Potentially Preventable
Readmissions: Overview of
Definitions and Clinical Logic
HSCRC
April 6, 2010
Elizabeth McCullough, 3M Health Information Systems
6 April 2010
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.
2
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
3
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
4
Phase I :Identify Excluded Admissions and Non-events
5
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
•
•
–
Discharge status indicates limited hospital & provider control
•
•
–
–
•
•
Left against medical advice
Transferred to another acute care hospital
Neonates
Other exclusions
•
•
–
Major or metastatic malignancies treated medically
Multiple trauma, burns
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
6
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
7
Phase II: Determine Preliminary Classification of
Remaining Admissions
8
Example Readmission
Phase I
Phase II
Admission 1
(discharge home)
APR DRG 133
Initial Admission
Phase I
Phase II
Admission 1
(discharge home)
APR DRG 133
Initial Admission
Days
Between
3
Admission 2
(discharge home)
APR DRG 133
Readmission
Days
Between
14
Admission 3
(discharge home)
APR DRG 140
Readmission
Phase I
Phase II
Admission 1
(discharge home)
APR DRG 133
Initial Admission
Days
Between
3
Admission 2
(discharge home)
APR DRG 133
Readmission
Days
Between
20
Admission 3
(discharge home)
APR DRG 140
Only Admission
Patient 2C
Patient 2A
Patient 2D
Days
Between
4
Admission 2
(discharge home)
APR DRG 133
Readmission
9
Examples of a Non Events
Admissions that get “ignored”
Patient 2B
Phase I
Phase II
Admission 1
(discharge home)
Days
Between
Admission 2
(discharge home)
Days
Between
Admission 3
(discharge home)
APR DRG 133
Initial Admission
3
APR DRG 860
Non Event
14
APR DRG 140
Readmission
10
Transfer Example
Transfer To Another facility:
Patient 2E
Phase I
Phase II
Admission 1
(discharge home)
APR DRG 174
Initial Admission
Days
Between
3
Admission 2
(transferred)
APR DRG 198
Readmission
Days
Between
0
Admission 3
(discharge home)
APR DRG 198
Only Admission
Days
Between
14
Admission 3
(discharge home)
APR DRG 139
Readmission
Transferred from To Another facility:
Phase I
Phase II
Admission 1
(transferred)
APR DRG 174
Transfer
Days
Between
0
Admission 2
(discharge home)
APR DRG 194
Only Admission
Phase I
Phase II
Admission 1
(transferred)
APR DRG 174
Transfer
Days
Between
0
Admission 2
(discharge home)
APR DRG 140
Initial Admission
Patient 2F
Patient 2J
11
Excluded and Only Admissions Example
Phase I
Phase II
Admission 1
(discharge home)
APR DRG 174
Only Admission
Phase I
Phase II
Admission 1
(discharge home)
APR DRG 20
Excluded
Days
Between
3
Phase I
Phase II
Admission 1
(discharge home)
APR DRG 174
Only Admission
Days
Between
32
Patient 2L
Patient 2G
Patient 2M
Admission 2
(discharge home)
APR DRG 194
Only Admission
Admission 2
(discharge home)
APR DRG 174
Only Admission
12
Phase III: Identify PPRs and Determine Final Classification of
Admissions
13
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 postdischarge period after the initial admission.
14
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.
15
P
Q
R
S
T
Craniotomy for trauma
Craniotomy exc for trauma
Ventricular shunt proc
Spinal procedures
Extracranial vascular proc
Oth nervous syst & relat proc
Spinal disorders & injuries
Nervous system malignancy
U
V
W
X
Y
Z
AA AB
Non-bact nerv infect exc VM
O
Bact & tuberculous nerv infect
N
Periph, cranial, auton nerv dx
M
Transient ischemia
L
Nonspec CVA & precereb occl
K
CVA w infarct
J
Intracranial hemorrhage
I
Mult sclerosis/oth demyelin dx
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
PPR
RA APR→
IA APR↓
MDC Type IA APR Desc
00
MS
Liver trans &/or intest trans
1
00
MS
Heart &/or lung transplant
2
00
MS
Bone marrow transplant
3
00
MS
ECMO or trach w MV w extn proc
4
00
MS
Trach w MV wo exten proc
5
00
MS
Pancreas transplant
6
01
XTB Craniotomy for trauma
20
01
MS
Craniotomy exc for trauma
21
01
MS
Ventricular shunt proc
22
01
MS
Spinal procedures
23
01
MS
Extracranial vascular proc
24
01
MS
Oth nervous syst & relat proc
26
01
M
Spinal disorders & injuries
40
01
XMA Nervous system malignancy
41
01
M
Degeneratv nerv sys dis exc MS
42
01
M
Mult sclerosis/oth demyelin dx
43
01
M
Intracranial hemorrhage
44
01
M
CVA w infarct
45
01
M
Nonspec CVA & precereb occl
46
01
M
Transient ischemia
47
01
M
Periph, cranial, auton nerv dx
48
01
M
Bact & tuberculous nerv infect
49
01
M
Non-bact nerv infect exc VM
50
H
Degeneratv nerv sys dis exc MS
2
G
Pancreas transplant
M - Medical
MS - Major Surgical
OS - Other Surgical
EM - Elective Medical
ES - Elective Major Surgical
EO - Elective Other Surgical
XMA - Malignancy Exclusion
XTB - Trauma Exclusion
XNN - Neonatal Exclusion
XOB - Obstectrical Exclusion
XOG - Other Exclusion
F
Trach w MV wo exten proc
E
ECMO or trach w MV w extn proc
D
Bone marrow transplant
1
C
Heart &/or lung transplant
A
Liver trans &/or intest trans
Methodology for Selecting Potentially
Preventable Readmissions (PPRs)
MS MS MS MS MS MS XTB MS MS MS MS MS M XMA M
1
2
3
4
5
6 20 21 22 23 24 26 40 41 42
M
43
M
44
M
45
M
46
M
47
M
48
M
49
M
50
X
X
X
X
2B
X
G
X
X
X
X
X
X
G
X
1
X
X
X
X
X
X
X
X
X
X
X
3
X
G
3
3
X
X
X
X
G
X
X
1
1
1
1
X
X
X
X
X
X
X
3
X
G
3
3
X
3
X
X
G
X
X
1
1
1
1
X
X
X
X
X
X
X
3
X
G
3
3
X
3
X
X
G
X
X
1
1
1
1
X
X
X
X
X
X
X
3
X
G
3
3
X
3
2B
X
G
X
X
1
1
1
1
X
X
X
X
X
X
X
2B
X
G
2B
3
2B
2B
2B
3
G
2B
2B
2B
2B
2B
2B
1
2B
2B
X
X
X
X
3
X
G
3
3
3
X
3
X
G
X
X
X
X
X
X
X
1
X
X
X
X
X
3
X
G
3
3
3
X
3
X
G
X
X
X
X
X
X
X
X
1
4
X
X
X
X
X
G
X
X
X
X
X
X
G
X
X
X
X
X
X
X
X
X
X
4
X
X
X
X
G
X
X
X
X
X
X
G
X
X
X
X
X
X
X
X
X
X
X
4
X
X
X
G
X
X
X
X
X
X
G
X
X
X
X
X
X
X
X
X
5
5
5
X
4
5
G
5
5
5
5
5
X
G
X
X
X
X
X
X
X
X
X
3
1
3
X
4
3
G
3
3
3
3
3
X
G
X
X
X
X
X
X
X
X
X
X
X
X
X
X
4
G
X
X
X
X
X
X
G
X
X
X
X
X
X
X
X
X
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
X
X
X
X
4
X
G
4
4
X
4
X
X
G
X
X
X
X
X
X
X
X
X
X
X
X
X
4
X
G
4
4
X
X
4
X
G
X
X
X
X
X
X
X
X
X
X
X
X
X
4
X
G
X
X
4
X
X
X
G
X
X
X
X
X
X
X
X
X
X
X
X
X
4
X
G
X
X
X
4
5
X
G
X
X
X
X
X
X
X
X
X
X
X
X
X
4
X
G
4
4
4
4
4
X
G
X
X
X
X
X
X
X
X
X
X
X
X
X
3
X
G
X
X
1
X
3
X
G
X
X
X
X
X
X
X
X
X
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
X
X
X
X
2B
X
G
2B
2B
2B
2B
2B
2B
G
1
1
2B
2B
2B
2B
2B
2B
2B
16
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
17
18
Phase III- Identify PPRs and Determine Final
Classification of Admission
19
Phase III- Identify PPRs and Determine Final
Classification of Admission
Determine if a Readmission Chain is Terminated
Reasons for terminating a readmission chain
–
Admissions with a discharge status of “died”
•
–
Excluded admissions
•
–
Still classified as PPR, but PPR terminates the readmission chain
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
20
Phase III- Identify PPRs and Determine Final
Classification of Admission
Re-classify Readmission when not Clinically Related to Initial Admission
21
Phase III- Identify PPRs and Determine Final Classification of Admission
Re-classify Initial Admission when Readmission not Clinically Related
22
Reasons for Readmission
Florida, All Patients, 2004-2005
Reason
Reason Description
Count
Percent
1
Medical – continuation of initial problem
57,515
24.7
2A
Medical – 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
233,050
100.0
Total
23
Top 15 Initial Admissions followed by
one or more PPR - 2007
APR
DRG
194
140
720
139
175
753
460
463
201
173
198
751
383
221
750
HEART FAILURE
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
SEPTICEMIA & DISSEMINATED INFECTIONS
OTHER PNEUMONIA
PERCUTANEOUS CARDIOVASCULAR PROCEDURES W/O AMI
BIPOLAR DISORDERS
RENAL FAILURE
KIDNEY & URINARY TRACT INFECTIONS
CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS
OTHER VASCULAR PROCEDURES
ANGINA PECTORIS & CORONARY ATHEROSCLEROSIS
MAJOR DEPRESSIVE DISORDERS & OTHER/UNSPECIFIED PSYCHOSES
CELLULITIS & OTHER BACTERIAL SKIN INFECTIONS
MAJOR SMALL & LARGE BOWEL PROCEDURES
SCHIZOPHRENIA
Initial
Admissions Percent of
Initial
Followed by
Admissions
PPRs
15 Day Window
5.77%
1,838
3.70%
1,178
3.21%
1,024
2.40%
765
2.31%
737
1.99%
634
2.14%
683
1.90%
606
1.90%
604
1.53%
489
1.70%
542
1.61%
512
1.58%
505
1.66%
529
1.59%
506
PPR
Rate
12.03%
10.02%
10.14%
6.55%
8.02%
7.53%
9.85%
7.60%
6.93%
10.38%
5.93%
6.87%
4.73%
10.36%
9.16%
Initial
Admissions Percent of
Initial
Followed by
Admissions
PPRs
30 Day Window
5.78%
2,567
3.81%
1,693
2.97%
1,321
2.43%
1,078
2.39%
1,063
2.07%
918
2.02%
896
1.88%
836
1.87%
830
1.69%
752
1.69%
752
1.65%
732
1.63%
724
1.62%
718
1.60%
709
PPR
Rate
18.80%
15.67%
14.31%
9.61%
11.81%
11.56%
14.01%
11.11%
9.95%
16.61%
8.68%
10.29%
7.01%
14.14%
13.85%
Top 15 represents 35% of all initial admissions followed by PPRs
24
Top 15 Reasons for PPRs - 2007
APR
DRG
720
194
140
130
460
133
721
139
711
137
753
750
45
248
890
SEPTICEMIA & DISSEMINATED INFECTIONS
HEART FAILURE
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
RESPIRATORY SYSTEM DIAG W VENTILATOR SUPPORT 96+ HOURS
RENAL FAILURE
PULMONARY EDEMA & RESPIRATORY FAILURE
POST-OPERATIVE, POST-TRAUMATIC, OTHER DEVICE INFECTIONS
OTHER PNEUMONIA
POST-OP, POST-TRAUMA, OTHER DEVICE INFECTIONS W O.R. PROC
MAJOR RESPIRATORY INFECTIONS & INFLAMMATIONS
BIPOLAR DISORDERS
SCHIZOPHRENIA
CVA & PRECEREBRAL OCCLUSION W INFARCT
MAJOR GASTROINTESTINAL & PERITONEAL INFECTIONS
HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS
Number of
Number of
Total
Admissions
Total
Admissions
Identified Charges for Identified as Charges for
PPRs
a PPR
PPRs
as a PPR
30 Day Window
15 Day Window
3,041 $57,464,024
1,945 $36,578,709
4,712 $45,489,197
2,929 $28,621,634
2,317 $19,740,461
1,338 $11,695,437
352 $19,531,963
247 $13,131,776
1,568 $17,288,207
993 $10,852,746
1,145 $17,236,788
755 $11,477,824
1,241 $13,552,588
904 $9,858,735
1,376 $12,538,408
878 $8,208,719
441 $11,882,757
298 $8,652,870
855 $11,476,928
599 $7,545,054
1,365 $10,923,940
883 $7,083,904
1,085 $10,247,781
678 $6,867,837
796 $9,976,474
550 $6,946,806
890 $9,544,644
562 $5,873,658
335 $9,451,503
231 $6,893,043
Top 15 PPRs represents 42% of charges on PPRs
for a 30 day readmission time window
25
Top Five PPR Reasons for an Initial
Admission of Heart Failure - 2007
Number of
Number of
Admissions
Total
Admissions
Total
Identified Charges for Identified as Charges for
as a PPR
PPRs
a PPR
PPRs
APR
DRG
15 Day Window
30 Day Window
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
26
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)
27