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apr-drgs potentially preventable readmissions module

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apr-drgs potentially preventable readmissions module

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    1. APR-DRGs Potentially Preventable Readmissions Module 3M HIS Clinical Research Department

    2. 9/27/2011

    3. 9/27/2011 IMPORTANT CAVEATS Not all readmissions are preventable! It is the rates that we are interested in! Even if we are primarily interested in the rates, readmission rate must have clinical meaning and thus must be carefully defined.

    4. 9/27/2011 Current APR-DRG Research: Readmission Module Hypothesis: Readmissions – e.g. within 15 days are useful for two purposes – identify opportunities for quality improvement in the initial/index hospitalization and/or identify good candidates for care management after hospital discharge

    5. 9/27/2011 providing excellent care during the first hospitalization; and  putting into place the best possible coordination plans with the outpatient setting – including both the outpatient health professional team and the patient/family/caregiver.

    6. 9/27/2011

    7. 9/27/2011 Research Results AHRQ has published a summary synthesis/ new analysis providing support for looking at readmissions. Hannen et al (JAMA August 13,2003) published an article entitled: Predictors of Readmission for Complications for Coronary Artery Bypass Graft Surgery. In this study, 15.3% of approximately 16,000 patients were readmitted within 30 days after discharge following CABG surgery. Of these readmissions, 85% were readmitted for purposes that were identified as complications directly related to the CABG. Approximately 60 of the 2,111 readmitted patients died during their readmission.

    8. 9/27/2011 Research Approach for the Development of the APR-DRG Readmission Module Provide Readmission Definition Develop logic Specify classification system identifying which APR subclasses we hypothesize as likely resulting in a readmission Test the classification methodology with appropriate data bases

    9. 9/27/2011 General Definition of Readmission A readmission to the hospital within 15 days is considered applicable for the APR-DRG readmission methodology if reasonable clinicians would agree that the readmission was likely related to the index hospital stay. The APR-DRG readmission methodology contains detailed logic excluding readmissions unlikely to be related to the index hospitalization and excluding readmissions unlikely to represent a quality improvement opportunity for either the hospital stay and/or the coordination process between the hospital discharge team and the receiving outpatient health care team.

    10. 9/27/2011 Develop Logic and Define Parameters: ·    the site (e.g. nursing home, rehabilitation, hospital) or level of care of care to which the return occurs; time period within which the return occurs;   ·      the clinical definition of the return; and   ·      the type of admission of the return.

    11. 9/27/2011 Level of Care of Return Probably the most fundamental element of a hospital readmission is the level of care to which the return occurs. By definition, the APR-DRG readmission module involves the return of a patient to inpatient acute care. It is beyond the scope of this effort to examine admissions after hospital discharge to other intermediate levels of care such as nursing homes or rehabilitation hospitals.

    12. 9/27/2011 Time Period of Return  Experience suggests that a flexible approach to defining time periods for hospital readmissions may be best. This type of definition can initially focus on 15 days, then extend to longer intervals such as 30 days as more experience with the use of this indicator is developed and hospitals increasingly coordinate services with the outpatient sector. Our norms will be developed for 15 days.

    13. 9/27/2011 Clinical Definition of Return While some pay for performance arrangements identify an index condition/procedure (e.g. CABG) and consider all hospital admissions occurring within 15 days as readmissions, it is important to have a clearly specified methodology that excludes admissions that are likely not to be related to the index admission.

    14. 9/27/2011 Types of Readmissions The following types of readmissions are excluded from the APR-DRG readmission methodology - - readmissions for which there is no possible clinical relation to the index admission (hip replacement two weeks after a finger operation); - readmissions that are not clearly related to improvement opportunities in either hospital or outpatient care (e.g. readmissions for malignancy care or motor vehicle accidents); and

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    16. 9/27/2011

    17. 9/27/2011 I.- Exclusion Logic: stops a chain, won’t be part of a chain and won’t reinitiate a new chain. This logic applies to all global exclusions and left against medical advice. II.- Transfer Logic: stops a chain but only after being considered as a possible valid readmission. No subsequent readmission is allowed. The subsequent admission can be considered an initial admission if followed by a valid readmission within the 15 days. This logic applies only to Transfers (TA).

    18. 9/27/2011 Types of Chain Logic III.- Other Trauma PDX Logic: stops any existing chain and won’t be part of that chain, but can initiate a new chain if followed by a valid readmission within 15 days. This logic applies to hospitalizations that have any PDX of trauma except those already globally excluded because of multiple significant trauma or burn (Multiple TR). Note the global exclusions (MA, TR, etc.) and left against medical advice (LA) terminate any existing chain, so by definition, they cannot have a subsequent readmission (RA) even if the days to the next hospitalization is within 15 days

    19. 9/27/2011 Non-Event Readmissions – do NOT count as a readmission but do NOT break a chain Identify rehabilitation and aftercare cases with APR-DRGs 860, 862, 863 and mark them as a “non-event” (NE).

    20. 9/27/2011 Patients who died during the hospitalization Identify cases that are not part of a chain and have a discharge status of 20-Died, and mark them as only admissions-died (OD). They do not count in the denominator of the readmissions rate formulas

    21. 9/27/2011 Thus, for example: Any elective surgical admission that occurs after a medical admission is not considered to be related and thus “terminates” a chain.

    22. 9/27/2011 Patients with a significant chronic mental health problem Have a higher risk of readmission Are included in the readmission rate but added “weight” is given to this type of patient

    23. 9/27/2011 Number of readmissions in a chain

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    25. 9/27/2011 Sample Cases with DRGS Selected for Defining Readmission Rates

    26. 9/27/2011

    27. 9/27/2011 Readmission Rate- Major Surgical Procedures – 15 days

    28. 9/27/2011 Readmission Rate- Major Surgical Procedures – 30 days

    29. 9/27/2011 Coronary Bypass with Cardiac Cath-30 days

    30. 9/27/2011 COPD – 30 Day Readmissions

    31. 9/27/2011 Summary The APR-DRG Readmission Module is a clinically meaningful classification system which provides useful information to consumers and hospitals on hospital centric readmission rates. Recommendation: Consider Implementation of APR-DRG Readmission module as a refinement to reporting single readmission rate (Future Steps: Consider moving from a “hospital-centric to a “patient-centric” view of readmissions by tracking patients as the axis for analysis)

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