission => decrease PPR rate with 1.45%

8. Results 15 days interval Top 5 PPR adjusted APR chain level –Also in top 10 Florida study –No Pareto principle : 200 different DRG’s Top 20 DRG’s -> 35% of chains 80% of chains -> 90 different DRG’s

9. Results Number of chains per DRG in top 5: 25-28 Of each top 5 DRG record review of 10 chains –Clinically related ? Yes –Potentially preventable ??? –Often rather complex cases

10. Example APR-DRG 139 other pneumonia –Boy 10 years –Development disorder –With severe psychomotoric retardation –Intractable epilepsy –Frequent aspiration pneumonia –And problems with nutrition (PEG-sonde) –Chain of 4 admissions, all DRG 139 severity 4

11. Example APR-DRG 140 Chronic Obstructive Pulmonary Disease –Often COPD GOLD III or IV –Often geriatric patients with multipathology –% with DNR code, or deceased in the meanwhile

12. Results 30 days interval: 2 top 5 DRG’s –‘Clinically related’ ? Yes –30 days: clinical relationship reason: more “Ambulatory care sensitive conditions”

13. Remarks 1) oncology Exclusion of oncology only for medical admissions  PPR rate ↑ when a lot of surgery for malignancies  APR-DRG 221 PPR chains: 60% malignancies

14. Remark 2) psychiatry Top 10 Florida : 3 psychiatric DRG’s More readmissions when psychiatric sdx In Belgium in MHD: AAAAAA code 7 à 8 % of IA with major mental health issue

15. Remark 3) difference IA OA Differences between –IA with PPR chain –and OA without PPR chain LOS Severity distribution

16. Remark 3) different LOS Mean LOS of IA with PPR chain > mean LOS of OA without PPR chain Standardized for DRG/severity  hypothesis of ‘premature discharge’ ???

17. Remark 3): different severity distribution

18. Limitations No exhaustive validation of 1)planned readmissions identified by PPR 2)unplanned readmissions identified by PPR 3)planned readmissions not identified by PPR 4)unplanned readmissions not identified by PPR

19. Conclusion no feedback available about clinically related readmissions FB Flemish Community –7 days interval –unplanned readmissions –basis: stayhosp: “code readmission” – “number of days since former discharge”; filled in by hospital; “scope” = MCD, day care and ambulatory emergencies included –few exclusions –no notion of ‘clinically related’

20. Conclusion PPR software Computes number of days between discharge and subsequent admission –Dates are needed: available in MHD (not in MCD) Focus on clinical relationship –Clinically related : validity OK –Potentially preventable ???

21. Conclusion PPR software => Selection unplanned readmissions => Risk adjustment is needed:  SRR: Standardised Readmission Ratio o Belgian benchmark is needed o Feedback, risk adjusted, interesting

22. Conclusion PPR software Indicator ! –Interpretation together with other indicators like SMR, clinical indicators CAVE financial implications –Severity 4 for UZ’s always negative financial results (BFM, drug forfait) –Risk adjustment based on administrative data is difficult !