PPR Clinical Vetting Session:

1. PPR Clinical Vetting Session: November 1st 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)

8. Top 10 Surgical APR DRGs for Frequency of PPRs, by SOI (Florida 2005-2006)

9. Predicted v. Actual Number of PPRs for Reporting Year 2007Florida, Selected APR DRGs (Based on Calendar Year 2005 Rate)

10. Predicted v. Actual Number of PPRs for Reporting Year 2007Florida, Selected APR DRGs (Based on Calendar Year 2005 Rate)

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:

14. Readmissions with one of these procedures following an Initial Admission for DRG 301 (Total Hip Replacement) will be considered PLANNED, and not preventable:

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.