1. PPR Clinical Vetting Session: November 1 st 2010

2. 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.

3. 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.

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

5. Time Interval for Preventable Readmissions

6. Risk Adjustment – APR DRG Severity of Illness Levels

7. Top 10 Medical APR DRGs for Frequency of PPRs, by SOI (Florida 2005-2006) Medical APR DRG All PtsSOI 1SOI 2SOI 3SOI 4 194Heart Failure Chains15,0531,3048,1514,675923 Rate12.58.911.715.019.4 140Chronic Obstructive Lung Disease Chains8,2711,7373,7452,416373 Rate9.77.39.312.717.3 750Schizophrenia Chains7,5923,3823,93125128 Rate17.717.118.120.816.8 139Other Pneumonia Chains7,5793933,2953,394497 Rate7.72.76.511.416.4 751Major Depressive Disorder Chains5,6081,8143,39133964 Rate10.98.312.616.510.8 198 Angina Pectoris & Coronary Atherosclerosis Chains5,1511,4142,68598270 Rate5.63.76.29.917.3 753Bipolar Disorders Chains4,8302,3662,26017925 Rate14.012.715.318.811.6 720Septicemia & Disseminated Infection Chains4,370468811,8081,635 Rate12.63.68.312.719.3 460Renal Failure Chains4,288924713,250475 Rate12.811.010.612.521.1 201Card Arrhythmia & Conduction Disturbance Chains4,0668981,9501,070148 Rate6.34.06.410.216.0 All Other Medical APR DRGs Chains41,4128,03615,94213,0114,423 Rate2.91.72.55.09.4 Total Medical APR-DRG Chains108,22021,48246,70231,3758,661 Rate5.03.24.77.411.7

8. Top 10 Surgical APR DRGs for Frequency of PPRs, by SOI (Florida 2005-2006) Surgical APR DRG All PtsSOI 1SOI 2SOI 3SOI 4 175Percutaneous Cardiovascular Procs w/o AMI Chains7,2603,2222,8501,043145 Rate7.96.49.012.714.8 221Major Small & Large Bowel Procedures Chains3,4266061,201913706 Rate9.46.08.311.119.5 173Other Vascular Procedures Chains3,1866271,1401,075344 Rate11.36.910.216.923.7 174 Percutaneous Cardiovascular Procedures with AMI Chains3,1157911,288648388 Rate9.86.410.014.418.5 165Coronary Bypass with Cath or PCI Chains2,6381019091,073555 Rate12.37.29.313.921.5 301Hip Joint Replacement Chains2,8701,1231,106445196 Rate6.25.16.08.921.4 308 Hip/femur Procedure x Joint Replacement d/t Trauma Chains2,3952341,115835211 Rate8.04.96.910.619.5 302Knee Joint Replacement Chains2,3737801,32323337 Rate4.02.94.57.413.1 161Cardiac Defibrillator & Heart Assist Implant Chains2,0481136141,132189 Rate9.34.97.411.116.9 171Perm Card Pacemaker w/o AMI, CHF, or Shock Chains2,0445231,06838271 Rate8.15.58.712.719.6 All Other Surgical Chains36,6088,94013,14210,1964,330 Rate6.13.26.212.418.6 Total Surgical APR-DRG Chains67,96317,06025,75617,9757,172 Rate6.84.06.812.319.0

9. Predicted v. Actual Number of PPRs for Reporting Year 2007 Florida, Selected APR DRGs (Based on Calendar Year 2005 Rate) Admission Volume APRDescriptionSOI CY 05 PPR Rate RY07 VolumePredictedActual 540 Cesarean delivery 1 0.03%56,6891516 2 0.06%17,269119 3 0.09%4,82042 4 0.98%29531 Sub Total 0.04%79,0733328 139 Other pneumonia 1 3.14%6,828215246 2 7.38%21,9871,6221,677 3 12.71%12,3141,5651,654 4 17.77%1,387246222 Sub Total 8.58%42,5163,6483,799 175 Percutaneous cardiovascular procedures w/o AMI 1 7.90%20,3121,6041,474 2 11.15%14,9021,6621,596 3 15.84%4,906777761 4 18.04%639115164 Sub Total 10.20%40,7594,1583,995

10. 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 VolumePredictedActual 194 Heart failure 1 11.04%4,852535591 2 14.61%24,7693,6183,767 3 18.53%14,8332,7482,820 4 18.38%1,870344373 Sub Total 15.64%46,3247,2457,551 750 Schizophrenia 1 21.26%4,610980941 2 22.42%10,1382,2732,407 3 25.44%791201191 4 20.51%45912 Sub Total 22.23%15,5843,4643,551 460 Renal failure 1 13.76%3875347 2 13.29%2,283303286 3 14.21%16,0402,2792,258 4 18.17%1,331242295 Sub Total 14.36%20,0412,8782,886

11. 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

12. “Elective” Admissions as a proxy for planned readmissions

13. 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 0071Revision of hip replacement, acetabular component 0072Revision of hip replacement, femoral component 0073 Revision of hip replacement, acetabular liner and/or femoral head only 8153Revision of hip replacement, not otherwise specified

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

15. 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.

16. 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.